Emergency personnel are exposed to particularly high levels of physical and psychological stress, entailing occupational risk of mental illness. ^{Reference Vandentorren, Pirard and Sanna1} Because of this risk, sampling procedures are in place at certain organizations to determine the resilience of personnel to occupational stressors. In recent years, topics such as mental fitness, healthy sleep, and well-being of workers have come into focus. ^{Reference Bajo, Blanco and Stavraki2} Forms of preventive preparation and follow-up procedures for specific target groups have been developed.

Some studies have identified occupation-specific as well as gender-specific changes after a high-stress rescue operation, ^{Reference Birkeland, Blix and Solberg3,Reference Brooks, Dunn and Amlôt4} which has led to the recommendation of gender-specific preparation and follow-up procedures. Observed differential changes should be considered and incorporated into preventive measures to establish health-related equality in initial and continuing training. ^{Reference Wesemann, Zimmermann and Mahnke5}

To meet the needs of different gender groups, a systematic assessment of gender-specific effects after extreme events is necessary. Non-cisgender identities are no exception within emergency or military personnel; in the US military, the rate of transgender adults is 2 to 3 times higher than in the comparable civilian population. ^{Reference Tucker6} In Germany, a third gender, “diverse,” (non-binary; German: divers) was only established as an official gender in 2019, so statistics are not yet available for German forces. However, due to special medical coverage, such as the absorption of costs for sex reassignment, and protection against dismissal or discrimination, the proportion of transgender employees is likely to be higher among state and federal institutions than civilian employers.

International studies have observed reluctance to use existing health-care services among this population. This reluctance seems to especially affect mental health. Poor mental health has been seen in non-cisgender US military veterans, compared with cisgender male and female veterans, and the suicide rate among transgender veterans is double that among the general population of veterans. ^{Reference Tucker6}

Despite poorer mental health in this population, there are still no studies on outcomes of transgender individuals after a potentially traumatizing incident. The rate of harassment, trauma, and sexual assault is higher among transgender and gender queer participants in the database of Center for Collegiate Mental Health Database 2012–2016 than among cisgender men or women. Approximately 50% of the 892 genderqueer participants reported all 3 of these experiences. ^{Reference Tyler Lefevor, Boyd-Rogers and Sprague7} In contrast, a study in Brazil did not find that being transgender was a risk factor for increased stress. Rather, rejection by society and friends, present in 90% of cases, seemed to lead to increased psychological stress. ^{Reference Lobato, Soll and Costa8}

In summary, psychological stress and symptoms of mental illness are generally higher in non-cisgender populations than cisgender populations. In particular, rejection from society and exclusion seem to play a decisive role in the development of psychological symptoms. Furthermore, it has been shown that the integration of this population into existing health-care systems is deficient in multiple countries. ^{Reference Beckwith, McDowell and Reisner9} Thus, a future goal is to establish health-related equality in this regard.

An exploratory pilot study on the effects of the terror attack at Breitscheidplatz in Berlin revealed indications of gender differences among first-responding emergency personnel. ^{Reference Wesemann, Zimmermann and Mahnke5} In a subsequent confirmative study, the findings of increased stress and paranoid ideation among female personnel could be replicated. ^{Reference Wesemann, Mahnke and Polk10} The results were attributed to more frequent sexual assaults against women in male-dominated professions, which could increase vulnerability. Sexual harassment and sexual assault are found to be higher in the transgender population, as well. ^{Reference Tyler Lefevor, Boyd-Rogers and Sprague7} It is, therefore, assumed that the differences prevail here as well.

The objective of this single-case-versus-group comparison is to investigate whether gender-specific differences in stress and paranoid ideation following a terror attack are also present in a transgender male emergency worker.

Results

The transgender male rescue worker showed comparable scores in stress (PHQ) to both cisgender groups at both time points.

At the first time point, there were no adverse effects on aggressiveness or hostility in the transgender male worker, and his scores fell 1 SD below that of cisgender male group, as well as that of the overall group. This difference was no longer present after 2 y. The transgender male worker showed increased paranoid ideation at the first time point (2 SDs above cisgender males and 1 SD above the overall group), which normalized by the second time point as shown in Table 1. He also reported interpersonal sensitivity scores 1 SD above cisgender males and the overall group. All other scores were inconspicuous.

Table 1. Increased paranoid ideation in the transgender man and cisgender women

Abbreviations: CI, confidence interval; SD, standard deviation; SE, standard error; Transg., transgender.