Skyler Miguel Santiago Laboy looks in the mirror and smiles. He can hardly believe it. For the first time in 27 years, he feels comfortable in his own body — he sees his reflection and reaffirms, “This is me.”

Since starting masculinizing hormone therapy more than a year ago, his breathing has changed, his voice has deepened, his once-straight hair has grown wavier, the hair on his body has thickened, and the pores on his face have expanded.

“It created a lot of gender euphoria for me. I felt good seeing those changes… For the first time, I looked in the mirror and said: ‘This is me,’” says Skyler — a photographer, graphic designer, and film student  —to the Gender Investigative Unit, a partnership between Todas and the Centro de Periodismo Investigativo (CPI).

He never imagined that a psychiatric crisis and a hospitalization three years ago at San Juan Capestrano Hospital, a facility specializing in mental health, would change his life and help him understand — and accept — that he is a trans man.

It was there that he was diagnosed with gender dysphoria, a feeling of distress that occurs when a person’s gender identity does not align with the sex assigned at birth. It was also the first time — in more than a decade of receiving mental health diagnoses — that he encountered professionals truly prepared to work with members of the LGBT+ community, a deeply diverse collective represented by those initials.

Santiago Laboy’s story mirrors a well-documented reality: LGBT+ youth experience higher rates of anxiety, depression, and suicidal ideation. Experts consulted by the Gender Investigative Unit, along with other studies, link these mental health challenges among LGBT+ people to discrimination, harassment, and lack of access to adequate, specialized care.

It wasn’t his first mental health diagnosis. Since age five — the year his father left home — Skyler had been diagnosed with attention deficit hyperactivity disorder (ADHD). As a teenager, he was also diagnosed with bipolar disorder, depression, and anxiety.

Still, the gender dysphoria diagnosis in 2022 had the most profound impact. That year, his mother took him to a psychiatric hospital because the sadness brought on by a recent breakup had led him to abuse drugs and alcohol. He struggled to perform basic daily tasks, such as eating or going out. Having already battled depression and anxiety, he admitted himself voluntarily, where he was told not only that he showed signs of gender dysphoria but was also diagnosed with borderline personality disorder (BPD), which affects a person’s ability to regulate emotions.

“I went into shock,” recalls Skyler, describing the moment he received both diagnoses. “It was like, ‘Two more diagnoses on top of the four I already had?’ I completely broke down inside, started having panic attacks. If that happens too often in there, they restrain you. And I thought, ‘They’re going to strap me into a straightjacket…’”

Skyler’s resilience — and that of so many other trans and nonbinary people — goes far beyond what most can imagine. Embracing an identity that is denied across so many spheres, including the public policies of U.S. President Donald Trump, who, since returning to the White House, has signed more than 20 executive orders targeting LGBT+ people and ordered the removal of health information about them from federal websites, means choosing to live authentically in the face of rejection. It means living in constant risk. And while some may not yet feel the direct effects of these policies, they could represent just the tip of the iceberg in a broader effort to dismantle civil rights for everyone.

“It’s been really hard to see how certain people want to erase our existence when we’ve always been here. Trans identity didn’t appear overnight. It’s not something that just came up now. It’s always been part of humanity,” Skyler says, running his hand over one of the tattoos on his arm — another form of self-expression.

A Life of Resistance: Surviving School Bullying

From an early age, Skyler always felt different. He never fit the stereotypes of what it meant to be a “girl,” and that made him a target of bullying — a form of harassment that affects one in every five children in Puerto Rico’s schools, but hits LGBT+ students even harder.

More than 95% have heard homophobic or transphobic remarks at school; 84% have been insulted or threatened; 42% have experienced cyberbullying; between 25 and 31% have suffered physical harassment because of their sexual orientation or gender identity; and 79% said they had been subjected to discriminatory school policies. Those figures come from the 2017 Puerto Rico School Climate Survey, one of the few studies to document the experiences of LGBT+ students on the island, conducted by the Gay, Lesbian, and Straight Education Network (GLSEN).

“My dad always dressed me like a boy. It wasn’t something that happened overnight. At school, I didn’t like hanging out with the girls; I was kind of masked [masculine, but hiding it], but I was afraid of what people would say,” Skyler recalls.

After being diagnosed with ADHD at the start of elementary school and starting on medication, he felt it became harder to adapt. “I didn’t fit in because of how I was, how I expressed myself, how I dressed,” he says. He feared speaking up about the bullying he endured, as happens in most of these cases. “They called me a tomboy. It wasn’t so much verbal aggression — it was more physical. They’d exclude me, tell me I couldn’t be there because I might ‘cross a line’ with the girls.”

From elementary school, Skyler sensed that his orientation was not heterosexual. He didn’t dare talk about it with his family, even though he has LGBT+ uncles and cousins. It was one of those subjects never discussed. He confided his deepest fears and worries only to a close friend who later came out as gay. “He was always there for me. He was one of the people who inspired me not to feel ashamed of who I am,” Skyler says with a smile about the friend who remains in his life today.

The pressure and hate Skyler endured grew so intense that he began self-harming. “I used to hurt myself physically because I was trying [to fit in]. There came a time when I changed my body, how I looked, just to be accepted,” he recalls. At 14, he decided to confide in his mother about what he was going through. She hadn’t noticed the injuries because they were hidden under his clothes.

His mother went to the school, and administrators tried to intervene, but that only led to one of the worst confrontations he ever experienced. His classmates found out he had reported his bullies. They surrounded him, cornered him, pushed him, and beat him. Skyler remembers little of the attack and prefers it that way. It’s one of many traumas he continues to work through in therapy. Shortly after the incident, his mother decided to move and transfer him to another school. The hardest part for him was leaving his friend and ally behind.

After that period, he began seeing a psychologist. He was dealing not only with bullying but also with the transition to a new school and the internal struggle of understanding his identity — just one of many battles that define adolescence. Around that time, one of his uncles died of an overdose and his older brother was murdered — two tragedies that left him reeling. It was then that, on top of his ADHD, he was diagnosed with depression, anxiety, and bipolar disorder.

LGBT+ Youth at Continuous Risk

Skyler is just one of many LGBT+ young people in Puerto Rico who face mental health challenges at higher rates than their heterosexual peers, mainly due to the hostile environments in which they are forced to live.

That reality is confirmed by the report Risk Behaviors Among Adolescents by Sexual Identity, part of the 2020–22 Youth Consultation commissioned by the Puerto Rico Mental Health and Addiction Services Administration (ASSMCA). El Nuevo Día revealed the findings in July 2024, but more than a year later, the agency has still not published the report on its website.

The Gender Investigative Unit obtained a presentation of the report, conducted by the Universidad Central del Caribe (UCC) in collaboration with researchers from the University of Puerto Rico. The study surveyed more than 145,000 students in grades seven through 12 and is the first government study to include students’ sexual orientation in a mental health analysis.

The findings reveal that students who identify as gay, lesbian, or bisexual show higher rates across every category of risk conduct, compared with heterosexual students, including substance use, depression and anxiety, oppositional defiance, aggressive behavior, conduct problems, suicidal ideation, suicide attempts, and being victims of harassment based on sexual orientation. Even students who “describe their identity in another way” exceed heterosexual students in most of those same categories.

“These problems Skyler has faced are not unique to him; many other trans and nonbinary people have experienced them before — and that doesn’t mean they caused these problems themselves,” said Ínaru Nadia de la Fuente Díaz, activist and co-founder of La Sombrilla Cuir, an organization dedicated to improving conditions for LGBT+ people in Puerto Rico. Their work focuses on supporting Black trans, queer, and nonbinary individuals living with disabilities, neurodiversity, and poverty.

“Being trans is not a mental health disorder. What causes this is discrimination,” they emphasized. “If we lived in a society that didn’t create stress factors for LGBTQ+ communities, there wouldn’t be such a statistical prevalence of these disorders among us. We live under greater stress. That’s true for all minority groups.”

Why Does the LGBT+ Community Face Greater Mental Health Challenges?

The theory of chronic stress helps explain why LGBT+ people experience more symptoms associated with mental health issues, specifically, how prolonged stress can affect someone’s well-being, mainly when they belong to a marginalized group.

Clinical psychologist Caleb Esteban Reyes, a professor at Ponce Health Sciences University (PHSU) and one of Puerto Rico’s leading researchers on LGBT+ populations, knows this concept firsthand. “Usually, heterosexual people experience common stressors, work, debt, and so on, but LGBT+ people face an additional one: the stigma tied to their sexual orientation or gender identity,” Esteban said.

For trans and nonbinary individuals, that stress can be even greater, leaving them “constantly hypervigilant,” a condition that, he noted, has worsened with the wave of anti-trans legislation introduced in recent years, both in Puerto Rico and the United States.“It’s not that having a different sexual orientation causes depression,” explained Esteban, “but rather the stress associated with belonging to a minority group. It involves a lot of discrimination, prejudice, and microaggressions. Microaggressions are nothing more than insults, jokes, and bullying. Imagine facing that every day of your life. Over time, those experiences chip away at your self-esteem.”

This constant stress not only increases the likelihood of developing mental health conditions but can also harm physical health, leading to higher rates of cardiovascular disease, hypertension, diabetes, and even cancer, Esteban added.

Social determinants of health (SDOH) are nonmedical factors that influence people’s well-being and quality of life. Just as pollution, poverty, rural or urban living, and diet affect physical and mental health, having an LGBT+ identity can also have an impact, explained Miguel Vázquez Rivera, clinical psychologist and co-founder and executive director of the True Self Foundation.

“That’s why we have to evaluate people’s data both publicly and privately,” he said, “because these are matters that can expose individuals to violence if that information is disclosed,” emphasizing the importance of privacy for study participants.

For Vázquez, another critical factor is family acceptance, or rejection, as well as having friends, support groups, or a broader community network.

A “traditional, patriarchal, and machista society” also plays a major role, said clinical psychologist Margarita Francia Martínez, a board member of the Puerto Rico Psychology  Association (APPR in Spanish), co-coordinator of the association’s Committee on Sex, Gender, and Sexual Diversity, and director of the Employee Assistance Program at United EAP Resources within the San Juan Capestrano health system.

“Unfortunately, the messages spread by many churches and certain religious sectors are demonizing,” Francia said. “They tell people, ‘If you belong to this community, you’re a sinner — you won’t go to heaven, you’ll go to hell, we have to change you, we have to fix you because you’re broken.’ Those narratives contribute to members of this community feeling marginalized and discriminated against.”

According to Francia, such religious pressures have been linked to depressive symptoms and to coping mechanisms that many people turn to, such as alcohol and substance use, “to deal with a very harsh reality.”

A 2020 report titled Faith Communities and the Well-Being of LGBT Youth, published by the Group for the Advancement of Psychiatry, found that LGBT+ youth living in non-affirming or rejecting religious contexts face higher risks of depression, anxiety, substance use, and suicide.

Lack of Data and Funding: Barriers to Understanding a Stigmatized and Undercounted Community

The lack of data and scientific research remains one of the biggest challenges when seeking funding to study issues affecting the LGBT+ community. Most existing research relies on small sample sizes, often conducted by academics or students in the field of mental health.

Another major obstacle is the absence of a national directive to collect statistics on this population. In the United States, efforts to include questions about sexual orientation and gender identity in the Census have been repeatedly blocked.

During the 2020 Census, it was President Trump who opposed adding questions about sexual orientation and gender identity. As a result, the only related item asked whether a person lived with or was married to someone of the same sex, a narrow metric that severely limits understanding of the LGBT+ population.

According to those Census figures, Puerto Rico had at least 3,016 same-sex married couples, representing 0.58% of all marriages, and about 6,215 unmarried same-sex couples living together, or 5.45% of total cohabiting couples.

Trump’s administration also pursued a broader agenda against trans people, seeking to restrict their access to health care, exclude them from the military, and even ordering the removal of gender-related terminology from scientific studies.One of the few available data points on Puerto Rico’s LGBT+ population comes from the Women and Health Center at the University of Puerto Rico, which in 2018 estimated that there are just over 74,000 people on the island who identify as LGBT+, roughly 3% of the population.

Although the Census Bureau has collected LGBT+ data in recent years, these surveys have focused on the United States and have not included Puerto Rico. One such survey, conducted during the COVID-19 pandemic and later removed from the Census website earlier this year, revealed that nearly half (47.9%) of LGBT respondents reported feeling anxious more than half the week, compared with 23.5% of non-LGBT people. Non-heterosexual respondents also reported higher rates of depression.

In addition to erasing data about LGBT+ individuals, the Census Bureau stopped producing statistics that could help protect this population’s rights, former Census Director Robert Santos acknowledged in an interview with NPR. Santos resigned in February.

If the Census collected data on this population, it would increase visibility and help shape better public policies, said Esteban. “What isn’t counted isn’t seen,” he emphasized. “Questions about sexual orientation and gender identity should be included in all government agencies to identify and document where discrimination is most prevalent.”

Last year, the U.S. Census Bureau considered including more questions about sexual orientation and gender identity, but Republican lawmakers opposed the idea. This year, those efforts have been further constrained by President Trump’s policies, which have amounted to an open war against LGBT+ people.

That means federal agencies such as the Centers for Disease Control and Prevention (CDC), which until recently gathered and published data about LGBT+ populations, may soon stop doing so altogether.

“Every time there’s news about a bill or even an election, especially given the recent results in the United States, our communities are affected because we’re afraid of what could happen,” said Vázquez. “Afraid they’ll take away our marriage rights, adoption rights, and the rights of diverse families.”

“The spread of misinformation during media tours or public hearings has serious consequences for our communities and for the political climate,” he added.

Trump has also signed two executive orders to end diversity, equity, and inclusion (DEI) programs and to eliminate federal contracts tied to those initiatives. The measures have had a direct impact on the LGBT+ community and on the funding for programs that research and support them. Many employees of those programs have already been laid off, and some have sued the Trump administration, alleging that they were targeted for holding opposing views.

“When such important information [about LGBT+ people] isn’t published, I have to base my strategies for addressing the community’s needs on what I know anecdotally, not on real data,” explained Vázquez. “That means I don’t always know how urgent certain issues are or where to focus.”

Without reliable data, he added, it’s nearly impossible to apply for funding or design effective services.

Beyond the Data: The Need for Education

For clinical psychologist Francia, it’s essential to “develop empathy and competence” among both mental and physical health professionals when working with this population. Educating teachers, students, and the public is also key to breaking the cycle of prejudice.

Through the Puerto Rico Psychology Association’s Committee on Sex, Gender, and Sexual Diversity, psychologists attend training sessions on LGBT+ issues. Francia has also created courses to be integrated into psychology curricula, an initiative that several universities have already adopted.

However, she noted, these efforts often fall short because they are limited to a single class, sometimes an elective, within a multiyear degree program. That’s rarely enough to overcome the biases many health professionals were raised with.

“In reality, it’s often just a two- or three-hour course,” said Esteban. “Those who already have prejudices don’t ask questions; they don’t change their views. So, when they graduate, they lack the tools and skills to work with the LGBT+ community and often end up treating them through the lens of their own biases.”

One of the studies led by Esteban and Francia, along with other colleagues, examined the experiences of sexual minorities in therapy services in Puerto Rico. It found that while some LGBT+ people were satisfied with their therapists, “others encountered invalidation, lack of knowledge about the LGBT+ community, homophobic or biphobic experiences, and religious beliefs used as part of psychological treatment.” Some therapists reacted with discomfort toward their patients’ sexual orientation, preventing the development of a healthy therapeutic relationship.

These experiences often extend to other medical relationships and help explain why many LGBT+ people either avoid seeking care when they have a health problem or abandon their treatments. They fear facing prejudice and discrimination.

Skyler recalls that some of his friends stop going to medical appointments because they’re misgendered or called by their “dead name” — the name a trans person was given at birth but no longer uses. He says the organizations that provide services for the community are essential because they make people feel “in the right place.”

A Glimmer of Hope

Amidst so much hostility, Skyler finds inspiration in figures like actor Elliot Page, a trans man who has spoken openly about his transition and continued to thrive in the film industry. “He’s someone I’d call a role model,” Skyler says. “He really helped me recognize myself as a trans guy.” He also admires a trans professor at his university, “someone I can truly be myself around.”

Without intending to, Skyler has become a role model for others — trans people who reach out seeking advice, support, and a glimmer of light in the darkness. “The hardest part is not having someone who listens to you,” he says. “They come to me because they feel comfortable with how I talk about my process,” without sugarcoating the challenges he’s faced, because he knows that, despite everything, he’s not giving up.

Little by little, Skyler is building a name for himself as a filmmaker, even though he’s the only trans man in his class. He co-founded a production company with other students, produces several projects, and leans on the support of friends and family.

He now participates in a trans men’s support group and is saving money for chest masculinization surgery.

“I don’t have to go back into the closet for someone who refuses to acknowledge my identity,” he says with a smile. “Trans resistance means continuing to be yourself, no matter what others say.”

This investigation was made possible through a fellowship from the Journalism Training Institute of the Centro de Periodismo Investigativo, with support from the True Self Foundation, the Coalición Orgullo Arcoíris, and Amnesty International Puerto Rico.

This translation was generated with the assistance of AI and reviewed by our editorial team to ensure accuracy and clarity.