Transgender people whose identity documents match their gender identity have better mental health than those whose IDs do not match, according to a study by Drexel University researchers.

The study, which analyzed 22,286 responses to the 2015 U.S. Transgender Survey using the Kessler Psychological Distress Scale, is the first in the country to examine the relationship between IDs and mental health. It was published in the Lancet Public Health Journal this month.

Among transgender people whose IDs did not match their gender presentation, a third experienced being denied access to services, harassment, or violence, or all three. IDs are required to access health care, housing, education, employment, immigration, travel, security clearances, social service applications and many more services and resources.

“Many people take for granted having identity documents that they can use in daily life without thinking about it too much,” said Ayden Scheim, an assistant professor in epidemiology and biostatistics in the Dornsife School of Public Health at Drexel and the lead author of the paper. “For trans people, if their ID conflicts with how they identify, they can be outed and subjected to stigma and discrimination.”

According to the survey, only 11% of transgender people in the United States have their preferred name and gender marker on all of their IDs and official records. That group experienced a 32% reduction in serious psychological distress and a 22% to 25% reduction in suicidal ideation and suicide planning when compared with the group whose IDs did not match their gender.

The requirements for name and gender changes on IDs vary by state, but most require a court-ordered name change. To begin the process, many states require medical letters or proof of gender-affirming surgeries, which can be a big obstacle to some transgender folks. In Pennsylvania, people must submit a letter from their physician stating that they have had clinical treatment for gender transition in order to change the gender marker on a birth certificate.

“When you really sit down and think about the day-to-day impacts as having their documents not match, it makes a lot of sense,” Scheim said. “There might also be positive mental-health impacts in terms of self-esteem. You’re affirmed in social interactions and interactions with institutions, and you’re not having people question you.”

Transgender people are one of the groups most at risk for poor mental health, research shows. The Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System shows that more transgender adults experienced poor mental health in the last 30 days than cisgender adults. More than 50% of transgender adults experience clinical depression, while 30% of cisgender adults do. The lifetime prevalence of suicide attempts among transgender adults is estimated to be 32% to 41%, compared with less than 9% for the general population, and between 10% and 20% for lesbian, gay and bisexual adults.

“It’s really notable that only 11% of trans people had all of their IDs matching their name, gender, and yet that group saw the biggest reductions in psychological distress in suicide ideation and suicide planning,” Scheim said. “This is something that’s really easy to change, policy-wise.”