Transgender and Gender-Diverse Adolescents’ Experiences of Violence, Depression, Anxiety, and Suicidal Ideation in the People’s Republic of China | Adolescent Medicine | JAMA Network Open | JAMA Network
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Public Health
September 6, 2019

Transgender and Gender-Diverse Adolescents’ Experiences of Violence, Depression, Anxiety, and Suicidal Ideation in the People’s Republic of China

Author Affiliations
  • 1USC Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles
JAMA Netw Open. 2019;2(9):e1911068. doi:10.1001/jamanetworkopen.2019.11068

Transgender and gender-diverse individuals are those whose gender identity (ie, the deep-seated internal sense of gender as a man, woman, or otherwise) differs from that which is socially expected of them given the sex assigned to them at birth. To my knowledge, the scant research literature in the behavioral health sciences on transgender and gender-diverse communities is almost exclusively on populations in the United States and Europe, with a few studies coming from other countries that also have large populations of people with European ancestry (eg, New Zealand). I commend Peng et al1 for conducting their ground-breaking research in the People’s Republic of China (hereafter China). They found that nearly all of the respondents (92.8%) reported at least 1 type of family-based harassment (eg, verbal and physical abuse, economic control), and more than three-quarters (76.5%) reported at least 1 experience of school-based harassment (eg, verbal or cyber bullying, social isolation). Almost half of the study participants (43.8%) were at risk for major depressive disorder, and more than one-third (37.4%) were at risk for an anxiety disorder. Nearly half of the study participants (47.8%) reported experiencing suicidal ideation in their lifetime.1 Transgender and gender-diverse adolescents in the sample reporting abuse, bullying, or neglect had increased odds of suicidal ideation in their lifetime. These data are concerning, although they are not surprising.

The study by Peng et al1 is in line with studies from other countries that have suggested that transgender and gender-diverse adolescents experience elevated rates of poor mental health and many forms of violence. A 2014 study using a nationally representative sample of high school–aged adolescents in New Zealand found that transgender and gender-diverse adolescents reported elevated depressive symptoms, greater likelihood of suicidal ideation, and more school-based harassment compared with their cisgender (ie, neither transgender nor gender-diverse) peers.2 Furthermore, similar to the study by Peng et al1 in which about 60% of the sample reported being forced by family to modify their gender expression and avoidance by family owing to their gender identity, the New Zealand–based study2 found that transgender and gender-diverse students had lower odds than their cisgender peers of feeling that their parents cared about them.

The exact causes of recorded elevated rates of poor mental health among transgender and gender-diverse youth have not been fully established, and more research is needed; however, it has become increasingly clear that the negative behavioral health trends among this group are likely attributable to social discrimination owing to their gender identity, such as the harassment by family members and in schools reported in the study by Peng et al.1,3 Targeted discrimination owing to gender identity can tax an individual’s positive evaluations of themselves and may lead to self-hatred (eg, internalized transphobia), which is thought to affect risk of depression, anxiety, and suicidal ideation in youths and adults. This conceptual pathway is termed the gender minority stress framework, and it is a valuable conceptual model for framing future research and interventions to uplift transgender and gender-diverse populations around the world. Research with transgender and gender-diverse people that attempts to understand the mechanisms by which social discrimination creates poor mental health could be of particular value for identifying specific clinical and structural factors for intervention.

The study by Peng et al1 noted limitations, but these do not take away from the study’s overall importance in establishing a research agenda to uplift transgender and gender-diverse people who face structural and stigma-based disadvantages. Some of these limitations included the relatively small cross-sectional convenience sample enrolled using a self-administered survey via the internet in a country where many areas lack access to the internet. Research using rigorous research methods conducted in partnership with transgender people,4 for example, by using community advisory boards, is essential to the future of improved health for transgender and gender-diverse people across varying cultural contexts around the world. Some of these research practices can be easily implemented. For example, researchers examining the experiences of transgender and gender-diverse people should follow best-practice guidelines for the assessment of sexual orientation, gender identity, and gender expression.5 A 2019 study by Kattari et al6 highlighted the importance of assessing and analyzing experiences at the intersection of sexual orientation (eg, lesbian, gay, bisexual, queer) and gender identity. Further, methods that access representative samples of transgender and gender-diverse people, who are considered difficult to reach by researchers owing to their marginalized social positioning, require the use of novel and promising data collection methods, such as respondent-driven sampling, to abstract the most reliable estimates of population experiences.7 The study by Peng et al1 used a combination of these methods (ie, respondent-driven, snowball, and convenience sampling) to make their sample more reliable in developing an understanding of mental health and school- and family-based experiences of transgender and gender-diverse people in China.

All this suggests that while continued research on the causes of negative behavioral health outcomes are needed, there is an equal need for interventions to improve the current lives of transgender and gender-diverse people. Such interventions in China, New Zealand, the United States, and elsewhere should seek to improve the mental health of transgender and gender-diverse people and, given the finding in the study by Peng et al1 that harassment was significantly associated with suicidal ideation, should include efforts to reduce the likelihood that transgender and gender-diverse youths encounter family- and school-based harassment. Existing guidance from researchers and community organizations recommend interventions that seek to educate and promote acceptance of human gender diversity by society and its institutions (eg, schools, health clinics and hospitals, places of employment). Potentially effective structural-level interventions to improve the lives of transgender and gender-diverse adolescents include school-based policy changes that direct administrators, teachers, and staff to embrace and protect transgender and gender-diverse students. Examples of such interventions include the establishment of school groups for transgender and gender-diverse youth (eg, a lesbian, gay, bisexual, transgender, and queer student coalition) and the enumeration of policies that guide and promote safe and positive gender transitioning in school.3

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Article Information

Published: September 6, 2019. doi:10.1001/jamanetworkopen.2019.11068

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Klemmer CL. JAMA Network Open.

Corresponding Author: Cary L. Klemmer, MSW, USC Suzanne Dworak-Peck School of Social Work, University of Southern California, 669 W 34th St, MRF 214, Los Angeles, CA 90089-0411 (

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Kattari  SK, Atteberry-Ash  B, Eugene Walls  N, Rusow  J, Klemmer  C, Kattari  L.  Differential sexual behavior experiences of LGBQ and transgender/nonbinary young people in Colorado [published online June 19, 2019].  Youth Soc. doi:10.1177/0044118X19854783Google Scholar
Bauer  GR, Scheim  AI, Pyne  J, Travers  R, Hammond  R.  Intervenable factors associated with suicide risk in transgender persons: a respondent driven sampling study in Ontario, Canada.  BMC Public Health. 2015;15(1):525. doi:10.1186/s12889-015-1867-2PubMedGoogle ScholarCrossref
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