The article by Wang and colleagues in JAMA Network Open makes an important contribution to the global health literature examining the well-being of transgender youth.1 Using a school-based population survey of secondary school students in Suzhou, China, from 2019, the authors document that transgender adolescents report higher rates of anxiety, depressive symptoms, sleep problems, and suicidality when compared with their cisgender peers. The data set used by the authors includes detailed items measuring both sex assigned at birth and current gender identity, allowing the authors to accurately identify transgender youth and examine how mental health problems and potential psychosocial correlates differ within subgroups of transgender youth—a key advancement over the majority of the existing literature examining the mental health of this vulnerable population.
This work adds to the nascent but growing global literature documenting dire mental health disparities between transgender youth and their cisgender peers. Researchers have described extremely high rates of mental health problems among transgender youth. For example, using a nationwide online sample of adolescents in the United States, we recently found that 85% of transgender youth experienced suicidal ideation during their lifetime, and more than half of transgender youth reported a prior suicide attempt.2 In the current Chinese sample, risk for suicidal ideation and behavior were uniformly elevated among subgroups of transgender youth. However, in our US sample, risk for suicidal ideation and behavior was highest among transgender youth with binary identities. These findings indicate that subgroup analyses are indispensable in identifying which transgender youth are at highest risk for mental health problems and should be prioritized in future risk reduction interventions. The alarming rates of mental health problems among transgender youth may result from disproportionate experiences of psychosocial stress during childhood and adolescence, including peer victimization, parental rejection, and pervasive stigmatization of their minority gender identity.
Unfortunately, unlike the data set used by Wang et al,1 the vast majority of representative surveys of adolescents do not include the necessary measures of gender identity to accurately identify transgender youth and categorize them into meaningful subgroups. Thus, we cannot rigorously assess the mental health of transgender youth in our highest-quality surveys of adolescent health, and we still lack knowledge of accurate epidemiologic estimates of how many youth in countries around the world currently identify as transgender. Researchers recommend assessing both sex assigned at birth and current gender identity to properly identify and characterize individuals’ gender identity within health sciences research,3 as Wang and colleagues did. Furthermore, participants should be able to endorse a range of response options when their current gender identity is queried, including all common gender identities and an “other” option with free-response text entry. However, many surveys still use a single item to assess whether youth identify as transgender. For example, the Youth Risk Behavior Surveillance System, a biennial nationally representative survey of adolescent health in the United States, does not currently include rigorous assessment of gender identity. Beginning in 2017, the Youth Risk Behavior Surveillance System included a pilot item assessing transgender identity in some states and school districts, but this item only allowed participants to respond “Yes, I am transgender” or “No, I am not transgender.”4 Researchers have noted the limitations of this measurement approach. Subsequent analyses of these data have been unable to do any subgroup analyses among transgender youth because researchers cannot determine whether transgender youth were responding about their sex assigned at birth or current gender identity when endorsing either “male” or “female” to the question “What is your sex?” (the only 2 response options given).4 Inclusion of recommended measures of both sex assigned at birth and current gender identity in future representative surveys of adolescents around the globe would help to advance the empirical literature on transgender adolescent health in multiple ways.
First, use of 2-step measures would enable researchers to accurately estimate and compare the prevalence of gender minority identities across nations. As indicated by the sample used by Wang et al, a sizable minority of Chinese adolescents identify as transgender in a representative survey, and adolescents are probably identifying with minority gender identities in increasing numbers around the globe. However, current limited measurement of gender identity in representative surveys precludes accurate prevalence estimates of adolescents who identify as transgender across nations.
Second, comprehensive measures of gender identity would enable examination of psychosocial stressors and mental health across subgroups of transgender adolescents, including examining nonbinary and binary identities as well as understanding differences based on sex assigned at birth. Only with comprehensive 2-step assessments of sex assigned at birth and current gender identity can these subgroup differences be examined, and this work would shed light on potential cultural differences influencing the mental health of transgender youth in different countries. The Wang et al study found that transgender youth assigned male at birth experience the highest levels of peer victimization, but initial evidence from US studies found that transgender youth assigned female at birth reported higher peer victimization.5 These differing subgroup findings across nations could point to unique psychosocial stressors within these countries that differ based on sex assigned at birth or current gender identity. Given the substantial variation across nations in civil rights and health care available to transgender individuals,6 understanding structural and cultural influences on subgroups of transgender youth remains a key area for further inquiry.
Third, future research must also consider variability in transgender adolescents’ mental health within nations, with particular focus on how intersections of multiple identities are associated with mental health among transgender youth. For example, recent research in the United States indicates that the psychosocial context and well-being of transgender youth vary in important ways based on their racial/ethnic identity,7 likely because of culturally specific experiences of gender identity-related stressors and social support. Prior research on this topic has been limited by small and racially homogeneous samples of transgender youth, but large representative surveys of adolescents can remedy these limitations. Accurately identifying transgender youth in representative surveys would allow us to leverage these large, diverse samples to investigate experiences of transgender youth at the intersections of other marginalized identities.
The study by Wang et al adds to mounting evidence that transgender youth around the globe are experiencing alarmingly high rates of mental health problems compared with their cisgender peers. Given their extremely high risk for mental health problems, transgender youth must be prioritized in future intervention and prevention strategies designed to improve mental health among adolescents. However, our knowledge about the scope of this public health problem, including the potential psychosocial antecedents of impoverished mental health outcomes among transgender youth, continues to be inhibited by inadequate measures of gender identity in our highest-quality surveys of adolescent health. It is imperative that representative surveys of adolescents around the world implement comprehensive measures of sex assigned at birth and gender identity. This would provide robust data on the mental health and psychosocial experiences of transgender youth at the population level, affording researchers more of the tools they need to begin to develop and implement effective treatments to reduce the burden of mental health problems within this vulnerable population around the globe.
Published: October 27, 2020. doi:10.1001/jamanetworkopen.2020.23412
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Thoma BC et al. JAMA Network Open.
Corresponding Author: Brian C. Thoma, PhD, 3318 O’Hara St, Pittsburgh, PA 15213 (firstname.lastname@example.org).
Conflict of Interest Disclosures: Dr Thoma reported receiving grants from the National Institutes of Health during the conduct of the study. No other disclosures were reported.
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Thoma BC, Choukas-Bradley S. Mental Health of Transgender Adolescents Around the Globe—A Call for Comprehensive Assessment of Gender Identity. JAMA Netw Open. 2020;3(10):e2023412. doi:10.1001/jamanetworkopen.2020.23412
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