Mental Health and Psychosocial Risk and Protective Factors Among Black and Latinx Transgender Youth Compared With Peers | Adolescent Medicine | JAMA Network Open | JAMA Network
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Table 1.  Demographic Characteristics for Black and Latinx Transgender Youth and Their Peers
Demographic Characteristics for Black and Latinx Transgender Youth and Their Peers
Table 2.  Estimated Prevalence and Means of Mental Health Symptoms and Psychosocial Factors by Peer Groups
Estimated Prevalence and Means of Mental Health Symptoms and Psychosocial Factors by Peer Groups
Table 3.  Comparison of Mental Health Symptoms and Psychosocial Factors Between Black and Latinx Transgender Youth and Peer Groups
Comparison of Mental Health Symptoms and Psychosocial Factors Between Black and Latinx Transgender Youth and Peer Groups
Table 4.  Association of Psychosocial Factors With Mental Health Symptoms in Black and Latinx Transgender Youth
Association of Psychosocial Factors With Mental Health Symptoms in Black and Latinx Transgender Youth
1.
Singh  AA.  Transgender youth of color and resilience: negotiating oppression and finding support.   Sex Roles. 2013;68:690-702. doi:10.1007/s11199-012-0149-zGoogle ScholarCrossref
2.
Becerra-Culqui  TA, Liu  Y, Nash  R,  et al.  Mental health of transgender and gender nonconforming youth compared with their peers.   Pediatrics. 2018;141(5):e20173845. doi:10.1542/peds.2017-3845PubMedGoogle Scholar
3.
Johns  MM, Lowry  R, Andrzejewski  J,  et al.  Transgender identity and experiences of violence victimization, substance use, suicide risk, and sexual risk behaviors among high school students—19 states and large urban school districts, 2017.   MMWR Morb Mortal Wkly Rep. 2019;68(3):67-71. doi:10.15585/mmwr.mm6803a3PubMedGoogle ScholarCrossref
4.
Veale  JF, Watson  RJ, Peter  T, Saewyc  EM.  Mental health disparities among Canadian transgender youth.   J Adolesc Health. 2017;60(1):44-49. doi:10.1016/j.jadohealth.2016.09.014PubMedGoogle ScholarCrossref
5.
Price-Feeney  M, Green  AE, Dorison  S.  Understanding the mental health of transgender and nonbinary youth.   J Adolesc Health. 2020;66(6):684-690. doi:10.1016/j.jadohealth.2019.11.314PubMedGoogle ScholarCrossref
6.
Alegria  M, Vallas  M, Pumariega  AJ.  Racial and ethnic disparities in pediatric mental health.   Child Adolesc Psychiatr Clin N Am. 2010;19(4):759-774. doi:10.1016/j.chc.2010.07.001PubMedGoogle ScholarCrossref
7.
Pumariega  AJ, Rogers  K, Rothe  E.  Culturally competent systems of care for children’s mental health: advances and challenges.   Community Ment Health J. 2005;41(5):539-555. doi:10.1007/s10597-005-6360-4PubMedGoogle ScholarCrossref
8.
Kann  L, McManus  T, Harris  WA,  et al.  Youth risk behavior surveillance—United States, 2017.   MMWR Surveill Summ. 2018;67(8):1-114. doi:10.15585/mmwr.ss6708a1PubMedGoogle ScholarCrossref
9.
Moore  KL, Camacho  D, Munson  MR.  Identity negotiation processes among Black and Latinx sexual minority young adult mental health service users.   J Gay Lesbian Soc Serv. 2020;32(1):21-48. doi:10.1080/10538720.2019.1677542PubMedGoogle ScholarCrossref
10.
Perez-Brumer  A, Day  JK, Russell  ST, Hatzenbuehler  ML.  Prevalence and correlates of suicidal ideation among transgender youth in California: findings from a representative, population-based sample of high school students.   J Am Acad Child Adolesc Psychiatry. 2017;56(9):739-746. doi:10.1016/j.jaac.2017.06.010PubMedGoogle ScholarCrossref
11.
Garofalo  R, Deleon  J, Osmer  E, Doll  M, Harper  GW.  Overlooked, misunderstood and at-risk: exploring the lives and HIV risk of ethnic minority male-to-female transgender youth.   J Adolesc Health. 2006;38(3):230-236. doi:10.1016/j.jadohealth.2005.03.023PubMedGoogle ScholarCrossref
12.
Olson  J, Schrager  SM, Belzer  M, Simons  LK, Clark  LF.  Baseline physiologic and psychosocial characteristics of transgender youth seeking care for gender dysphoria.   J Adolesc Health. 2015;57(4):374-380. doi:10.1016/j.jadohealth.2015.04.027PubMedGoogle ScholarCrossref
13.
Connolly  MD, Zervos  MJ, Barone  CJ  II, Johnson  CC, Joseph  CLM.  The mental health of transgender youth: advances in understanding.   J Adolesc Health. 2016;59(5):489-495. doi:10.1016/j.jadohealth.2016.06.012PubMedGoogle ScholarCrossref
14.
Clark  TC, Lucassen  MFG, Bullen  P,  et al.  The health and well-being of transgender high school students: results from the New Zealand adolescent health survey (Youth’12).   J Adolesc Health. 2014;55(1):93-99. doi:10.1016/j.jadohealth.2013.11.008PubMedGoogle ScholarCrossref
15.
Reisner  SL, Vetters  R, Leclerc  M,  et al.  Mental health of transgender youth in care at an adolescent urban community health center: a matched retrospective cohort study.   J Adolesc Health. 2015;56(3):274-279. doi:10.1016/j.jadohealth.2014.10.264PubMedGoogle ScholarCrossref
16.
Holt  V, Skagerberg  E, Dunsford  M.  Young people with features of gender dysphoria: demographics and associated difficulties.   Clin Child Psychol Psychiatry. 2016;21(1):108-118. doi:10.1177/1359104514558431PubMedGoogle ScholarCrossref
17.
Reisner  SL, Biello  KB, White Hughto  JM,  et al.  Psychiatric diagnoses and comorbidities in a diverse, multicity cohort of young transgender women: baseline findings from Project LifeSkills.   JAMA Pediatr. 2016;170(5):481-486. doi:10.1001/jamapediatrics.2016.0067PubMedGoogle ScholarCrossref
18.
Wilson  EC, Turner  C, Arayasirikul  S,  et al.  Housing and income effects on HIV-related health outcomes in the San Francisco Bay Area—findings from the SPNS transwomen of color initiative.   AIDS Care. 2018;30(11):1356-1359. doi:10.1080/09540121.2018.1489102PubMedGoogle ScholarCrossref
19.
Balzer  C, Hutta  JS, Adrián  T, Hyndal  P, Stryker  S.  Transrespect Versus Transphobia Worldwide: A Comparative Review of the Human-Rights Situation of Gender-Variant/Trans People. Transgender Europe (TGEU); 2012. Accessed February 17, 2021. https://transrespect.org/wp-content/uploads/2015/08/TvT_research-report.pdf
20.
Dinno  A.  Homicide rates of transgender individuals in the United States: 2010–2014.   Am J Public Health. 2017;107(9):1441-1447. doi:10.2105/AJPH.2017.303878PubMedGoogle ScholarCrossref
21.
Bukowski  LA, Hampton  MC, Escobar-Viera  CG,  et al.  Intimate partner violence and depression among Black transgender women in the USA: the potential suppressive effect of perceived social support.   J Urban Health. 2019;96(5):760-771. doi:10.1007/s11524-019-00355-3PubMedGoogle ScholarCrossref
22.
Sherman  ADF, Poteat  TC, Budhathoki  C, Kelly  U, Clark  KD, Campbell  JC.  Association of depression and post-traumatic stress with polyvictimization and emotional transgender and gender diverse community connection among Black and Latinx transgender women.   LGBT Health. 2020;7(7):358-366. doi:10.1089/lgbt.2019.0336PubMedGoogle ScholarCrossref
23.
Jefferson  K, Neilands  TB, Sevelius  J.  Transgender women of color: discrimination and depression symptoms.   Ethn Inequal Health Soc Care. 2013;6(4):121-136. doi:10.1108/EIHSC-08-2013-0013PubMedGoogle ScholarCrossref
24.
Johns  MM, Beltran  O, Armstrong  HL, Jayne  PE, Barrios  LC.  Protective factors among transgender and gender variant youth: a systematic review by socioecological level.   J Prim Prev. 2018;39(3):263-301. doi:10.1007/s10935-018-0508-9PubMedGoogle ScholarCrossref
25.
Szapocznik  J, Coatsworth  JD. An ecodevelopmental framework for organizing the influences on drug abuse: a developmental model of risk and protection. In: Glantz  M, Hartel  CR, eds.  Drug Abuse: Origins and Interventions. American Psychological Association; 1999:331-366. doi:10.1037/10341-014
26.
Gower  AL, Rider  GN, Coleman  E, Brown  C, McMorris  BJ, Eisenberg  ME.  Perceived gender presentation among transgender and gender diverse youth: approaches to analysis and associations with bullying victimization and emotional distress.   LGBT Health. 2018;5(5):312-319. doi:10.1089/lgbt.2017.0176PubMedGoogle ScholarCrossref
27.
Coulter  RWS, Bersamin  M, Russell  ST, Mair  C.  The effects of gender- and sexuality-based harassment on lesbian, gay, bisexual, and transgender substance use disparities.   J Adolesc Health. 2018;62(6):688-700. doi:10.1016/j.jadohealth.2017.10.004PubMedGoogle ScholarCrossref
28.
Arango  A, Cole-Lewis  Y, Lindsay  R, Yeguez  CE, Clark  M, King  C.  The protective role of connectedness on depression and suicidal ideation among bully victimized youth.   J Clin Child Adolesc Psychol. 2019;48(5):728-739. doi:10.1080/15374416.2018.1443456PubMedGoogle ScholarCrossref
29.
Gower  AL, Rider  GN, Brown  C,  et al.  Supporting transgender and gender diverse youth: protection against emotional distress and substance use.   Am J Prev Med. 2018;55(6):787-794. doi:10.1016/j.amepre.2018.06.030PubMedGoogle ScholarCrossref
30.
Resnick  MD, Bearman  PS, Blum  RW,  et al; Findings from the National Longitudinal Study on Adolescent Health.  Protecting adolescents from harm: findings from the National Longitudinal Study of Adolescent Health.   JAMA. 1997;278(10):823-832. doi:10.1001/jama.1997.03550100049038PubMedGoogle ScholarCrossref
31.
Austin  G, Polik  J, Hanson  T, Zheng  C.  School Climate, Substance Use, and Student Well-being in California, 2015-17: Results of the Sixteenth Biennial Statewide Student Survey, Grades 7, 9, and 11. WestEd; 2018. Accessed February 17, 2021. https://data.calschls.org/resources/Biennial_State_1517.pdf
32.
Bersamin  M, Coulter  RWS, Gaarde  J, Garbers  S, Mair  C, Santelli  J.  School-based health centers and school connectedness.   J Sch Health. 2019;89(1):11-19. doi:10.1111/josh.12707PubMedGoogle ScholarCrossref
33.
Stone  S, Whitaker  K, Anyon  Y, Shields  JP.  The relationship between use of school-based health centers and student-reported school assets.   J Adolesc Health. 2013;53(4):526-532. doi:10.1016/j.jadohealth.2013.05.011PubMedGoogle ScholarCrossref
34.
McNeely  CA, Nonnemaker  JM, Blum  RW.  Promoting school connectedness: evidence from the National Longitudinal Study of Adolescent Health.   J Sch Health. 2002;72(4):138-146. doi:10.1111/j.1746-1561.2002.tb06533.xPubMedGoogle ScholarCrossref
35.
Lewinsohn  PM, Rohde  P, Seeley  JR, Baldwin  CL.  Gender differences in suicide attempts from adolescence to young adulthood.   J Am Acad Child Adolesc Psychiatry. 2001;40(4):427-434. doi:10.1097/00004583-200104000-00011PubMedGoogle ScholarCrossref
36.
Miranda-Mendizabal  A, Castellví  P, Parés-Badell  O,  et al.  Gender differences in suicidal behavior in adolescents and young adults: systematic review and meta-analysis of longitudinal studies.   Int J Public Health. 2019;64(2):265-283. doi:10.1007/s00038-018-1196-1PubMedGoogle ScholarCrossref
37.
Eynan  R, Langley  J, Tolomiczenko  G,  et al.  The association between homelessness and suicidal ideation and behaviors: results of a cross-sectional survey.   Suicide Life Threat Behav. 2002;32(4):418-427. doi:10.1521/suli.32.4.418.22341PubMedGoogle ScholarCrossref
38.
Ruch  DA, Sheftall  AH, Schlagbaum  P, Rausch  J, Campo  JV, Bridge  JA.  Trends in suicide among youth aged 10 to 19 years in the United States, 1975 to 2016.   JAMA Netw Open. 2019;2(5):e193886. doi:10.1001/jamanetworkopen.2019.3886PubMedGoogle Scholar
39.
Vance  SR  Jr, Mesheriakova  VV.  Documentation of gender identity in an adolescent and young adult clinic.   J Adolesc Health. 2017;60(3):350-352. doi:10.1016/j.jadohealth.2016.10.018PubMedGoogle ScholarCrossref
40.
Deutsch  MB, Green  J, Keatley  J, Mayer  G, Hastings  J, Hall  AM; World Professional Association for Transgender Health EMR Working Group.  Electronic medical records and the transgender patient: recommendations from the World Professional Association for Transgender Health EMR Working Group.   J Am Med Inform Assoc. 2013;20(4):700-703. doi:10.1136/amiajnl-2012-001472PubMedGoogle ScholarCrossref
41.
Institute of Medicine.  Collecting Sexual Orientation and Gender Identity Data in Electronic Health Records: Workshop Summary. National Academies Press; 2013. doi:10.17226/18260
42.
University of California San Francisco Center of Excellence for Transgender Health. Recommendations for inclusive data collection for trans people in HIV prevention, care and services. Published 2009. Accessed November 1, 2020. https://prevention.ucsf.edu/transhealth/education/data-recs-long
43.
Turban  JL, King  D, Carswell  JM, Keuroghlian  AS.  Pubertal suppression for transgender youth and risk of suicidal ideation.   Pediatrics. 2020;145(2):e20191725. doi:10.1542/peds.2019-1725PubMedGoogle Scholar
44.
de Vries  AL, McGuire  JK, Steensma  TD, Wagenaar  ECF, Doreleijers  TAH, Cohen-Kettenis  PT.  Young adult psychological outcome after puberty suppression and gender reassignment.   Pediatrics. 2014;134(4):696-704. doi:10.1542/peds.2013-2958PubMedGoogle ScholarCrossref
45.
Simons  L, Schrager  SM, Clark  LF, Belzer  M, Olson  J.  Parental support and mental health among transgender adolescents.   J Adolesc Health. 2013;53(6):791-793. doi:10.1016/j.jadohealth.2013.07.019PubMedGoogle ScholarCrossref
46.
Truong  NL, Zongrone  AD, Kosciw  JG. Erasure and resilience: the experiences of LGBTQ students of color: Black LGBTQ youth in US schools. Accessed February 17, 2021. https://www.glsen.org/sites/default/files/2020-06/Erasure-and-Resilience-Black-2020.pdf
47.
Zongrone  AD, Truong  NL, Kosciw  JG. Erasure and resilience: the experiences of LGBTQ students of color: Latinx LGBTQ youth in US schools. Accessed February 17, 2021. https://www.glsen.org/sites/default/files/2020-03/Erasure-and-Resilience-Latinx-2020-0.pdf
48.
Turan  JM, Elafros  MA, Logie  CH,  et al.  Challenges and opportunities in examining and addressing intersectional stigma and health.   BMC Med. 2019;17(1):7. doi:10.1186/s12916-018-1246-9PubMedGoogle ScholarCrossref
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    Original Investigation
    Pediatrics
    March 26, 2021

    Mental Health and Psychosocial Risk and Protective Factors Among Black and Latinx Transgender Youth Compared With Peers

    Author Affiliations
    • 1Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco
    • 2Department of Epidemiology and Biostatistics, University of California, San Francisco
    • 3Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco
    JAMA Netw Open. 2021;4(3):e213256. doi:10.1001/jamanetworkopen.2021.3256
    Key Points

    Question  Do Black and Latinx transgender youth experience greater mental health symptoms than their White transgender and Black and Latinx cisgender peers?

    Findings  In this survey study of 19 780 participants, analyses of a statewide school-based survey data set indicated that Black and Latinx transgender youth had high rates of depressive symptoms and suicidality, similar to those among White transgender youth but higher than those among Black and Latinx cisgender youth.

    Meaning  These findings suggest that Black and Latinx transgender youth are susceptible to mental health symptoms that should be addressed through clinical services that consider both race/ethnicity and gender identity.

    Abstract

    Importance  Black and Latinx transgender youth experience stigma that may increase their susceptibility to mental health symptoms.

    Objective  To compare past-year mental health symptoms and psychosocial factors among Black and Latinx transgender youth, White transgender youth, and Black and Latinx cisgender youth.

    Design, Setting, and Participants  This survey study used data from the 2015-2017 Biennial California Healthy Kids Survey with a weighted sample (N = 45 269) representative of California’s secondary school population. The analytic sample (n = 19 780) included Black and Latinx transgender youth, White transgender youth, and Black and Latinx cisgender youth in the 9th and 11th grades. Data analysis was conducted from July 2020 to February 2021.

    Main Outcomes and Measures  Outcomes include past-year depressive symptoms and suicidality. Psychosocial risk factors include school-based victimization, gender-based harassment, sexuality-based harassment, and race-based harassment; protective factors include school connectedness and caring adult relationships.

    Results  The analytic sample of 19 780 participants (in 9th grade: weighted percentage, 51% [95% CI, 50% to 52%]; female participants: weighted percentage, 50% [95% CI, 49% to 51%]) included 252 Black and Latinx transgender youth (weighted percentage, 1.3% [95% CI, 1.1% to 1.5%]), 104 White transgender youth (weighted percentage, 0.7% [95% CI, 0.6% to 0.8%]), and 19 424 Black and Latinx cisgender youth (weighted percentage, 98.0% [95% CI, 97.8% to 98.2%]). For Black and Latinx transgender youth, estimated prevalence of depressive symptoms and suicidality were 50% (95% CI, 44% to 57%) and 46% (95% CI, 39% to 52%), respectively. Logistic regression models adjusted for grade, living arrangement, and reported sex indicated that compared with White transgender youth, Black and Latinx transgender youth had similar odds of depressive symptoms (adjusted odds ratio, 0.6; 95% CI, 0.4 to 1.1) and suicidality (adjusted odds ratio, 1.1; 95% CI, 0.6 to 1.8) and similar odds of all forms of harassment (eg, race-based harassment: adjusted odds ratio, 1.5; 95% CI, 0.8 to 2.6). Regression models indicated that compared with White transgender youth, Black and Latinx transgender youth had similar levels of victimization (adjusted linear regression coefficient, 0.5; 95% CI, −0.3 to 1.3) and caring adult relationships (adjusted linear regression coefficient, −0.6; 95% CI, −1.4 to 0.09) but lower levels of school connectedness (adjusted linear regression coefficient, −1.6; 95% CI, −2.9 to −0.4). With similar analyses, compared with Black and Latinx cisgender youth, Black and Latinx transgender youth had higher odds of depressive symptoms (adjusted odds ratio, 2.7; 95% CI, 2.0 to 3.7) and suicidality (adjusted odds ratio, 5.9; 95% CI, 4.3 to 8.0), higher odds and levels of all forms of harassment and victimization (eg, race-based harassment: adjusted odds ratio, 3.2; 95% CI, 2.4 to 4.5), and lower levels of school connectedness (adjusted linear regression coefficient, −2.6; 95% CI −3.3 to −1.8) and caring adult relationships (adjusted linear regression coefficient, −0.9; 95% CI −1.3 to −0.5).

    Conclusions and Relevance  In this study, Black and Latinx transgender youth had high rates of mental health symptoms, with rates comparable with White transgender youth but higher than Black and Latinx cisgender youth. Their unique pattern of psychosocial risk and protective factors for these mental health symptoms should be factored in clinical preventive services and school-based interventions to support them.

    Introduction

    Although Black and Latinx transgender youth (BLTY) are culturally and psychosocially heterogenous, they share experiences of belonging to racial/ethnic minority groups and being gender diverse, meaning their gender identity does not align with the gender assumed from their birth-assigned sex. Having dual-minority realities, they may experience both transphobia and racism, which may amplify their susceptibility to poorer mental health outcomes.1 Higher rates of depression and suicidality among the general transgender youth population compared with cisgender (ie, nontransgender) peers are well documented.2-5 Compared with White youth, Black and Latinx youth have higher rates of mood symptoms or disorders while being less likely to have access to mental health services.6-9

    There is a paucity of comparable data focused specifically on the mental health of BLTY. One study of past-year suicidality in a representative sample of Californian students10 did not find significant differences between White transgender youth and transgender youth from racial/ethnic minority groups; comparisons of other mental health symptoms were not reported. Other quantitative studies have not reported direct comparisons of mental health symptoms between BLTY and other youth cohorts that share lived experiences of gender diversity or racial/ethnic minority status.2,3,11-16 Black and Latinx transgender adults face a tremendous burden of poor outcomes, including high levels of depression and substance abuse and negative psychosocial experiences, including racial discrimination, transphobia, and physical victimization.17-23 To our knowledge, the youth antecedents to these poor adult outcomes for Black and Latinx transgender individuals have not been elucidated.

    School is an important socioecological domain where youth spend a large portion of time and have psychosocial experiences with peers and nonparental adults that influence their mental health.24,25 School-based verbal and physical harassment and bullying are prevalent among US students, with higher rates of victimization reported among transgender students.3 Research indicates that past-year victimization at school was associated with past-year suicidality among transgender youth.10 Perceived harassment due to gender, gender expression, and sexuality has been found to contribute to mental health symptoms among transgender youth.4,26,27 In contrast, school-based protective factors, such as school connectedness and caring adult relationships at school, have been found to be protective against mental health symptoms.4,28-30 To our knowledge, these potential risk and protective factors for mental health symptoms have not been examined specifically among BLTY.

    Examining associations between risk and protective factors in the context of school is critical for addressing mental health disparities experienced by BLTY. Using a large, school-based survey sample representative of the California secondary student population, our study addresses 3 specific aims. First, we compare BLTY with White transgender peers and Black and Latinx cisgender peers to document prevalence of past-year depressive symptoms and suicidal ideation. Second, we compare these peer groups to assess differences in psychosocial risk and protective factors. Finally, we examine associations between psychosocial risk and protective factors and mental health symptoms among BLTY. Based on prior research, we hypothesized that BLTY experience disparities in mental health symptoms compared with their peers. Moreover, we posited that mental health symptoms among BLTY would be associated with higher rates of victimization and different types of harassment (ie, gender-based, sexuality-based, and race-based) and fewer protective factors, such as school connectedness and caring adult relationships at school. Although BLTY are a heterogenous group, our overall goal was to provide critically needed documentation of potential disparities in mental health and psychosocial factors given BLTY risk of experiencing different forms of stigma.

    Methods
    Data Source

    Data were derived from 9th- and 11th-grade students who participated in the 2015-2017 Biennial State California Healthy Kid Survey.31 This survey is a modular, self-reported assessment administered to students biennially by WestEd with support from the California Departments of Education and Health Care Services to comprehensively capture California youth health risk and resilience data. Schools were randomly selected, and student data were weighted to reflect the California secondary school student population; the survey was administered from fall 2015 to spring 2017. In compliance with state law, opt-out (passive) parental consent was required for survey participation. If a parent did not want their child to participate, they could provide written or verbal notification to the school; students had to assent to complete the survey.31 Students excluded from the survey included 1.1% of respondents due to questionable response validity, and an additional 1.7% of respondents were excluded due to missing data in required survey modules. The final sample included 45 269 students. In the 2015-2017 survey, 7th-grade students were not asked about suicidal ideation; thus, they were excluded from this research. The California Office of Statewide Health Planning and Development Committee for the Protection of Human Subjects approved survey implementation. The University of California, San Francisco institutional review board approved this study.

    Measures
    Sociodemographic Measures

    A single item assessed both gender identity and sexual orientation: “Which of the following best describes you? (Mark All That Apply.): Heterosexual (straight), Gay or Lesbian or Bisexual, Transgender, Not sure, Decline to respond.” From these options, a dichotomous transgender variable was derived with 0 indicating cisgender for all participants who did not mark transgender and 1 indicating transgender for those who marked transgender. We derived the sexual identity variable into 4 categories: sexual minority if they selected gay, lesbian, or bisexual; heterosexual if they only checked heterosexual; unsure if they only checked not sure; and no answer if they declined to answer. Youth who selected gay, lesbian, or bisexual were categorized as sexual minority even if other answers were selected. Students were queried on their race (“What is your race?”) and Hispanic/Latino origin (yes or no). The race and ethnicity items of interest were combined into 3 mutually exclusive race/ethnicity categories: non-Hispanic/Latinx White, non-Hispanic/Latinx Black, and Hispanic/Latinx. A peer group variable was derived with the following groups: BLTY (inclusive of all transgender students who were categorized as non-Hispanic/Latinx Black and/or Hispanic/Latinx), White transgender youth (non-Hispanic White youth who selected transgender) and Black and Latinx cisgender youth (all non-Hispanic/Latinx Black and Latinx youth who did not select transgender).

    Mental Health Outcomes

    Depressive symptoms were measured using 1 dichotomous question, “During the past 12 months, did you ever feel so sad or hopeless almost every day for 2 weeks or more that you stopped doing some usual activities?” Suicidal ideation was measured using 1 dichotomous question, “During the past 12 months, did you ever seriously consider attempting suicide?”

    Psychosocial Risk and Protective Factors

    School-based victimization was assessed with a 9-item measure. Each item asked whether the participant had experienced the following in the past 12 months: “been pushed, shoved, slapped, hit, or kicked by someone who wasn’t just kidding around”; “been afraid of being beaten up”; “had mean rumors or lies spread about you”; “had sexual jokes, comments, or gestures made to you”; “been made fun of because of your looks or the way you talk”; “had your property stolen or deliberately damaged, such as your car, clothing or books”; “been threatened or injured with a weapon (gun, knife, club, etc.)”; “been threatened with harm or injury”; and “been made fun of, insulted, or called a name.” Each item’s response was dichotomized to 0 times or 1 or more times, and a count variable was created with score 0 indicating no victimization and 9 indicating high victimization.10,31 Harassment was assessed by 3 questions focused on frequency of 3 different types of harassment due to real or perceived belonging to specific social groups. For these types of harassment, students were asked, “During the past 12 months, how many times on school property were you harassed or bullied for any of the following reasons?: Your race, ethnicity, or national origin; Your gender (being male or female); Because you are gay or lesbian or someone thought you were.” Each harassment item’s response was dichotomized to 0 times or 1 or more times and coded as race-based harassment, gender-based harassment, and sexuality-based harassment, respectively.

    School connectedness was assessed using a 5-item measure that was calculated by adding the responses to each item.32-34 An example school connectedness item was “I feel close to people at this school,” with 1 indicating strong disagreement and 5 indicating strong agreement. Caring adult relationship scores were calculated from a 3-item scale for which a composite score was created by summing raw Likert scores.10,32,33 An example caring adult item was, “At my school, there is a teacher or some other adult who really cares about me,” with responses of 1 indicating not at all true and 4 indicating very much true.

    Covariates

    Sociodemographic covariates included reported sex, grade, and living arrangement. Reported sex was measured with the question, “What is your sex?” (male or female). Of note, the survey did not provide a definition of sex, sex assigned at birth, or gender identity. For living arrangement, students were asked, “What best describes where you live?” Students could select 1 of 8 categories. The variable was recoded and dichotomized to 1 of the following: a home with at least 1 parent or guardian or an alternative living arrangement (eg, other relative’s home or foster/group care).

    Statistical Analysis

    Statistical analyses were conducted starting July 15, 2020 and concluded February 5, 2021. Descriptive and multivariable analyses were conducted in Stata version 16.1 (StataCorp). All analyses used the sampling plan and sampling weights provided by WestEd using the Stata svy package. Descriptive analyses were conducted for demographic characteristics, mental health symptoms, and psychosocial factors. Because the sample was weighted, estimated prevalence was calculated for dichotomous measures, and estimated means were calculated for continuous measures. A series of logistic regression analyses were conducted to compare mental health symptoms and dichotomous psychosocial factors between BLTY and White transgender youth and between BLTY and Black and Latinx cisgender youth and to examine associations between mental health symptoms and psychosocial factors for BLTY. Linear regression analyses were used to compare peer groups on continuous psychosocial factors. All regression analyses included grade, reported sex, and living arrangement as covariates given their associations with mental health symptoms.35-38 All hypothesis testing used 2-tailed P < .05 as the significance level and 95% CIs. Cases with missing data were list-wise deleted for all analyses.

    Results

    A total of 45 269 students completed the survey, and 566 (1.3%) identified as transgender. Data from a total of 19 780 students were used for this study because they were in 9th or 11th grade and belonged to the derived peer groups, ie, BLTY, White transgender youth, or Black and Latinx cisgender youth. The 19 780 participants (9th grade: weighted percentage, 51% [95% CI, 50%-52%]; female participants: weighted percentage, 50% [95% CI, 49%-51%]) included 252 BLTY (weighted percentage, 1.3% [95% CI, 1.1%-1.5%]), 104 White transgender youth (weighted percentage, 0.7% [95% CI, 0.6%-0.8%]), and 19 424 Black and Latinx cisgender youth (weighted percentage, 98.0% [95% CI, 97.8%-98.2%]). Table 1 presents the demographic characteristics for each peer group.

    Table 2 provides prevalence estimates and 95% CIs for past-year depression symptoms, past-year suicidality, and all forms of harassment for each peer group. For BLTY, estimated prevalence of depressive symptoms and suicidality were 50% (95% CI, 44%-57%) and 46% (95% CI, 39%-52%), respectively. Table 2 also provides estimated means for each peer group for the continuous psychosocial factors of victimization, school connectedness, and caring adult relationships. Of note, higher scores for victimization indicate higher victimization, while higher scores for school connectedness and caring adult relationships indicate higher levels of these psychosocial factors.

    Mental health symptoms and psychosocial factors were compared between BLTY and White transgender youth and between BLTY and Black and Latinx cisgender youth (Table 3). There were no significant differences between BLTY and White transgender youth in terms of mental health symptoms (depressive symptoms: adjusted odds ratio, 0.6; 95% CI, 0.4 to 1.1; suicidality: adjusted odds ratio, 1.1; 95% CI, 0.6 to 1.8), victimization (adjusted linear regression coefficient, 0.5; 95% CI, −0.3 to 1.3), and forms of harassment (eg, race-based harassment: adjusted odds ratio, 1.5; 95% CI, 0.8 to 2.6). BLTY and White transgender youth had similar levels caring adult relationships (adjusted linear regression coefficient, −0.6; 95% CI, −1.4 to 0.09), but BLTY had lower levels of school connectedness than White transgender youth (adjusted linear regression coefficient, −1.6; 95% CI, −2.9 to −0.4). Compared with Black and Latinx cisgender youth, BLTY had 2.7 (95% CI, 2.0 to 3.7) higher odds of past-year depressive symptoms and 5.9 (95% CI 4.3 to 8.0) higher odds of past-year suicidality. Additionally, BLTY had higher odds of each form of harassment when compared with Black and Latinx cisgender youth, including race-based harassment (adjusted odds ratio, 3.2; 95% CI, 2.4 to 4.5). BLTY had significantly higher victimization (adjusted linear regression coefficient, 1.8; 95% CI, 1.3 to 2.3) and significantly lower levels of school connectedness (adjusted linear regression coefficient, −2.6; 95% CI −3.3 to −1.8) and caring adult relationships (adjusted linear regression coefficient, −0.9; 95% CI −1.3 to −0.5) compared with Black and Latinx cisgender youth.

    The multivariable regression models assessing associations between mental health symptoms and psychosocial factors for BLTY appear in Table 4. All forms of harassment and victimization were associated with higher odds of both past-year depression and suicidality among BLTY when controlling for demographic covariates. Neither school connectedness nor caring adult relationships were associated with mental health symptoms among BLTY.

    Discussion

    To our knowledge, this is the first study of a large population-based sample with a robust number of transgender youth, permitting investigation of differences in mental health symptoms and psychosocial risk and protective factors among BLTY compared with peers. Our approach provided a unique opportunity to compare BLTY with other youth with whom BLTY potentially share experiences of stigma and discrimination, such as harassment and bullying. BLTY were compared with White transgender youth, with whom BLTY may share experiences, such as bullying because of their gender expression or being misgendered (being referred to by incorrect names or pronouns). Additionally, BLTY were compared with Black and Latinx cisgender youth, with whom they share racial/ethnic minority status. Our study elucidates the unique realities and stigma BLTY experience within school settings.

    Compared with White transgender youth, BLTY experienced similar odds of mental health symptoms, counter to our initial hypothesis. However, the pattern of psychosocial risk and protective factors were unique for BLTY. For BLTY, victimization and harassment increased their risk of mental health symptoms, but school connectedness and caring adult relationships were not protective. These findings suggest that it may be particularly salient for pediatric clinicians to screen BLTY for school-based bullying and partner with schools to mitigate such harassment.

    Consistent with our hypothesis, compared with Black and Latinx cisgender youth, BLTY had significantly higher odds of mental health symptoms, higher odds and levels of psychosocial risk factors, and lower levels of psychosocial protective factors. Despite potentially similar experiences of racism, BLTY had higher odds of experiencing race-based harassment compared with Black and Latinx cisgender youth. This finding may point to the complex interplay of BLTY’s unique experiences with stigma or how BLTY perceive harassment in relation to their identities, including their race. For example, a BLTY student who is seen as different by peers because of both their race and gender identity may experience or perceive more harassment in general. Moreover, our findings suggest that school-based stigma experienced by BLTY affects their mental health. BLTY would benefit from pediatric clinicians evaluating their symptoms while considering stigma stemming from both race and gender identity.

    Our study suggests multiple implications. The rates of mental health symptoms for both BLTY and White transgender youth are notably higher than estimates for transgender students from the 2013-2015 survey,10 consistent with concerning national trends of students increasingly experiencing these symptoms.8 Given that suicide is a leading cause of death for adolescents, our study reinforces the need for pediatric clinicians to screen transgender youth, who are particularly at risk.8 Moreover, psychosocial supports, such as mental health and counseling services in school-based health centers and clinical settings for transgender youth, are important. The differential patterns of psychosocial risk and protective factors for BLTY compared with peer groups suggest that BLTY may require approaches in promoting their resilience while accounting for experiences of belonging to racial/ethnic minority groups and being gender diverse.

    BLTY includes youth with diverse cultural experiences. Our study grouped Black and Latinx transgender youth as an important first step in documenting and examining their experiences of belonging to racial/ethnic and gender minority groups. Also, our approach of focusing on BLTY is grounded in the poor psychosocial and health outcomes observed in their Black and Latinx adult counterparts.18,19,23 Our study reinforces the need to further examine the mental health needs of BLTY and mechanisms that lead to such marked disparities in adulthood using an intersectional stigma lens. Elucidating protective factors among transgender youth will aid in promoting a healthy transition from adolescence to adulthood. Moreover, future studies—both quantitative and qualitative—are needed to examine the nuanced differences among specific race and ethnic minority groups and to determine the culturally specific experiences of intersectionality for these groups.48 Furthermore, it is imperative that future research examine BLTY and other transgender youth of color in other socioecological domains within families, peers, and community organizations and to explore how social and environmental factors, such as food insecurity and homelessness, are associated with their mental health. Finally, future research must explore forms of resilience, such as cultural pride, spirituality, and community connectedness, as potential protective factors and as potential areas of focus to promote and support resilience in BLTY. A concerted effort from schools and pediatric medical professionals can potentially address mental health disparities experienced by BLTY through the comprehensive lens of their psychosocial experiences.

    Limitations and Strengths

    This study has limitations. First, given that this is an observational study, causality cannot be inferred among peer groups, mental health symptoms, and psychosocial factors. Additionally, this research only focused on past-year depressive symptoms and suicidality; further studies to assess severity and other mental health symptoms, such as anxiety and gender dysphoria, among BLTY are critical. Misclassification was possible given that transgender identity was not measured separately from sexual identity; instead, 1 item queried both sexual identity and gender identity. Sex was also not defined in the survey as birth-assigned sex or distinguished from gender identity. Current best practices recommend assessment of gender identity using a 2-step method querying current gender identity and assigned sex at birth.39-42 The only gender diverse option provided was transgender; youth who identify as nonbinary or gender fluid may not have selected transgender. Without additional gender diverse options, it is not possible to conduct comparisons among youth with different designated sexes at birth or gender identities; this is crucial to address in future studies and population-based survey development. Furthermore, the survey only captured youth in school and may not be generalizable to youth not attending school. Moreover, asking youth to provide attributions for why they were harassed or bullied—eg, because of their race, perceived sexuality, or gender—may create attribution bias. It is difficult, if not impossible, for people to meaningfully separate different aspects of their identities or attribute harassment they experience to a single aspect of their identity. The survey also did not capture information regarding access to gender-affirming medical treatments or parental support, which have been shown to directly affect mental health for transgender youth.43-45

    Despite limitations, our study had numerous strengths. The large, representative probability sample allowed us to make novel comparisons between relevant peer groups. Additionally, the survey assessed important psychosocial factors that allowed comprehensive assessments of BLTY resilience and risk. Finally, this survey was administered in a school setting, an important socioecological domain for youth.24,25 Schools are particularly salient targets for culturally based interventions to support BLTY. Organizations such as the Gay, Lesbian, and Straight Education Network recommend intersectional approaches in supporting Black and Latinx sexual minority and gender diverse youth. These approaches include supporting student clubs, such as Gay Straight Alliance, and ethnic/cultural clubs collaborating to address their needs and professional development for school staff that addresses unique experiences of these youth.46,47 Pediatric and adolescent medicine clinicians should be involved in school-based efforts to address the unique needs of these youth. For example, they could provide in-service training referral resources for school staff and parent-teacher organizations.

    Conclusions

    In this survey study, BLTY and White transgender youth had comparable high rates of mental health symptoms; however, BLTY had disproportionally higher rates than Black and Latinx cisgender youth. The unique pattern of psychosocial risk and protective factors for these mental health symptoms among BLTY should be factored in clinical preventive services and school-based interventions to support them.

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    Article Information

    Accepted for Publication: February 4, 2021.

    Published: March 26, 2021. doi:10.1001/jamanetworkopen.2021.3256

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Vance SR Jr et al. JAMA Network Open.

    Corresponding Author: Stanley R. Vance Jr, MD, Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, 3333 California St, Ste 245, San Francisco, CA 94118 (stanley.vance@ucsf.edu).

    Author Contributions: Drs Vance and Glidden had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Vance, Glidden, Sevelius.

    Acquisition, analysis, or interpretation of data: Vance, Boyer.

    Drafting of the manuscript: Vance, Boyer, Glidden.

    Critical revision of the manuscript for important intellectual content: Vance, Boyer, Sevelius.

    Statistical analysis: Vance, Glidden.

    Obtained funding: Vance.

    Supervision: Boyer.

    Conflict of Interest Disclosures: None reported.

    Funding/Support: This study was supported by a grant from the Robert Wood Johnson Foundation Amos Medical Faculty Development Program to Dr Vance. Additional support was provided by grant K24DA051328 from the National Institute on Drug Abuse to Dr Sevelius.

    Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Additional Information: The California Healthy Kids Survey was developed by WestEd under contract to the California Department of Education.

    References
    1.
    Singh  AA.  Transgender youth of color and resilience: negotiating oppression and finding support.   Sex Roles. 2013;68:690-702. doi:10.1007/s11199-012-0149-zGoogle ScholarCrossref
    2.
    Becerra-Culqui  TA, Liu  Y, Nash  R,  et al.  Mental health of transgender and gender nonconforming youth compared with their peers.   Pediatrics. 2018;141(5):e20173845. doi:10.1542/peds.2017-3845PubMedGoogle Scholar
    3.
    Johns  MM, Lowry  R, Andrzejewski  J,  et al.  Transgender identity and experiences of violence victimization, substance use, suicide risk, and sexual risk behaviors among high school students—19 states and large urban school districts, 2017.   MMWR Morb Mortal Wkly Rep. 2019;68(3):67-71. doi:10.15585/mmwr.mm6803a3PubMedGoogle ScholarCrossref
    4.
    Veale  JF, Watson  RJ, Peter  T, Saewyc  EM.  Mental health disparities among Canadian transgender youth.   J Adolesc Health. 2017;60(1):44-49. doi:10.1016/j.jadohealth.2016.09.014PubMedGoogle ScholarCrossref
    5.
    Price-Feeney  M, Green  AE, Dorison  S.  Understanding the mental health of transgender and nonbinary youth.   J Adolesc Health. 2020;66(6):684-690. doi:10.1016/j.jadohealth.2019.11.314PubMedGoogle ScholarCrossref
    6.
    Alegria  M, Vallas  M, Pumariega  AJ.  Racial and ethnic disparities in pediatric mental health.   Child Adolesc Psychiatr Clin N Am. 2010;19(4):759-774. doi:10.1016/j.chc.2010.07.001PubMedGoogle ScholarCrossref
    7.
    Pumariega  AJ, Rogers  K, Rothe  E.  Culturally competent systems of care for children’s mental health: advances and challenges.   Community Ment Health J. 2005;41(5):539-555. doi:10.1007/s10597-005-6360-4PubMedGoogle ScholarCrossref
    8.
    Kann  L, McManus  T, Harris  WA,  et al.  Youth risk behavior surveillance—United States, 2017.   MMWR Surveill Summ. 2018;67(8):1-114. doi:10.15585/mmwr.ss6708a1PubMedGoogle ScholarCrossref
    9.
    Moore  KL, Camacho  D, Munson  MR.  Identity negotiation processes among Black and Latinx sexual minority young adult mental health service users.   J Gay Lesbian Soc Serv. 2020;32(1):21-48. doi:10.1080/10538720.2019.1677542PubMedGoogle ScholarCrossref
    10.
    Perez-Brumer  A, Day  JK, Russell  ST, Hatzenbuehler  ML.  Prevalence and correlates of suicidal ideation among transgender youth in California: findings from a representative, population-based sample of high school students.   J Am Acad Child Adolesc Psychiatry. 2017;56(9):739-746. doi:10.1016/j.jaac.2017.06.010PubMedGoogle ScholarCrossref
    11.
    Garofalo  R, Deleon  J, Osmer  E, Doll  M, Harper  GW.  Overlooked, misunderstood and at-risk: exploring the lives and HIV risk of ethnic minority male-to-female transgender youth.   J Adolesc Health. 2006;38(3):230-236. doi:10.1016/j.jadohealth.2005.03.023PubMedGoogle ScholarCrossref
    12.
    Olson  J, Schrager  SM, Belzer  M, Simons  LK, Clark  LF.  Baseline physiologic and psychosocial characteristics of transgender youth seeking care for gender dysphoria.   J Adolesc Health. 2015;57(4):374-380. doi:10.1016/j.jadohealth.2015.04.027PubMedGoogle ScholarCrossref
    13.
    Connolly  MD, Zervos  MJ, Barone  CJ  II, Johnson  CC, Joseph  CLM.  The mental health of transgender youth: advances in understanding.   J Adolesc Health. 2016;59(5):489-495. doi:10.1016/j.jadohealth.2016.06.012PubMedGoogle ScholarCrossref
    14.
    Clark  TC, Lucassen  MFG, Bullen  P,  et al.  The health and well-being of transgender high school students: results from the New Zealand adolescent health survey (Youth’12).   J Adolesc Health. 2014;55(1):93-99. doi:10.1016/j.jadohealth.2013.11.008PubMedGoogle ScholarCrossref
    15.
    Reisner  SL, Vetters  R, Leclerc  M,  et al.  Mental health of transgender youth in care at an adolescent urban community health center: a matched retrospective cohort study.   J Adolesc Health. 2015;56(3):274-279. doi:10.1016/j.jadohealth.2014.10.264PubMedGoogle ScholarCrossref
    16.
    Holt  V, Skagerberg  E, Dunsford  M.  Young people with features of gender dysphoria: demographics and associated difficulties.   Clin Child Psychol Psychiatry. 2016;21(1):108-118. doi:10.1177/1359104514558431PubMedGoogle ScholarCrossref
    17.
    Reisner  SL, Biello  KB, White Hughto  JM,  et al.  Psychiatric diagnoses and comorbidities in a diverse, multicity cohort of young transgender women: baseline findings from Project LifeSkills.   JAMA Pediatr. 2016;170(5):481-486. doi:10.1001/jamapediatrics.2016.0067PubMedGoogle ScholarCrossref
    18.
    Wilson  EC, Turner  C, Arayasirikul  S,  et al.  Housing and income effects on HIV-related health outcomes in the San Francisco Bay Area—findings from the SPNS transwomen of color initiative.   AIDS Care. 2018;30(11):1356-1359. doi:10.1080/09540121.2018.1489102PubMedGoogle ScholarCrossref
    19.
    Balzer  C, Hutta  JS, Adrián  T, Hyndal  P, Stryker  S.  Transrespect Versus Transphobia Worldwide: A Comparative Review of the Human-Rights Situation of Gender-Variant/Trans People. Transgender Europe (TGEU); 2012. Accessed February 17, 2021. https://transrespect.org/wp-content/uploads/2015/08/TvT_research-report.pdf
    20.
    Dinno  A.  Homicide rates of transgender individuals in the United States: 2010–2014.   Am J Public Health. 2017;107(9):1441-1447. doi:10.2105/AJPH.2017.303878PubMedGoogle ScholarCrossref
    21.
    Bukowski  LA, Hampton  MC, Escobar-Viera  CG,  et al.  Intimate partner violence and depression among Black transgender women in the USA: the potential suppressive effect of perceived social support.   J Urban Health. 2019;96(5):760-771. doi:10.1007/s11524-019-00355-3PubMedGoogle ScholarCrossref
    22.
    Sherman  ADF, Poteat  TC, Budhathoki  C, Kelly  U, Clark  KD, Campbell  JC.  Association of depression and post-traumatic stress with polyvictimization and emotional transgender and gender diverse community connection among Black and Latinx transgender women.   LGBT Health. 2020;7(7):358-366. doi:10.1089/lgbt.2019.0336PubMedGoogle ScholarCrossref
    23.
    Jefferson  K, Neilands  TB, Sevelius  J.  Transgender women of color: discrimination and depression symptoms.   Ethn Inequal Health Soc Care. 2013;6(4):121-136. doi:10.1108/EIHSC-08-2013-0013PubMedGoogle ScholarCrossref
    24.
    Johns  MM, Beltran  O, Armstrong  HL, Jayne  PE, Barrios  LC.  Protective factors among transgender and gender variant youth: a systematic review by socioecological level.   J Prim Prev. 2018;39(3):263-301. doi:10.1007/s10935-018-0508-9PubMedGoogle ScholarCrossref
    25.
    Szapocznik  J, Coatsworth  JD. An ecodevelopmental framework for organizing the influences on drug abuse: a developmental model of risk and protection. In: Glantz  M, Hartel  CR, eds.  Drug Abuse: Origins and Interventions. American Psychological Association; 1999:331-366. doi:10.1037/10341-014
    26.
    Gower  AL, Rider  GN, Coleman  E, Brown  C, McMorris  BJ, Eisenberg  ME.  Perceived gender presentation among transgender and gender diverse youth: approaches to analysis and associations with bullying victimization and emotional distress.   LGBT Health. 2018;5(5):312-319. doi:10.1089/lgbt.2017.0176PubMedGoogle ScholarCrossref
    27.
    Coulter  RWS, Bersamin  M, Russell  ST, Mair  C.  The effects of gender- and sexuality-based harassment on lesbian, gay, bisexual, and transgender substance use disparities.   J Adolesc Health. 2018;62(6):688-700. doi:10.1016/j.jadohealth.2017.10.004PubMedGoogle ScholarCrossref
    28.
    Arango  A, Cole-Lewis  Y, Lindsay  R, Yeguez  CE, Clark  M, King  C.  The protective role of connectedness on depression and suicidal ideation among bully victimized youth.   J Clin Child Adolesc Psychol. 2019;48(5):728-739. doi:10.1080/15374416.2018.1443456PubMedGoogle ScholarCrossref
    29.
    Gower  AL, Rider  GN, Brown  C,  et al.  Supporting transgender and gender diverse youth: protection against emotional distress and substance use.   Am J Prev Med. 2018;55(6):787-794. doi:10.1016/j.amepre.2018.06.030PubMedGoogle ScholarCrossref
    30.
    Resnick  MD, Bearman  PS, Blum  RW,  et al; Findings from the National Longitudinal Study on Adolescent Health.  Protecting adolescents from harm: findings from the National Longitudinal Study of Adolescent Health.   JAMA. 1997;278(10):823-832. doi:10.1001/jama.1997.03550100049038PubMedGoogle ScholarCrossref
    31.
    Austin  G, Polik  J, Hanson  T, Zheng  C.  School Climate, Substance Use, and Student Well-being in California, 2015-17: Results of the Sixteenth Biennial Statewide Student Survey, Grades 7, 9, and 11. WestEd; 2018. Accessed February 17, 2021. https://data.calschls.org/resources/Biennial_State_1517.pdf
    32.
    Bersamin  M, Coulter  RWS, Gaarde  J, Garbers  S, Mair  C, Santelli  J.  School-based health centers and school connectedness.   J Sch Health. 2019;89(1):11-19. doi:10.1111/josh.12707PubMedGoogle ScholarCrossref
    33.
    Stone  S, Whitaker  K, Anyon  Y, Shields  JP.  The relationship between use of school-based health centers and student-reported school assets.   J Adolesc Health. 2013;53(4):526-532. doi:10.1016/j.jadohealth.2013.05.011PubMedGoogle ScholarCrossref
    34.
    McNeely  CA, Nonnemaker  JM, Blum  RW.  Promoting school connectedness: evidence from the National Longitudinal Study of Adolescent Health.   J Sch Health. 2002;72(4):138-146. doi:10.1111/j.1746-1561.2002.tb06533.xPubMedGoogle ScholarCrossref
    35.
    Lewinsohn  PM, Rohde  P, Seeley  JR, Baldwin  CL.  Gender differences in suicide attempts from adolescence to young adulthood.   J Am Acad Child Adolesc Psychiatry. 2001;40(4):427-434. doi:10.1097/00004583-200104000-00011PubMedGoogle ScholarCrossref
    36.
    Miranda-Mendizabal  A, Castellví  P, Parés-Badell  O,  et al.  Gender differences in suicidal behavior in adolescents and young adults: systematic review and meta-analysis of longitudinal studies.   Int J Public Health. 2019;64(2):265-283. doi:10.1007/s00038-018-1196-1PubMedGoogle ScholarCrossref
    37.
    Eynan  R, Langley  J, Tolomiczenko  G,  et al.  The association between homelessness and suicidal ideation and behaviors: results of a cross-sectional survey.   Suicide Life Threat Behav. 2002;32(4):418-427. doi:10.1521/suli.32.4.418.22341PubMedGoogle ScholarCrossref
    38.
    Ruch  DA, Sheftall  AH, Schlagbaum  P, Rausch  J, Campo  JV, Bridge  JA.  Trends in suicide among youth aged 10 to 19 years in the United States, 1975 to 2016.   JAMA Netw Open. 2019;2(5):e193886. doi:10.1001/jamanetworkopen.2019.3886PubMedGoogle Scholar
    39.
    Vance  SR  Jr, Mesheriakova  VV.  Documentation of gender identity in an adolescent and young adult clinic.   J Adolesc Health. 2017;60(3):350-352. doi:10.1016/j.jadohealth.2016.10.018PubMedGoogle ScholarCrossref
    40.
    Deutsch  MB, Green  J, Keatley  J, Mayer  G, Hastings  J, Hall  AM; World Professional Association for Transgender Health EMR Working Group.  Electronic medical records and the transgender patient: recommendations from the World Professional Association for Transgender Health EMR Working Group.   J Am Med Inform Assoc. 2013;20(4):700-703. doi:10.1136/amiajnl-2012-001472PubMedGoogle ScholarCrossref
    41.
    Institute of Medicine.  Collecting Sexual Orientation and Gender Identity Data in Electronic Health Records: Workshop Summary. National Academies Press; 2013. doi:10.17226/18260
    42.
    University of California San Francisco Center of Excellence for Transgender Health. Recommendations for inclusive data collection for trans people in HIV prevention, care and services. Published 2009. Accessed November 1, 2020. https://prevention.ucsf.edu/transhealth/education/data-recs-long
    43.
    Turban  JL, King  D, Carswell  JM, Keuroghlian  AS.  Pubertal suppression for transgender youth and risk of suicidal ideation.   Pediatrics. 2020;145(2):e20191725. doi:10.1542/peds.2019-1725PubMedGoogle Scholar
    44.
    de Vries  AL, McGuire  JK, Steensma  TD, Wagenaar  ECF, Doreleijers  TAH, Cohen-Kettenis  PT.  Young adult psychological outcome after puberty suppression and gender reassignment.   Pediatrics. 2014;134(4):696-704. doi:10.1542/peds.2013-2958PubMedGoogle ScholarCrossref
    45.
    Simons  L, Schrager  SM, Clark  LF, Belzer  M, Olson  J.  Parental support and mental health among transgender adolescents.   J Adolesc Health. 2013;53(6):791-793. doi:10.1016/j.jadohealth.2013.07.019PubMedGoogle ScholarCrossref
    46.
    Truong  NL, Zongrone  AD, Kosciw  JG. Erasure and resilience: the experiences of LGBTQ students of color: Black LGBTQ youth in US schools. Accessed February 17, 2021. https://www.glsen.org/sites/default/files/2020-06/Erasure-and-Resilience-Black-2020.pdf
    47.
    Zongrone  AD, Truong  NL, Kosciw  JG. Erasure and resilience: the experiences of LGBTQ students of color: Latinx LGBTQ youth in US schools. Accessed February 17, 2021. https://www.glsen.org/sites/default/files/2020-03/Erasure-and-Resilience-Latinx-2020-0.pdf
    48.
    Turan  JM, Elafros  MA, Logie  CH,  et al.  Challenges and opportunities in examining and addressing intersectional stigma and health.   BMC Med. 2019;17(1):7. doi:10.1186/s12916-018-1246-9PubMedGoogle ScholarCrossref
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