A Multipronged, Evidence-Based Approach to Improving Mental Health Among Transgender and Gender-Diverse Youth

A growing body of research indicates that transgender and gender-diverse (TGD) youth experience considerable mental health disparities when compared with their cisgender peers, including higher rates of depression, anxiety, and suicidality.¹ These disparities have been attributed to two processes: gender dysphoria and gender minority stress.¹ Gender dysphoria refers to distress related to one’s body developing in a way that is incongruent with one’s gender identity. It is important to note that not all TGD youth experience gender dysphoria, but that this can be a substantial source of distress for many. Gender minority stress refers to the ways in which society’s mistreatment of TGD people negatively impacts mental and physical health.¹ The gender minority stress model outlines both distal “external” factors (experiences of discrimination, rejection, and violence on the basis of gender identity) as well as subsequent proximal “internal” factors (expectations of rejection, concealment of one’s gender identity, and internalized transphobia).

Because of the multifactorial contributions to mental health disparities for TGD youth, reducing these disparities requires a multipronged approach, working on both gender dysphoria and gender minority stress. In this issue of JAMA Network Open, we find two excellent studies—one examining the treatment of physical gender dysphoria through gender-affirming medical care, and a second that aims to lessen stigma against TGD youth, with the greater goal of lessening the impact of gender minority stress.

The study by Tordoff and colleagues² demonstrates promising results in improving TGD youth mental health through the provision of gender-affirming medical care. This prospective cohort study of 104 TGD youth seeking care at a multidisciplinary gender clinic examined how receipt of puberty blockers (PB) and gender-affirming hormones (GAH) was associated with changes in depression, anxiety, and suicidality across the first year of participants receiving treatment. A substantial percentage of youth in their sample experienced high rates of mental health challenges at baseline: 57% had moderate to severe depression, 50% had moderate to severe anxiety, and 43% reported suicidal ideation or self-harm. After adjusting for potential confounders and temporal trends, the authors found that accessing PB/GAH was associated with 60% lower odds of moderate to severe depression and 73% lower odds of suicidality. No association was found between PB/GAH and anxiety. In the context of their thorough sensitivity analyses, these findings appear to be robust.

The results of this study are consistent with other recently published studies that found that those who access gender-affirming medical care during adolescence had lower odds of suicidality and other adverse mental health outcomes when compared with those who are unable to access such care.^3,4 However, medical intervention alone is not sufficient in addressing TGD youth mental health disparities. Indeed, the rate of suicidality among the Tordoff et al² sample after receiving gender-affirming care was still much higher than national rates of suicidality among youth in the US, denoting that, although gender-affirming medical care may improve mental health, other mental health determinants must be addressed as well, including gender minority stress.

Amsalem et al⁵ aimed to address this second determinant of mental health by conducting an elegant randomized clinical trial examining the efficacy of a brief video intervention on reducing transphobia and depression-related stigma and increasing help-seeking intentions among a sample of adolescents recruited online. The 110-second-long videos featured an empowered presenter speaking about their experience seeking out mental health supports. Teens randomized to the intervention groups viewed either a video of a transgender female adolescent or a transgender male adolescent. Those randomized to the control groups viewed either a video of a cisgender female adolescent or a cisgender male adolescent. In each of the videos, the presenter shared their intimate personal experiences of coping with depression (caused by gender minority stressors and gender dysphoria in the case of the transgender presenters), subsequently reaching out for help, and feeling better as a result. In their sample of 1098 youth—inclusive of TGD and cisgender youth—the authors found a significant decrease in depression-related stigma and a significant increase in treatment-seeking intentions across all trial groups. Additionally, the authors found a significant improvement in attitudes toward TGD people among those assigned to the intervention groups, demonstrating that these brief social contact–based videos were efficacious in reducing transphobia. The authors note that the next steps in their research will involve disseminating these videos more broadly, to hopefully reduce transphobia and stigma toward seeking mental health treatment on a larger scale.

Taken together, the studies by Tordoff et al² and Amsalem et al⁵ provide important evidence for interventions that improve TGD youth mental health by providing gender-affirming medical care and reducing transphobia, respectively. It is only through a multipronged approach that mental health disparities among TGD youth may be properly addressed. Another essential prong in this approach is education and training of health care professionals on topics related to pediatric gender identity. Health of TGD youth has not been a focus of professional health training programs, resulting in few clinicians feeling comfortable providing quality care to this population.⁶ It is vital that graduate and undergraduate medical education programs implement evidence-based and experiential learning programs to increase the size of the workforce competent in treating these young people.⁶ The National LGBTQIA+ Health Education Center is one resource through which clinicians can learn more. Without a properly trained workforce, it is likely that fewer youths will receive gender-affirming medical care, and uneducated clinicians themselves may contribute to gender minority stress.

Moreover, public policy is relevant to TGD youth mental health, especially in light of recent legislative initiatives that aim to prohibit access to gender-affirming care for TGD adolescents, despite such legislation being opposed by major medical organizations including The American Medical Association, The American Academy of Pediatrics, and The American Psychiatric Association.⁷ As seen in the Tordoff et al² study among others,^3,4 restricting access to gender-affirming care would be expected to have detrimental impacts on the well-being of TGD youth. Other proposed legislation likely to negatively impact the mental health of TGD youth includes bills that would prohibit their ability to use public facilities that match their gender identity and those that would prohibit their participation in sports teams that match their gender identity.⁸ It is particularly important to highlight that legislation targeting sexual and gender minority youth appears to have impacts beyond the direct impact of the legislation. For instance, Raifman et al.⁹ found that state same-sex marriage policies resulted in improved mental health for sexual minority teens, even though the participants were unlikely to be directly impacted by the legislation, given their ages. It appears clear that legislation has broader societal impacts that influence minority stress beyond the direct impacts of law. Even if antitransgender bills fail to pass, the recent discussions around them still serve to increase stigmatization of TGD youth, which is expected to worsen mental health.⁸

In conclusion, a multipronged approach inclusive of medical, social, educational, and policy-level interventions is crucial in combatting the mental health disparities seen among TGD youth. We hope that researchers will continue to contribute to this growing base of scientific evidence that provides health care professionals and policymakers key insights into how to best to support TGD youth mental health through evidence-based approaches.

Published: February 25, 2022. doi:10.1001/jamanetworkopen.2022.0926

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Dolotina B et al. JAMA Network Open.

Corresponding Author: Jack Turban, MD, MHS, 401 Quarry Rd, Palo Alto, CA 94304 (jturban@stanford.edu).

Conflict of Interest Disclosures: Dr Turban reports receiving textbook royalties from Springer Nature and expert witness payments from The American Civil Liberties Union and Lambda Legal. He has received a pilot research award for general psychiatry residents from The American Academy of Child & Adolescent Psychiatry and Its Industry Donors (Arbor & Pfizer) and a research fellowship from The Sorensen Foundation. No other disclosures were reported.