Historically, any identification with activities or expression outside of strict gender roles that were expected to align with one’s sex assigned at birth (SAB) have been frowned upon. Today, there is recognition of the differences between concepts such as gender roles, SAB, gender identity, and gender expression. Youth who do not identify with their SAB may identify as transgender and/or nonbinary (TGNB). TGNB individuals experience higher rates of mental health challenges, with anxiety and depression experienced at nearly 10 times the rate of their cisgender peers (Becerra-Culqui et al., 2018). Furthermore, according to The Trevor Project’s 2019 National Survey on LGBTQ Youth Mental Health, 54% of transgender and non-binary youth reported seriously considering suicide in the last year, and 29% made a suicide attempt (The Trevor Project, 2019a). Building on decades of empirical evidence linking minority stress to health disparities, research has recently begun to elucidate the relationship between chronic discrimination against TGNB individuals and the mental health disparities they experience (Hatzenbuehler, 2009, Testa et al., 2017).
While minority stress increases these mental health disparities — including the risk of anxiety, depression, and suicidality — among TGNB individuals, gender-affirming care has been shown to improve mental health. Gender-affirming care for TGNB youth may involve social, medical, and legal aspects. Gender-affirming care has been shown to reduce suicide ideation and attempts in transgender individuals, along with social support, familial support, and reduction of discrimination (Bauer et al., 2015, The Trevor Project, 2019b). This brief will review the empirical evidence on psychosocial outcomes related to gender-affirming care for youth with implications for how TGNB youth can be supported.
Social transition is the primary affirmative care intervention for prepubertal TGNB youth and involves encouraging them to present in the way that feels most genuine to them. It may also include the use of a different name or pronouns aligned with their gender identity.
The evidence for social transition builds upon what is already known regarding positive family and social support; that is, family acceptance of LGBTQ youth is associated with positive mental health (Ryan et al., 2010), whereas higher rates of family rejection are associated with the opposite. For example, young adults from highly accepting families attempt suicide at significantly reduced rates compared to those in low accepting families (31% versus 57%) (Ryan et al., 2009).
TGNB children who have socially transitioned demonstrate comparable levels of self-worth and depression as non-TGNB children. This has been demonstrated in research that asks parents to report on their child’s mental health (Olson et al., 2016) as well as asking the youth themselves (Durwood et al., 2017). Although TGNB youth who have socially transitioned report slightly higher levels of anxiety compared to non-TGNB peers (Durwood, et al., 2016; Olson et al., 2016) the fact that self-worth and depression outcomes are equal is powerful due to the significantly worse mental health outcomes experienced by non-supported TGNB youth.
Further, research has specifically shown lower suicidal ideation and suicidal behavior when a TGNB youth’s chosen name is consistently used. The more contexts that it is used (home, school, work, and friends), the stronger the effects (Russell et al., 2018). Usage of chosen name resulted in a 29% decrease in suicidal ideation and a 56% decrease in suicidal behavior for each additional context in which it was used.
Medical affirming care can include treatments that postpone physical changes as well as treatments that lead to changes that would affirm one’s gender identity. Pubertal suppression, commonly known as “puberty blockers,” is used to delay the onset of puberty, and hormone therapy is used to promote gender-affirming physical changes. Pubertal suppression and hormone therapy are two components of patient-centered care for youth that have been supported by empirical evidence (WPATH, 2012).
Pubertal suppression may be used for youth currently in the early stages of puberty who are experiencing distress over their sex assigned at birth and their gender identity. Delaying puberty can provide youth more time to explore their gender identity without the development of unwanted physiological changes and may also serve as a precursor to gender-affirming hormone therapy (GAHT). GAHT allows TGNB youth to develop physical characteristics that align with their gender identity. GAHT is specifically appropriate for TGNB youth who have already entered puberty or following a period of pubertal suppression.
Pubertal suppression is associated with decreased behavioral and emotional problems as well as decreased depressive symptoms (de Vries et a., 2011). Prior to pubertal suppression, 44% of youth experienced clinically significant behavioral problems; however, after an average of two years of pubertal suppression only 22% experienced them. And 30% experienced clinically significant emotional problems prior to pubertal suppression compared to 11% after two years of care. Pubertal suppression has also been shown to significantly improve overall psychological functioning after only six months of care (Costa et al., 2015). Additionally, transgender individuals who desired and received pubertal suppression as adolescents have significantly lower lifetime suicidal ideation compared to those who desired but did not receive it (Turban et al., 2020).
Research on GAHT for youth demonstrates positive effects on body image and overall psychological well-being as well as reduced suicidality. GAHT decreases both emotional and behavioral problems (de Vries et al., 2014), similar to what is seen in pubertal suppression. Recent research has also shown that GAHT decreases suicidality, with one study of transgender youth demonstrating that after approximately 1 year of treatment the average level of suicidality was 1/4th what it was before treatment (Allen et al., 2019).
Affirmative legal interventions allow a young person to change their name and/or gender on their legal documents, including their birth certificate, driver’s license, passport, and social security card. The laws on changing birth certificates or driver’s licenses vary on a state by state basis, whereas changes to a passport or social security card are determined at a federal level.
Early research with TGNB adults has shown that a legal name change may be considered a structural public health intervention that improves access to care and increases socioeconomic stability (Hill 2018). Research has also shown that discriminatory social policies, such as same sex marriage bans, directly contribute to adverse mental health outcomes (Hatzenbuehler 2010). Although more research on the psychosocial benefits of legal interventions for TGNB youth is necessary, existing research on affirming social transitions provides support for the expected psychosocial benefits of legal support for TGNB identities.
There have been many opponents to gender-affirming care for TGNB youth. Some of the hesitance regarding gender-affirming care may be due to a misunderstanding of the causes of mental health challenges in TGNB individuals. This brief demonstrates why such care is not only ethical, but medically-necessary (WPATH, 2016). Further, regret is low for gender-affirming care interventions, and a study of 55 transgender adults who had received gender-affirming care as adolescents showed that not one individual experienced regret (de Vries et al., 2014).
As the evidence for gender-affirming care grows, medical and mental health organizations are increasingly shifting to support it. Many major medical organizations have guidelines for working with transgender individuals centered around respect for the patient and shared decision making (American Psychological Association, 2015; American Psychiatric Association, 2018), with some organizations releasing statements explicitly opposing any efforts to prevent access to gender-affirming care. (American Academy of Child and Adolescent Psychiatry, 2019). Given the well-documented risks of negative mental health and suicidality outcomes among TGNB, it is necessary that those serving TGNB provide care that is patient-centered, affirming, and evidence-based.
Although available data solidly highlight the psychosocial benefits of gender-affirming care for TGNB youth, there remains a critical need for additional physical and mental health outcomes data, including through longitudinal studies. Large-scale data collection will better elucidate the risks and benefits of individual treatment options, so that youth and their families can make evidence-informed decisions regarding care. There is also a need for research on how legal and policy decisions about TGNB individuals impact their mental health and well-being. Such data will be crucial to advocacy efforts aimed at supporting TGNB youth.
The Trevor Project is committed to promoting the wellness of all LGBTQ young people and supports gender-affirming care as an evidence-based practice to support TGNB youth. Trevor’s advocacy team is dedicated to fighting against anti-TGNB policy positions and for policies that ensure that young people have access to beneficial gender-affirming care. Our research team conducts studies which seek to improve our understanding of ways to end suicide and reduce disparities for LGBTQ youth, including ways to better support TGNB youth. Our public education programs aim to further increase knowledge of ways to support TGNB youth in schools and communities. And our 24/7 crisis services via call, text, or chat ensure that every young person who reaches out to us receives the help they need in that moment.
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WPATH (2016). Position Statement on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage in the U.S.A. Available at: https://www.wpath.org/newsroom/medical-necessity-statement Accessed January 1, 2020.
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