Results: Changes in Protective Factors Over Time

Protective factors are the resources and supports that buffer minority stress and promote LGBTQ+ young people’s well-being. In this section, we examine how key protective factors changed over the first year of Project SPARK, including access to mental health care; affirming environments (at home and in school); medical, legal, and social supports for gender transition (such as transgender health care and document updates); family support; and help-seeking behaviors.

Access to Mental Health Care

Access to Desired Mental Health Care

Baseline Characteristics: At the start of the study, 81% of participants reported wanting mental health care in the past, and of those, 80% reported that they had been able to access the mental health care they desired. Access to desired mental health care varied by demographic groups. Across age groups, LGBTQ+ young people ages 13-17 reported lower rates of access (75%) compared to their 18-24-year-old peers (83%). By race/ethnicity, White (85%) youth reported higher rates of access to desired mental health care than youth of color (78%). More specifically, Black/African American (65%) and Native/Indigenous (67%) youth reported the lowest rates of access. Additionally, across gender identity, transgender and nonbinary youth (84%) and gender-questioning youth (80%) reported higher rates of access to desired mental health care compared to their cisgender peers (73%).

Among TGNB participants, 43% reported being physically threatened because of their gender identity in the last year. There were differences by sexual orientation and gender identity: queer (51%), gay (46%) and bisexual (46%) respondents reported higher rates than other sexual orientation groups. Transgender girls/women (57%) and transgender boys/men (56%) reported the highest rates overall. Gender identity-based victimization did not differ by age or race/ethnicity.

Changes Over Time: During the 12-month follow-up period, 60% of participants reported receiving the mental health care they wanted within the past year. Mental health care access still varied by gender identity, with 63% of transgender or nonbinary youth reporting access to desired mental health care, compared to 59% of gender-questioning youth and 56% of cisgender youth.

Helpfulness of Received Mental Health Care

Baseline Characteristics: Among those who were able to access the care they wanted in the past, 61% found the care helpful. Helpfulness differed by age: LGBTQ+ young people ages 13-17 reported a lower rate of helpful care (51%) than those ages 18-24 (67%).

Changes Over Time: During the 12-month follow-up period, 75% of LGBTQ+ young people reported that their mental health care had been helpful within the past year. Age differences persisted, with LGBTQ+ young people ages 13-17 reporting lower rates of helpful care (65%) compared to their 18-24-year-old peers (78%).

Mental Health-Related Hospitalization

Baseline Characteristics: At baseline, 21% of LGBTQ+ youth reported any prior mental health-related hospitalization. More specifically, 10% reported experiencing involuntary hospitalization, 7% voluntary, and 4% both. Past hospitalization varied by sexual orientation, with queer (31%) and questioning (27%) youth reporting the highest rates of past hospitalization, and gay and lesbian (16%) youth reporting the lowest. Past mental health-related hospitalization also varied by gender identity, with cisgender youth (9%) reporting lower rates than their TGNB peers (28%).

Changes Over Time: During the 12-month follow-up period, 4% of LGBTQ+ young people reported being hospitalized involuntarily or voluntarily. Rates varied by gender identity: 2% among cisgender youth compared to 5% among TGNB youth. Rates of hospitalization were highest among those who were hospitalized prior to baseline (31%).

Barriers to Care

Baseline Characteristics: At the start of the study, the most common reasons for being unable to access desired mental health care in the past were:

1. Inability to afford it (43%),
2. Fear of not being taken seriously (35%),
3. Fear of involuntary hospitalization (32%),
4. Fear of talking about mental health with someone else (31%), and
5. Previous negative experiences with a therapist (30%).

Changes Over Time: One year later, three of the five most common barriers reported at baseline remained among the top reasons for not accessing care:

1. Inability to afford care (46%),
2. Fear of talking about mental health with someone else (36%),
3. Not wanting to have to get a parent/caregiver’s permission (30%),
4. Fear of not being taken seriously (30%),
5. Fear that the care would not work (26%), and
6. Insurance not covering it (26%).

Access to Transgender Health Care

Access to Puberty Blockers

Baseline: Puberty blockers are medications that pause the physical changes of puberty. At baseline, 48% of TGNB youth had not taken puberty blockers and did not want them, while 49% had not taken them but wanted to. These rates differed by gender identity. While the vast majority of transgender boys/men (86%) and transgender girls/women (88%) reported they had not taken puberty blockers but wanted to do so, most nonbinary (57%) and gender-questioning (79%) young people expressed no interest in puberty blockers. Only 1% of all TGNB young people had taken puberty blockers in the past, and 2% were taking them currently.

Changes Over Time: Interest in and use of puberty blockers did not change over time, with 1% of TGNB participants reporting taking them at some point in the follow-up year, and 2% reporting taking them at the time of their follow-up survey.

Access to Hormones

Baseline: At baseline, 58% of TGNB participants wanted gender-affirming hormones – also referred to as hormone replacement therapy – which typically include testosterone or estrogen used to support gender-related physical changes. However, only 32% were able to access them. Among individuals who had taken hormones at some point in the past, 86% were on hormones at baseline. Access differed by age: participants ages 18-24 reported a higher rate of access (51%) compared to their younger 13-17-year-old peers (12%). Access also varied by sexual orientation, with heterosexual TGNB youth reporting the highest rate of access (60%), and asexual TGNB youth reporting the lowest (25%). Rates of access also differed by gender identity, with transgender boys/men (50%) having the highest, followed by transgender girls/women (37%), nonbinary young people (26%), and gender-questioning young people (7%).

Change Over Time: At the 12-month follow-up period, 36% of TGNB youth who wanted hormones had access to them (this includes youth who already had access at baseline and those who newly gained it). Access still varied by age and sexual orientation at the 12-month mark: 12% for younger (13-17) TGNB youth versus 51% for older (18-24) TGNB youth; 60% for heterosexual TGNB youth versus 25% for asexual TGNB youth. The association between gender identity and hormone access did not change over time.

A year after baseline, 30% of TGNB individuals who did not initially have access to hormones were able to access them. Additionally, 99% of those who had access at baseline maintained access, with only 1% no longer reporting access at follow-up.

Access to Gender-Related Surgeries to Support Gender Transition

In the U.S., gender-related surgeries – when pursued – are undertaken after careful clinical evaluation and informed consent with qualified medical professionals, in line with applicable standards of care and laws. Availability and eligibility vary by age, state, and insurance. As with all findings in this report, these results are based on a convenience (non-probability) sample and are not nationally representative population estimates.

Baseline: At baseline, 45% of TGNB youth reported not having gender-related surgery and not wanting it. However, 51% wanted surgery but had not had it, and 4% had already undergone gender-related surgery. Those who had gender-related surgery were an average of 21.3 years old. These rates differed by gender identity. Most transgender boys/men (87%) and transgender girls/women (85%) had not received gender-related surgery but wanted it, while most nonbinary (51%) and gender-questioning (79%) young people expressed no interest in surgery.

Changes Over Time: One year post-baseline, 2% of TGNB participants (n = 11, average age = 20.9 years old) reported having had gender-related surgery in the past year. There was no significant change in the percentage of participants who wanted surgery but did not have it, or those who were not interested in surgery.

Access to Tools Related to Gender Expression or Transition

Baseline Characteristics: TGNB youth were asked whether they were able to access tools – such as clothing, binders, or shapewear – that support their gender expression or transition. At baseline, 85% of TGNB youth expressed interest in tools supporting gender transition, and 59% of these TGNB youth were able to obtain the tools they wanted. Of these TGNB youth, 62% could access a few tools and 38% reported being able to access most tools they wanted. Access varied by age: those ages 13-17 reported lower rates of access (47%) than their older peers, ages 18-24 (68%). Access also varied by sexual orientation, with queer TGNB youth reporting the highest rate of access (71%) and TGNB youth questioning their sexual orientation reporting the lowest (44%). Among those who wanted tools to support their gender expression, access varied by gender identity. Transgender boys/men (84%) were the most likely to have access to at least some of the tools they wanted, followed by nonbinary young people (54%), transgender girls/women (51%), and gender-questioning young people (40%).

Changes Over Time: Over the 12-month follow-up period, 65% of TGNB youth reported being able to access tools they desired related to their gender expression or transition. Access again varied by age (52% for younger TGNB youth ages 13-17 vs. 72% for older youth ages 18-24) and sexual orientation (78% among heterosexual TGNB youth vs. 53% among TGNB questioning their sexual orientation). Though the pattern of access remained the same by gender identity one year later, there were notable increases in the rates of access for nonbinary young people (60%), transgender girls/women (59%), and gender-questioning young people (45%). Among those without access at baseline, 59% obtained the tools within a year; 98% of those who already had access maintained it, with only 2% losing access.

Ability to Change Identification Documents

Baseline: At baseline, 68% of TGNB participants reported wanting to change their identification documents (e.g., driver’s license, passport) to match their gender identity. Of those, 49% were able to do so, while 52% lived in states where they were unable to change their official documents. Changing an identification document, when desired, varied by age: 18-24-year-old participants (60%) were more likely to update their documents than their younger 13-17-year-old peers (36%). Transgender boys/men (60%) and transgender girls/women (51%) were more likely to change their documents than nonbinary (42%) or gender-questioning (27%) young people.

Changes Over Time: After 12 months, the proportion of TGNB young people wanting document changes remained 68%. Among those wanting changes, 53% had updated their documents by that point, an increase of 4% over the year.  Ability to change documents still varied: young TGNB youth (35%) were less able to update their documents than their older peers (63%). By race/ethnicity, youth of color (47%) were less able to update their documents than their White (57%) peers. Further, by sexual orientation, pansexual TGNB youth (46%) reported the lowest rate of being able to update identity documents, and heterosexual TGNB youth (79%) reporting the highest. There was no significant change in access by gender identity.

Affirming Spaces

Access to Affirming Schools

Baseline: At baseline, 53% of participants in school reported that their school was LGBTQ+-affirming. This varied by age, with those ages 13-17 (48%) reporting lower rates of affirming school environments compared to their 18-24-year-old counterparts (60%). Affirming school environments also varied by sexual orientation, with gay youth (43%) reporting the lowest rate, and queer youth (67%) reporting the highest. Finally, rates varied by gender identity: cisgender youth reported the lowest affirmation (42%) compared to TGNB youth (60%).

Changes Over Time: One year later, 58% of students reported that their school was LGBTQ+-affirming.  Age differences persisted (51% for 13-17-year-olds vs. 63% for 18-24-year-olds). Affirming school environments also varied by sexual orientation, with questioning youth (46%) reporting the lowest rate, and heterosexual TGNB youth (70%) the highest. By gender identity, cisgender youth (51%) reported the lowest rate, followed by TGNB youth (63%).

Access to Affirming Home Environments

Baseline: At baseline, 51% said their home was LGBTQ+-affirming. Rates were lower for youth ages 13-17 (42%) than for those ages 18-24 (56%). Affirming home environments also varied by sexual orientation, with questioning youth (37%) reporting the lowest rate, and gay (55%) and lesbian youth (58%) reporting the highest. Finally, it varied by gender identity, with cisgender youth (53%) reporting a higher rate than TGNB youth (50%).

Changes Over Time: In the 12-month follow-up period, there was no significant change in the percentage of youth who reported that their home was LGBTQ+-affirming. Despite this lack of overall change, differences by race/ethnicity emerged, with youth of color (47%) reporting lower rates than their White (60%) peers.

Types of Support Received by Family

LGBTQ+ youth answered 12 questions about specific family supportive actions (e.g., “Supported your gender expression,” “Talked with you respectfully about your LGBTQ+ identity”). Responses were on a 4-point scale (0 = no family members engaged in the action and 4 = all of the family members engaged in the action). Scores were summed to create a total score of supportive actions taken by the family.

Baseline: At baseline – when youth reported whether family members had ever engaged in each action – the mean number of family supportive actions (on a 4-point scale) was 1.92 (standard deviation [SD] = 0.66, range: 1-4), reflecting that “some” of their family members had been supportive. The mean number of supportive actions by family members differed by demographic variables. LGBTQ+ youth ages 13-17 reported experiencing fewer supportive actions (M = 1.86) than their 18-24-year-old peers (M = 1.95). Supportive family actions also varied by race/ethnicity, with White youth reporting less support (M = 1.85) than their peers of color (M = 1.95). Additionally, these actions varied by gender identity, with TGNB youth reporting less support (M = 1.78, SD = 0.61) than cisgender youth (M = 2.11, SD = 0.68). By sexual orientation, gay and lesbian youth reported receiving the most support (M = 2.07, SD = 0.63) and asexual youth reporting the least (M = 1.71, SD =0.62).

Changes Over Time: One year later – based on support received during the past 12 months – the mean number of family supportive actions was not significantly different to that at baseline at 1.87 (SD = 0.69, range: 1-4). The mean number of supportive actions by family members in the past year still differed by demographic variables. By gender identity, TGNB youth reported fewer supportive actions (M = 1.75, SD =0.64) than cisgender youth (M = 2.06, SD = 0.72). By sexual orientation, gay and lesbian youth reported the most support (M = 2.03, SD = 0.69) and asexual youth reported the least (M = 1.63, SD =0.67).

Gender Euphoria

Baseline characteristics: Gender euphoria captures how affirmed and comfortable young people feel in expressing their gender and being recognized for who they are. Following the Trans Youth CAN! Guide (Bauer et al., 2021), each participant’s score was calculated as the average of 11 items rated 1–5, yielding a 1–5 scale in which higher values indicate greater gender positivity. At baseline, the full sample of LGBTQ+ young people reported a mean gender positivity score of 3.17 (SD = 0.83). LGBTQ+ young people ages 18-24 reported higher mean gender positivity scores compared to those ages 13-17 (M = 3.26, SD = 0.84 vs. M = 3.00, SD = 0.79). There were differences by sexual orientation as well. Heterosexual transgender young people reported the highest mean gender positivity scores (M = 3.38, SD = 0.92) while asexual young people (of all gender identities) reported the lowest mean gender positivity scores (M = 2.98, SD = 0.76).

Gender positivity scores also varied by race/ethnicity. Indigenous/Native LGBTQ+ young people reported the lowest mean gender positivity scores (M = 2.73, SD = 0.74) and Asian American/Pacific Islander young people reported the highest (M = 3.43, SD = 0.82).

There were differences across gender identity, as well: cisgender girls/women reported the highest mean gender positivity scores (M = 3.27, SD = 0.80) and transgender girls/women reported the lowest mean gender positivity scores (M = 2.94, SD = 0.94).

Changes over time: Across the one-year period, mean gender positivity increased by 0.15 points on average.

Help-seeking Behaviors

Baseline characteristics: At baseline, 27% of participants reported that in the past 12 months they had not sought help from anyone when experiencing suicidal thoughts. There were no differences in not seeking help by age, race/ethnicity, sexual orientation, or gender identity.

When support was sought for suicidal thoughts, the main sources of support were:  a friend (45%), a mental health professional (32%), an intimate partner (31%), a phone helpline (23%), a parent or caregiver (16%), another relative (10%), a doctor or general practitioner (6%), and a religious leader (1%).

Help-seeking from a parent showed no demographic differences. Help-seeking from a friend differed by gender identity, with transgender girls/women reporting the highest rates of seeking help from friends (56%) and gender-questioning young people reporting the lowest (33%). Seeking help from a mental health professional differed by age: youth ages 18-24 reported higher rates of seeking help from a mental health professional when experiencing suicidal thoughts compared to their LGBTQ+ peers ages 13-17 (38% vs 27%, ꭓ=7.35). There were no differences across race/ethnicity, sexual orientation, or gender identity.

Changes over time: Over the follow-up year, the proportion of LGBTQ+ youth who sought help from no one when experiencing suicidal thoughts fell from 27% to 20%.  Help-seeking during suicidal thoughts in the past year rose across nearly every source: intimate partners (31 % → 62 %), friends (45 % → 73 %), parents (16 % → 35 %), other relatives (10 % → 28 %), mental health professionals (32 % → 64 %), phone helplines (23 % → 41 %), and doctors/general practitioners (6 % → 11 %). There was no change in those who went to a religious leader for support when experiencing suicidal thoughts.