The Mental Health and Well-being of LGBTQ Youth who are Intersex

Much of the current research on intersex communities focuses on medical treatment — and lumps all intersex youth in with trans, nonbinary, and other gender variant youth — leaving findings specific to intersex young people, and their mental health, largely unknown. This report uses data from a national sample of over 1,000 intersex youth ages 13-24 and grows our understanding of the mental health and well-being of this often overlooked group.
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EXECUTIVE SUMMARY

Intersex is an umbrella term meant to describe variations in physical sex traits or reproductive anatomy that are present at birth or emerge spontaneously later in life. Due to a lack of systematic data collection as well as a history of medical erasure, the prevalence of intersex traits is not concluvsively known, but experts have estimated that intersex people are make up about 2% of live births. The medicalization, pathologization, and medical (mis)treatment of intersex variations has left many individuals with negative physical and emotional consequences of procedures done without individual informed consent. Presently, much of the research on intersex communities remains focused on medical treatment and centers very little on the mental health and well-being of intersex individuals. Furthermore, when intersex youth are included in this type of research, they are often combined into a larger sample including transgender, nonbinary, and other gender variant youth, leaving findings specific to intersex youth largely unknown. This report grows our understanding of the mental health of LGBTQ youth who are intersex by using data from a national sample of more than 1,000 intersex youth ages 13–24 who participated in The Trevor Project’s 2021 National Survey on LGBTQ Youth Mental Health.

Key Findings

Intersex youth are diverse across many identities and experiences

  • Nearly half of intersex youth in our sample were people of color (Asian/Pacific Islander, Black, Hispanic/Latinx, Native/Indigenous, or multiracial), similar to our overall sample
  • 69% of intersex youth endorsed a multisexual identity (i.e., those who are attracted to more than one sex and/or gender such as bisexual or pansexual)
  • 58% of intersex youth identified as transgender or nonbinary or were questioning their gender identity

The rates of mental health challenges among intersex youth are disproportionately high compared to LGBTQ youth who are not intersex

  • 48% of intersex youth seriously considered suicide in the past 12 months, compared to 41% of LGBTQ youth who are not intersex
  • 19% of intersex youth attempted suicide in the past 12 months, compared to 14% of LGBTQ youth who are not intersex
  • 2 out of 3 intersex youth reported symptoms of major depressive disorder in the past two weeks

LGBTQ youth who are intersex are exposed to a number of harmful experiences that relate to suicide risk

  • 18% of intersex youth reported being subjected to conversion therapy, with 12% reporting the efforts were aimed at changing their gender identity
  • 2 out of 3 intersex youth reported that someone tried to convince them to change their sexual orientation or gender identity
  • Intersex youth reported twice the rate of having had a mental or physical healthcare provider attempt to convince them to change their sexual orientation or gender identity compared to LGBTQ youth who are not intersex
  • 1 in 4 intersex youth reported having experienced physical harm based on their sexual orientation or gender identity in the past year, including 32% of transgender and nonbinary intersex youth

Acceptance is a strong protective factor for reducing suicide risk for intersex youth

  • Intersex youth with at least one parent who was accepting of their sexual orientation had 55% lower odds of attempting suicide in the past year
  • Intersex youth with at least one parent who was accepting of their gender identity had 46% lower odds of attempting suicide in the past year
  • Intersex youth who have supportive friends report lower rates of attempting suicide in the past year
  • Transgender and nonbinary intersex youth whose pronouns were respected by all of the people they live with had 64% lower odds of reporting a suicide attempt

Methodology Summary

A quantitative cross-sectional design was used to collect data using an online survey platform between October and December 2020. An analytic sample of nearly 35,000 youth ages 13–24 who resided in the United States was recruited via targeted ads on social media. All youth were asked, “Some people are assigned male or female at birth but are born with sexual anatomy, reproductive organs, and/or chromosome patterns that do not fit the typical definition of male or female. This physical condition is known as intersex. Are you intersex?” with options: no, yes, and decline to answer. The current analyses include the 1,132 youth who responded they were intersex.

Recommendations

While historical medicalization and marginalization suggests that youth who are intersex might be at greater risk for poor mental health outcomes, intersex youth are often left out of important mental health research. Our findings show that intersex youth report rates of mental health challenges that are often higher than those reported by LGBTQ youth who are not intersex. Intersex youth also experience higher rates of suicide risk factors, such as increased rates of being exposed to conversion therapy and attempts to change their sexual orientation or gender identity. Not surprisingly, given the impact of holding multiple marginalized identities, intersex youth who are transgender, nonbinary, and/or multisexual often report higher rates of poor mental health and suicide risk. We must specifically address intersex youth in mental health research to better understand the specific risks and protective factors related to their lived experience, with harm prevention and affirming intervention in mind. With our findings showing just how important acceptance is for intersex youth, inclusion and policy efforts must consider intersex youth and their unique needs and must refrain from relying on assumptions of binary sex or the relationship between bodily traits and gender.

BACKGROUND

Intersex (sometimes referred to as variations in sex characteristics[1]) is an umbrella term meant to describe a wide range of variations in physical sex traits or reproductive anatomy that may cause bodies to differ from normative expectations for “male” or “female.” When people are born, they are usually immediately categorized as either a “boy” or a “girl,” typically based only on a visual inspection of external genitalia. This categorization is problematic as it inaccurately assumes that sex and gender are binary characteristics and arevisually apparent at birth. It is even more problematic when it comes to people who are born with intersex traits.

Human bodies are naturally varied, and intersex traits reflect natural variations in the development, appearance, and/or function of physical characteristics that we associate with someone’s sex. The tissues that make up genitals are homologous, meaning they are in the same place on the body and have the same tissue structure, and only with certain signals (such as from genes and hormones) do they become different. Beginning around the 6th week of pregnancy, a gonad will develop into a testis or ovary (or an ovotestis, or undifferentiated “streak” gonad), while the genital tubercle develops into a penis or a clitoris (or a size between that of a typical penis or clitoris) beginning around nine weeks of pregnancy, depending in part on the presence, or lack, of testosterone. The absence of these cues, insensitivity to some of them, or differences in the XY chromosomes may all result in intersex traits. This could be someone who is born appearing to be female, but having internal testes and XY chromosomes. It may also be someone who is born with genitals that are somewhat in-between normative expectations, for example a noticeably large clitoris or small penis. When someone is born with “ambiguous” external genitalia, the intersex trait is typically diagnosed at birth. However, sometimes a person is not found to be intersex until they reach the age of puberty and fail to menstruate or develop normative male genitalia, or when they are unable to conceive. It is also true that an intersex condition may not be discovered until an autopsy, and some people live and die never knowing they are intersex. According to interACT: Advocates for Intersex Youth, medical professionals have identified over 40 different medical terms for the different ways sex anatomy might develop (interACT, 2021b). Human body parts are naturally varied and as the Intersex Society of North America wrote, “Nature doesn’t decide where the category of ‘male’ ends and the category of ‘intersex’ begins, or where the category of ‘intersex’ ends and the category of ‘female’ begins. Humans decide. (Intersex Society of North America, 2008).” In other words, it is people, usually doctors, who determine how small a penis has to be or how large a clitoris has to be or how uncommon the combinations must be before a person is considered intersex.

Nature doesn’t decide where the category of ‘male’ ends and the category of ‘intersex’ begins, or where the category of ‘intersex’ ends and the category of ‘female’ begins. Humans decide

Intersex Society of North America

[1] Despite the use of the terms “disorder of sexual development” and “difference in sex development” (both abbreviated “DSD”) by many medical professionals, intersex is the preferred term among intersex advocates and, as such, will be used throughout this report. The phrases “intersex traits,” “intersex variations,” and “variations in sex characteristics” are considered interchangeable.

Given the lack of standardized data collection efforts and the lack of consensus regarding which variations to classify as intersex traits, estimates of the prevalence of intersex people vary widely, and definitive figures are difficult to come by. As mentioned, not only are people generally assigned male or female based solely on external genitalia, but intersex conditions may not present until puberty or attempts to conceive. One of the most commonly cited estimates comes from a review of medical literature between 1955 to 1997 using data from multiple countries, which found that intersex variations were present in as many as 2% of live births (Blackless, et al, 2000). This compares to 3% of live births that are twins in the United States (Martin, 2021). This estimate, despite its limitations, suggests that intersex traits are not that uncommon worldwide. Moreover, many advocates believe that the true incidence of intersex variations is likely much higher.

The medical treatment of intersex people has a sordid past that has left an indelible impact on the community of individuals with these variations. Until recently, it was common practice in the Western world to withhold an intersex diagnosis from patients, purportedly because it would have an impact on their gender identity formation. Specifically, psychologist and sexologist John Money at Johns Hopkins University developed a system for treating children who were intersex called the “optimum gender of rearing” model in the 1950s that was endorsed by the American Academy of Pediatrics (American Academy of Pediatrics, 1996; Fausto-Sterling, 1997). The belief was that gender identity was a “blank slate” at birth and developed entirely based on a child’s environment. It furthered  that, if done early enough, the child could be assigned any gender through a combination of surgical interventions to create “normative”-looking genitals and parental commitment to raising the child firmly in that gender category. The Johns Hopkins team, and others, reported alleged success of this particular sex reassignment in attempts to prove that physicians could create any gender out of an intersex child. However, it was clear from the adult testimony of former child patients who received these treatments that this was not the case. Intersex people, who have had their bodies surgically or hormonally modified as children, whether in the John Money era or more recently, have been left with physical and emotional consequences from medically unnecessary and irreversible procedures (Human Rights Watch, 2017; interACT, 2021b). This theory formed the basis of intersex medical “care” until at least the 1990s. Today, few practitioners will argue in favor of concealing medical information from their patients, but unnecessary surgery continues to be performed on intersex infants in hospitals around the country.

While it is now understood that gender identity is influenced by biology, environmental factors, and a person’s self-identification, there remains controversy around the treatment of intersex conditions by medical professionals. Presently, the treatment of intersex conditions remains problematic because treatment often hinges on acceptance of an anatomically strict theory of treatment: someone with a Y chromosome must have an “adequate” penis if they are to be assigned the male gender, and someone without a Y chromosome is declared a girl no matter their genitalia (Dreger, 1998). Advocacy efforts led by intersex individuals have resulted in several countries, organizations, and medical groups, including Human Rights Watch, the World Health Organization, and Amnesty International, recommending that choices about surgeries that are not medically urgent for the intersex child’s health be delayed for intersex people until they can make an informed decision for themselves (Commonwealth of Australia, 2013; World Health Organization, 2014; Human Rights Campaign, 2015; Amnesty International, 2017; Human Rights Watch, 2017). In the United States, some scholars and advocates have questioned whether early surgeries on intersex youth may fall afoul of laws regulating informed consent, sterilization of minors, and female genital cutting (Fraser, 2016; Tamar-Mattis, 2012).That said,, there are currently no state or federal laws that explicitly regulate intersex surgeries (interACT, 2021b).

The mental health and well-being of intersex individuals have largely been ignored. There is a presumption when treating intersex individuals that a psychosocial problem can be addressed medically or surgically. Although gender-affirming medical care, including surgery, is medically necessary treatment to alleviate gender dysphoria and distress among many transgender and nonbinary people (Almazan & Keuroghlian, 2021; Hughto, et al., 2020), medical interventions on intersex children are often performed because of parental distress and not because of the intersex person’s own gender dysphoria or other medical necessity. Because of this, the majority of research on intersex populations centers on outcomes and recommendations for surgery and hormone therapy (Cohen-Kettenis, 2005; Slijper & Drop, 1998). The little research on the mental health of intersex people that exists suggests that intersex adults may disproportionately experience negative mental health outcomes. Much of our understanding related to the mental health of intersex individuals has come out of research in Europe and Australia (Falhammer, et al., 2018), with an online Australian study of adults with intersex variations finding that 26% reported self-harm on the basis of having an in intersex variation, 60% had thought about suicide, and 19% had attempted suicide (Jones, 2016). The first national study of intersex adults in the U.S. found that more than half of the participants described their mental health as fair or poor (Rosenwohl-Marck, et al., 2020). Additionally, 61% reported having ever been diagnosed with a depressive disorder, 63% with an anxiety disorder, and 41% with post-traumatic stress disorder (PTSD). Even less research focuses on the mental health and well-being of intersex youth specifically. Reports often combine transgender and intersex youth into one gender variant sample despite the reality that being intersex may not necessarily impact youth’s experience of their gender (Smith, et al., 2015). Ultimately, mental health findings specific to intersex youth are not readily available.

This report contributes to our understanding of intersex youth by detailing the characteristics and mental health and well-being of a national U.S. sample of 1,132 intersex youth ages 13–24 who participated in our National Survey on LGBTQ Youth Mental Health.

Parental acceptance and family support are powerful protective factors for intersex youth. Intersex youth with high social support from their families reported half the rate of suicide attempts in the past year. Our findings also show that intersex youth who reported sexual orientation acceptance from at least one parent were 54% less likely to attempt suicide in the past year. Additionally, those who reported gender identity acceptance from at least one parent were 42% less likely to attempt suicide in the past year. Family support and acceptance is an important protective factor for LGBTQ youth well-being; however, for intersex youth, who may often find their family and parents to be the source of attempts to change their identity, support from them may be more meaningful and important.

METHODOLOGY

A quantitative cross-sectional design was used to collect data through an online survey platform between October and December 2020. A sample of LGBTQ youth ages 13–24 who resided in the United States was recruited via targeted ads on social media. The final analytic sample consisted of 34,759 LGBTQ youth. In the survey, participants were asked “Some people are assigned male or female at birth but are born with sexual anatomy, reproductive organs, and/or chromosome patterns that do not fit the typical definition of male or female. This physical condition is known as intersex. Are you intersex?” with options: no, yes, and decline to answer. This question was a recommended item for determining intersex identity as described in the Williams Institute’s Gender Identity in U.S. Surveillance (GenIUSS) report (GenIUSS Group, 2014). It was also selected because it aligns with best practices identified by interACT, including the provision of a definition to survey participants (interAct, 2021a). The current analyses include the 1,132 youth (3%) who identified as intersex. The overall survey included a maximum of 150 questions, including questions on considering and attempting suicide in the past 12 months taken from the Centers for Disease Control and Prevention’s Youth Risk Behavior Survey (Johns et al., 2020) and measures of anxiety and depression based on the GAD-2 and PHQ-2, respectively (Plummer et al., 2016; Richardson et al., 2010).

RESULTS

Intersex as a Diverse Community

Race and Ethnicity

In our national sample of LGBTQ youth, 3% reported that they were intersex. While the term intersex suggests a sense of community around a shared lived experience around sex traits, intersex people are diverse across additional identities and experiences. Within our sample of intersex youth, 51% were White, 20% were multiracial, 15% were Hispanic/Latinx, 7% were Asian/Pacific Islander, 6% were Black/African American, and 2% were Native/Indigenous, highlighting the fact that these findings reflect a diverse racial/ethnic experience. Furthermore, between 3–4% of respondents across all race/ethnicities were intersex. Additionally, 12% of intersex youth spoke a language other than English at home including Spanish, Portuguese, Farsi, and Russian. This compares to 10% of LGBTQ youth who are not intersex who spoke a language other than English at home. Also, 7% of intersex youth reported that they were born outside of the U.S. and 32% reported that at least one parent or caregiver was born outside of the U.S. LGBTQ youth who are not intersex reported being born outside of the U.S. and/or having a parent or caregiver who was born outside the U.S. at comparable rates to LGBTQ youth who are intersex.

Percentage of Intersex Youth Among Racial/Ethnic Groups Bar Chart

Sexual Orientation

A little over 1 in 3 intersex youth in our sample of LGBTQ youth identified as bisexual (35%) and 28% identified as gay or lesbian. Another 20% identified as pansexual, 12% as queer, 2% as straight and 3% responded that they were unsure of their sexual orientation. Most intersex youth also selected another sexual identity such as asexual, polyamorous, biromantic, sapphic, panromantic, and demisexual. The rates of identification with various sexual orientation labels among intersex youth is similar to that of the overall LGBTQ youth sample. Overall, 69% of intersex youth endorsed a multisexual identity (i.e., those who are attracted to more than one sex and/or gender, such bisexual or pansexual) and 31% of intersex youth reported a monosexual identity (i.e., attractions to one sex and/or gender, such as straight or lesbian).

Sexual Identity Among Intersex Youth Chart

Gender Identity and Expression

Overall, 58% of intersex youth in our sample identified as transgender, nonbinary or questioning compared to 47% of LGBTQ youth who are not intersex. Specifically, 32% of intersex youth identified as nonbinary, 29% as a cisgender woman, 13% as a cisgender man, 12% as a transgender man, and 5% as a transgender woman, with 9% questioning their gender identity. Comparatively, 1 in 3 intersex youth identified as nonbinary compared to 1 in 4 LGBTQ youth who are not intersex. Almost every intersex youth opted to use a gender identity label, with only one youth providing context for their choice by writing “I am intersex, incorrectly assigned female at birth.” Pronouns that were not exclusively binary (e.g., using they/them or she/they) were endorsed by 51% of intersex youth, a rate significantly higher than youth who were not intersex (42%). Finally, given the specific context of assigning sex at birth for intersex youth, 74% of our sample was assigned female at birth and 26% were assigned male. It is important to note that 3% of intersex youth declined to respond to the question asking sex assigned at birth, double the rate of the overall sample of LGBTQ youth.

Gender Identity Among Intersex Youth Chart
Pronouns for Intersex Youth Chart

Mental Health and Well-being Among Intersex Youth

Anxiety, Depression, and Self-Harm

Overall, 73% of intersex youth reported symptoms of generalized anxiety disorder in the past two weeks. These overall rates of generalized anxiety were similar to LGBTQ youth who are not intersex (71%). However, intersex youth who were 13–17 years old reported significantly higher rates of anxiety (75%) compared to intersex youth 18–24 years old (71%), as did transgender and nonbinary intersex youth (70%) compared to cisgender intersex youth (64%). Additionally, intersex youth who endorsed a multisexual identity reported higher rates of anxiety (75%) compared to intersex youth who were monosexual (69%).

Mental Health and Self-Harm Among Intersex Youth Chart

Nearly 2 out of 3 intersex youth reported symptoms of major depressive disorder in the past two weeks (66%), a rate significantly higher than LGBTQ youth who are not intersex (62%). Furthermore, we see similar patterns here as with generalized anxiety symptomatology with younger (13–17) intersex youth reporting higher rates of depression (70%) compared to older (18–24) intersex youth (62%) and transgender and nonbinary intersex youth (73%) reporting higher rates compared to cisgender intersex youth (56%). Furthermore, intersex youth who were multisexual reported higher rates of depression (69%) compared to monosexual intersex youth (58%). Rates of anxiety and depression did not differ between intersex youth of color and White intersex youth.

Almost 3 in 5 intersex youth reported intentionally harming themselves, or self-harm, in the past 12 months (59%). This rate of past-year self-harm was significantly higher for intersex youth than among youth who were not intersex (54%). Similar to previous findings, younger intersex youth (13–17) reported higher rates of self-harm (68%) compared to older (18–24) intersex youth (49%), as did transgender and nonbinary intersex youth (66%) compared to cisgender intersex youth (48%) and multisexual intersex youth (62%) compared to monosexual intersex youth (50%).

Suicide Risk

Almost half (48%) of intersex youth seriously considered attempting suicide in the past year, compared to 41% of LGBTQ youth who are not intersex. This rate includes more than half of intersex youth ages 13–17 (51%) and more than half of transgender and nonbinary intersex youth (55%). Intersex youth who are 18–24 years old or cisgender reported considering suicide at significantly lower rates (44% and 36%, respectively) compared to these groups. Furthermore, intersex youth who were multisexual reported higher rates of considering suicide in the past year (52%) compared to monosexual intersex youth (40%).

48% of intersex youth seriously considered attempting suicide in the past year.

Suicide Risk Among Intersex Youth: Age Chart

Nearly 1 in 5 intersex youth (19%) attempted suicide in the past 12 months. This compares to 14% of LGBTQ youth who are not intersex. Intersex youth who were 13–17 years old reported higher rates of attempting suicide in the past 12 months (24%) compared to intersex youth aged 18–24 (14%). Furthermore, transgender and nonbinary intersex youth reported higher rates of attempting suicide in the past 12 months (23%) compared to cisgender intersex youth (13%). Overall, 40% of intersex youth in our sample reported ever having attempted suicide in their lifetime, compared to 32% of LGBTQ youth who are not intersex who reported ever having attempted suicide in their lifetime.

Suicide Risk Among Intersex Youth: Sexual Identity Chart

Risk Factors for Poor Mental Health Among Intersex Youth

Change Attempts and Conversion Therapy Among Intersex Youth

For many intersex individuals, a large part of their lived experience is an attempt by others to define their sex and gender identity for them. Consistent with this, we found that nearly 2 out of 3 (66%) intersex youth reported that someone attempted to convince them to change their sexual orientation or gender identity. This is compared to 59% of LGBTQ youth who are not intersex. While 35% of LGBTQ youth who are not intersex reported that a parent or caregiver attempted to convince them to change their sexual orientation or gender identity, 42% of intersex youth reported this. Furthermore, intersex youth reported twice the rate of having had a healthcare provider, both mental healthcare (9%) and physical healthcare (6%), attempt to convince them to change their sexual orientation or gender identity compared to LGBTQ youth who are not intersex (4% and 3%, respectively). Intersex youth who reported that someone attempted to convince them to change their sexual orientation or gender identity reported more than twice the rate of past-year suicide attempts (22%) compared to intersex youth who did not (9%).

Change Attempts Among Intersex Youth and Non-Intersex Youth Chart

Historically, the recommended “treatment” for intersex individuals has often amounted to conversion therapy, a dangerous and discredited practice which includes any treatment by licensed professionals (e.g., psychologists or doctors) or unlicensed, often religious, counselors that attempts to change an individual’s sexual attractions and behaviors, gender expression, or gender identity. However, for intersex people this may happen in such a systemic way, involving every person in the youth’s life, and starting from birth, that intersex youth may not even be aware that it is happening. This may lead intersex youth to under-report their experiences with conversion therapy and other change efforts by adults in their lives. That said, 18% of intersex youth report having been subjected to conversion therapy, and those who did reported twice the rate of attempting suicide in the past year (28%) compared those who did not (14%). Importantly, intersex youth also reported more than twice the rate of having been subjected to conversion efforts by a healthcare professional (9%) compared to LGBTQ youth who are not intersex (4%). Intersex youth also reported having higher rates of being subjected to change efforts by a religious leader (21%) compared to LGBTQ youth who are not intersex (13%). Furthermore, half of intersex youth (50%) reported that the change efforts were directed at both their sexual orientation and gender identity compared to 32% of LGBTQ youth who are not intersex. Additionally, twice as many intersex youth reported the conversion therapy was meant to change just their gender identity (12%) compared to LGBTQ youth who are not intersex (6%).

Who Performed the Conversion Efforts Among Intersex Youth Chart

Discrimination and Victimization Among Intersex Youth

More than 3 in 5 (64%) intersex youth reported having experienced discrimination based on their sexual orientation or gender identity in the past year compared to 59% of LGBTQ youth who are not intersex. Intersex youth who experienced sexual orientation- or gender identity-based discrimination reported twice the rate of attempting suicide (22%) compared to intersex youth who had not experienced it (11%). Furthermore, 64% of intersex youth reported having specifically experienced discrimination based on their gender identity, including 26% of whom experienced gender identity-based discrimination in a doctor’s office, 45% from teachers or administrators at schools, and 19% in the hiring process. Additionally, half (50%) of intersex youth reported having ever been prevented or discouraged from using a bathroom that corresponds with their gender identity. Intersex youth who were 13–17 years old (68%) or identified as transgender or nonbinary (73%) reported higher rates of discrimination based on their sexual orientation or gender identity compared to intersex youth who were 18–24 (61%) or cisgender (50%). There were no differences based on race/ethnicity or sexual orientation.

Suicide Attempts Among Intersex Youth Based on Discrimination and Physical Harm Chart

Overall, 1 in 4 (25%) intersex youth reported having experienced physical harm based on their sexual orientation or gender identity in the past year. This is in comparison to 19% of LGBTQ youth who are not intersex. Intersex youth who experienced physical harm based on their sexual orientation or gender identity reported more than three times the rate of attempting suicide (37%) than intersex youth who did not experience physical harm based on their sexual orientation or gender identity (12%). Intersex youth who were under age 18 (28%) or transgender and nonbinary (32%) reported higher rates of physical harm based on their sexual orientation or gender identity compared to intersex youth who were ages 18–24 (23%) and cisgender (14%), respectively. There were no within-group differences in experiencing physical harm based on one’s sexual orientation or gender identity by race/ethnicity or sexual orientation.

Intersex youth who experienced dating violence reported 3X the rate of attempting suicide.

Dating violence was defined as being physically hurt on purpose by someone who youth were dating or going out with. Among intersex youth who had reported dating someone in the past year, 18% reported experiencing dating violence, which is nearly twice the rate reported by LGBTQ youth who are not intersex (10%). Intersex youth who experienced dating violence in the past year reported three times the rate of attempting suicide in the past year (36%) compared to intersex youth who did not experience past-year dating violence (12%). Rates of dating violence were higher among intersex youth of color (24%) compared to White intersex youth (13%) and among transgender and nonbinary intersex youth (21%) compared to cisgender intersex youth (14%). There were no differences in rates of dating violence for intersex youth by age or sexual orientation.

Housing Instability and Food Insecurities Among Intersex Youth

Overall, 38% of intersex youth reported food insecurities in the past month compared to 30% of LGBTQ youth who are not intersex. This rate included 40% of multisexual intersex youth, 42% of intersex youth of color, and 45% of transgender and nonbinary intersex youth. Intersex youth who reported food insecurities in the past month reported nearly three times the rate of a past-year suicide attempt (30%) as those who did not experience food insecurities (12%).

Suicide Attempts Among Intersex Youth Based on Food and Shelter Chart

Nearly 2 out of 5 (39%) intersex youth reported ever having experienced homelessness, been kicked out, or run away. This compares to nearly 1 out of 3 LGBTQ youth who are not intersex (29%). Intersex youth who were 18–24 reported higher rates of housing instability (44%) compared to intersex youth ages 13–17 (33%). Furthermore, transgender and nonbinary intersex youth experienced higher rates of housing instability (46%) compared to cisgender intersex youth (26%). Intersex youth who had experienced housing instability reported over three times the rates of attempting suicide attempt in the past year (34%) compared to intersex youth who had not experienced housing instability (10%).

Protective Factors for Intersex Youth

Supportive People

While it is important to understand the things that put intersex youth at risk for mental health challenges, it is also just as important to understand things that can help them thrive. For many youth, acceptance of their identities is a powerful protective factor, and that is no different for intersex youth. Overall, 75% of intersex youth reported that at least one parent accepted their sexual orientation. There were no differences in parental acceptance of sexual orientation by age, race/ethnicity, gender identity, or sexual orientation. Intersex youth who reported that at least one of their parents was accepting of their sexual orientation reported lower rates of attempting suicide in the past year (18%) compared to intersex youth who did not have this acceptance (33%). Indeed, intersex youth with at least one parent who was accepting of their sexual orientation were 55% less likely to attempt suicide in the past year, after controlling for the effects of gender identity, race/ethnicity, and age.

Intersex youth with at least one parent supportive of their sexual orientation were 55% less likely to attempt suicide in the past year.

Suicide Attempts Based on Parental Acceptance Among Intersex Youth Chart

Relatedly, 60% of intersex youth reported that at least one parent accepted their gender identity. There were no significant differences by age, race/ethnicity, or sexual orientation. Intersex youth who had at least one parent who was accepting of their gender identity reported just over half the rate of attempting suicide in the past year (17%) compared to intersex youth who did not have a parent who was accepting of their gender identity (30%). Similarly, intersex youth with at least one parent who is accepting of their gender identity were 46% less likely to attempt suicide in the past year, after controlling for the effects of sex assigned at birth, age, race/ethnicity, and sexual orientation.

Suicide Attempts Based on Social Support Among Intersex Youth Chart

Supportive relationships in general, not just specific to one’s sexual orientation or gender identity, were also protective for intersex youth. Intersex youth who reported high levels of family support reported half the rate of attempting suicide in the past year (9%) compared to intersex youth who did not (20%). Intersex youth with supportive friends also reported lower rates of attempting suicide in the past year (15%) compared to intersex youth without a high level of support from friends (24%).

Affirming Spaces

LGBTQ-affirming spaces were also protective for intersex youth. Specifically, intersex youth who reported having access to LGBTQ-affirming online spaces reported lower rates of attempting suicide in the past year (16%) compared to intersex youth who did not have access to affirming online spaces (22%). The same was found for intersex youth who had LGBTQ-affirming schools and LGBTQ-affirming homes both reporting lower rates of attempting suicide in the past year (16% and 13%, respectively) compared to intersex youth without LGBTQ-affirming schools (23%) or LGBTQ-affirming homes (21%).

Suicide Attempts Based on Access to LGBTQ-Affirming Spaces Chart

Despite their association with lower rates of suicide attempts, intersex youth do not necessarily have access to these spaces. While the majority of intersex youth reported they had access to an LGBTQ-affirming online space (70%), only half of intersex youth reported an LGBTQ-affirming school environment, and even less, a little over 1 in 3, reported an LGBTQ-affirming home environment.

Where Intersex Youth Access LGBTQ-Affirming Spaces Chart

Respect for Pronouns

Respecting one’s pronouns is an important indicator of support for their gender identity. Among intersex youth who are transgender or nonbinary, 31% reported that all or most of the people with whom they live respect their pronouns. Transgender and nonbinary intersex youth who reported having their pronouns respected by all or most of the people they live with attempted suicide at half the rate (13%) of transgender and nonbinary intersex youth who reported that none of the people they live with respect their pronouns (32%). Transgender and nonbinary intersex youth whose pronouns were respected by all of the people they lived with were 64% less likely to report a suicide attempt in the past year when compared to transgender and nonbinary intersex youth whose pronouns were respected by none of the people with whom they live, after controlling for the effects of sex assigned at birth, age, race/ethnicity, and sexual orientation.

Suicide Attempts Based on Respect for Pronouns Among Transgender and Nonbinary Intersex Youth Chart

RECOMMENDATIONS

The experiences of intersex youth need to be considered in suicide prevention efforts. In our sample of LGBTQ youth, 3% identified as intersex. Intersex youth in our sample are diverse in their sexual orientation and gender identity, and are from all racial and ethnic backgrounds. The current findings suggest that intersex youth report disproportionately higher rates of depression, self-harm, suicidal thoughts, and attempted suicide compared to LGBTQ youth who are not intersex. Intersex youth are also exposed to many risk factors for poor mental health, such as attempts to change their gender identity or sexual orientation, discrimination, and victimization, at higher rates than LGBTQ youth who are not intersex. These rates are particularly concerning given that LGBTQ youth already report much higher rates of mental health challenges and suicide risk than their straight, cisgender peers. Overall, these findings support increased efforts to specifically address intersex youth in initiatives and programs that aim to improve youth mental health and prevent suicide. As is the case across most examinations of mental health and well-being, our findings show that intersex youth who hold multiple marginalized identities often reported greater exposure to risk factors and higher rates of mental health challenges, emphasizing the need to take an intersectional approach to this work.

Intersex youth have unique stressors that must be addressed in prevention and intervention programs. Though often conflated with gender identity and sexual orientation, intersex status comes with a distinct set of inequities and stressors, both socially and medically. Intersex youth were subjected to conversion therapy from a healthcare professional at more than twice the rate of LGBTQ youth who are not intersex. Furthermore, intersex youth reported twice the rate of a mental or physical healthcare provider attempting to convince them to change their sexual orientation or gender identity. As noted, these self-reported rates may not reflect all of the intersex youth confronted with attempts to change their identity within the medical community because such change efforts often start in infancy, with genital or gonadal surgery, making this a pervasive and particularly insidious issue for many intersex individuals. Regardless, our findings confirm that converversion therapy and other change efforts remain a large part of lived experiences among intersex youth. Given that these experiences are associated with increased risk for a past-year suicide attempts, it is imperative that more be done to address them.

Parental acceptance and family support are powerful protective factors for intersex youth. Intersex youth with high social support from their families reported half the rate of suicide attempts in the past year. Our findings also show that intersex youth who reported sexual orientation acceptance from at least one parent were 54% less likely to attempt suicide in the past year. Additionally, those who reported gender identity acceptance from at least one parent were 42% less likely to attempt suicide in the past year. Family support and acceptance is an important protective factor for LGBTQ youth well-being; however, for intersex youth, who may often find their family and parents to be the source of attempts to change their identity, support from them may be more meaningful and important. 

Research efforts must do more to consider the psychological well-being of intersex youth. Being transgender or nonbinary comes with similar experiences in bias and stigma related to cisnormativity; however, being intersex has unique stressors that are not adequately addressed when intersex youth are simply included within a sample of “gender variant” or “gender nonconforming” individuals. The current report was inclusive of intersex youth and specifically assessed intersex status; however, given this was not a study exclusively designed for intersex youth, many questions remain unanswered. It is not clear, for example, how many intersex youth in our study experienced issues unique to being intersex such as childhood genital surgery or hormone administration. Furthermore, because our study was specific to LGBTQ youth, the mental health of intersex youth who do not identify as part of the LGBTQ community is unclear. Intersex-specific research is needed to not only examine the risks for poor mental health among intersex youth, but also the protective factors that are unique to them.

Policies built around the assumption of a sex or gender binary are inherently problematic for intersex youth. The forced categorization of people into groupings of either male or female on the basis of observable physical characteristics is problematic for youth who do not neatly fit into them. This not only applies to youth who are transgender and nonbinary, but also youth who are intersex — for whom a binary never existed. As we begin to consider ways to be more inclusive in our policies and practices, we must also ensure that the rights of intersex youth are considered. Gendered bathrooms and locker rooms, binary gendered sports participation, forms and documents that only allow male or female sex markers, excluding intersex realities from health and sex education, and many other examples in which aspects of everday life are gendered according to a binary represent stressors for intersex youth and signal that they are not permitted to be who they are. These can be addressed with inclusive policy changes that directly consider intersex individuals and their needs.

The Trevor Project is dedicated to the increased visibility of intersex youth and finding ways to improve their mental health. The Trevor Project strives to raise awareness and increase the visibility of intersex youth not only through research reports such as this one, but also through public training of youth-serving adults and organizations and strategic marketing campaigns and partnerships. Our research team will continue to release findings specific to intersex youth to support efforts to understand their unique challenges and strengths. Our Crisis Services team has a goal of providing all LGBTQ youth with high-quality crisis intervention, including those who are intersex. We recognize that prevention efforts cannot be one-size-fits-all and must address the specific needs of youth we wish to help in our continued efforts to end suicide among all LGBTQ young people.

The authors of this report acknowledge and extend our deepest thanks to Sylvan Fraser and interACT for providing feedback and guidance on the creation of this report.

ABOUT THE TREVOR PROJECT

The Trevor Project is the world’s largest suicide prevention and crisis intervention organization for lesbian, gay, bisexual, transgender, queer & questioning (LGBTQ) young people. The Trevor Project offers a suite of 24/7 crisis intervention and suicide prevention programs, including TrevorLifelineTrevorText, and TrevorChat as well as the world’s largest safe space social networking site for LGBTQ youth, TrevorSpace. Trevor also operates an education program with resources for youth-serving adults and organizations, an advocacy department fighting for pro-LGBTQ legislation and against anti-LGBTQ rhetoric/policy positions, and a research team to discover the most effective means to help young LGBTQ people in crisis and end suicide. If you or someone you know is feeling hopeless or suicidal, our trained crisis counselors are available 24/7 at 1-866-488-7386 via chat www.TheTrevorProject.org/Get-Help, or by texting START to 678-678.

This report is a collaborative effort from the following individuals at The Trevor Project:

Myeshia N. Price, PhD
Senior Research Scientist

Amy E. Green, PhD
Vice President of Research

Jonah DeChants, PhD
Research Scientist

Carrie Davis, MSW
Chief Community Officer

Recommended Citation: Price, M.N., Green, A.E, DeChants, J.P, & Davis, C.K. (2021).The mental health and well-being of LGBTQ youth who are intersex. New York, New York: The Trevor Project.

Media inquiries:

[email protected]

Research-related inquiries:

[email protected]Project.org

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Table 1: Intersex Youth Characteristics
Age (n =1,132) Race and Ethnicity (n = 1,094) 
Under 1853%White51%
18 and over47%More than one race20%
Sex Assigned at Birth (n=1,132) Latinx15%
Female74%Asian/Pacific Islander7%
Male26%Black/African American6%
Sexual Orientation (n = 1,132) Native/Indigenous2%
Bisexual35%Pronouns (n = 1,131) 
Gay or lesbian28%She or he only49%
Pansexual20%Pronouns outside of the gender binary51%
Queer12%Speak a language other than English at home (n= 1,132)12%
I am not sure3%Just meeting basic needs (n = 1,015)26%
Straight2%U.S. Immigrant Status (n =1,125) 
Gender Identity (n = 1,095) Youth born outside of the U.S.7%
Nonbinary32%At least one parent/caregiver born outside of the U.S.32%
Cisgender woman29%Region (n = 1,132) 
Cisgender man13%South33%
Transgender man12%Midwest27%
Questioning9%West25%
Transgender woman5%Northeast16%