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

School Absenteeism Among Racially and Ethnically Minoritized Transgender High School Students and Their Peers: A Cross-Sectional Study

PURPOSE

To explore absenteeism among racially and ethnically minoritized transgender youth (trans REMY) compared to their White transgender (trans WY) and racially and ethnically minoritized cisgender (cis REMY) peers and identify associated psychosocial factors.

METHODS

Biennial California Healthy Kids Survey 2017-2019 data was analyzed with a weighted sample of California's secondary school population. Students reported past 30-day absences due to mental health and harassment, depressive symptoms, suicidal ideation, cyberbullying, victimization, and school connectedness. Poisson and linear regression compared absenteeism and psychosocial factors among peer groups. For trans REMY, Poisson regression assessed associations between absenteeism and psychosocial factors. Analyses were adjusted for grade, sex, and socioeconomic status.

RESULTS

The analytical sample (n = 25,085) included 206 trans REMY, 64 trans WY, and 24,815 cis REMY. Trans REMY had higher relative risk of absenteeism due to mental health concerns and harassment compared to cis REMY (adjusted relative risk 2.9, 95% confidence interval 2.1-4.0 and adjusted relative risk 8.1, 95% confidence interval 4.0-16.6, respectively) but similar risk when compared to trans WY. For trans REMY, depressive symptoms, suicidal ideation, and victimization were associated with higher relative risk of absenteeism due to mental health concerns. Cyberbullying was associated with a higher risk of absenteeism due to harassment. Higher school connectedness was associated with lower risk of absenteeism due to mental health concerns.

DISCUSSION

Trans REMY reported higher rates of school absenteeism due to mental health concerns and harassment compared to some of their peers. Mental health symptoms, victimization, cyberbullying, and school connectedness were associated with absenteeism among trans REMY.

Community-Derived Recommendations for Improving Gender Affirmation of Black and Latine Transgender/Nonbinary Youth

BACKGROUND

Gender affirmation is a process by which gender-diverse individuals are supported in their gender identity. Parents are critical in how gender-diverse youth, including Black and Latine transgender/nonbinary youth (BLTY), access various forms of gender affirmation-for example, social and medical transition. Culturally relevant supports are needed to bolster how BLTY and their parents navigate gender affirmation.

PURPOSE

This study aimed to explore recommendations for aiding BLTY and parents in navigating the youth's gender journey.

METHODS

Semi-structured interviews were conducted with parents of BLTY, BLTY, and BLT young adults (BLTYAs) recruited from clinics, community organizations, and social media. Interviews focused on gender affirmation and recommendations to promote BLTY's gender affirmation. Primary and secondary analysts coded transcripts using a priori and emergent codes. For this analysis, excerpts pertaining to recommended supports were analyzed to identify themes.

RESULTS

Ten parents of BLTY, 10 BLTY (14-18 years), and 23 BLTYAs (18-30 years) participated. Participants provided recommendations at different socio-ecological levels. On the societal level, participants recommended improvements in media representation of racial and ethnic minority gender-diverse individuals. For organizations, participants recommended more clinicians who shared minoritized identities, clinicians knowledgeable in gender-affirming care, affordability of gender-affirming services, and school-based education regarding gender diversity. On interpersonal/individual levels, they suggested culturally informed peer support among BLTY and parents, including support groups, peer mentors, and camps with individuals who share their minoritized identities.

CONCLUSIONS

Participants provided salient insights to supporting gender affirmation of BLTY, which can inform intervention development for BLTY and their families.

Parental Gender Affirmation Model: A culturally informed framework

Benefits of parental gender-affirming behaviors on the mental health and well-being of the broader gender-expansive youth population have been extensively documented. However, the nature and impact of these behaviors have not been explored by centering Black and Latine transgender/non-binary youth (BLTY). This article offers a new framework called the "Parental Gender Affirmation Model." This framework conceptualizes parental gender-affirming behaviors toward BLTY through the lenses of intersectional stigma and cultural gender norms and uses the Theory of Planned Behavior and Modified Gender Affirmation Model as foundational frameworks. We analyzed qualitative data from 43 interviews with BLTY, parents of BLTY, and Black and Latine transgender/non-binary young adults from California in the United States to develop the framework. The "Parental Gender Affirmation Model" starts with behavioral antecedents and ends with impacts of these behaviors on BLTY's well-being. This framework will inform the development of critically needed, culturally-informed interventions to support parental gender affirmation of BLTY.

Estimating Transgender and Gender-Diverse Youth Populations in Health Systems and Survey Data

OBJECTIVES

To identify and examine demographic variation in estimates of gender-diverse youth (GDY) populations from the PEDSnet learning health system network and the Youth Risk Behavior Survey (YRBS).

METHODS

The PEDSnet sample included 14- to 17-years-old patients who had ≥2 encounters at a member institution before March 2022, with at least 1 encounter in the previous 18 months. The YRBS sample included pooled data from 14- to 17-year-old in-school youth from the 2017, 2019, and 2021 survey years. Adjusted logistic regression models tested for associations between demographic characteristics and gender dysphoria (GD) diagnosis (PEDSnet) or self-reported transgender identity (YRBS).

RESULTS

The PEDSnet sample included 392 348 patients and the YRBS sample included 270 177 youth. A total of 3453 (0.9%) patients in PEDSnet had a GD diagnosis and 5262 (1.9%) youth in YRBS self-identified as transgender. In PEDSnet, adjusted logistic regression indicated significantly lower likelihood of GD diagnosis among patients whose electronic medical record-reported sex was male and among patients who identified as Asian, Black/African American, and Hispanic/Latino/a/x/e. In contrast, in the YRBS sample, only youth whose sex was male had a lower likelihood of transgender identity.

CONCLUSIONS

GDY are underrepresented in health system data, particularly those whose electronic medical record-reported sex is male, and Asian, Black/African American, and Hispanic/Latino/a/x/e youth. Collecting more accurate gender identity information in health systems and surveys may help better understand the health-related needs and experiences of GDY and support the development of targeted interventions to promote more equitable care provision.

School Connectedness and Suicide Among High School Youth: A Systematic Review

BACKGROUND

Suicide is a leading cause of death for adolescents, and school connectedness is a potential, modifiable protective factor for suicide. We sought to examine if school connectedness protected against suicide among high school students and if potential moderators affected the relationship between school connectedness and suicide.

METHODS

We searched online databases (PubMed, EMBASE, CINAHL, and PsycINFO) on December 12, 2021, for studies that examined the effects of school connectedness on suicide among high school students.

RESULTS

This systematic review identified 34 studies that examined the effects of school connectedness on adolescent suicidality. Results indicated mixed findings of school connectedness on suicidality. Among studies that assessed a suicide ideation outcome, 73.3% found that school connectedness protected against suicide. Among studies that assessed a suicide attempts outcome, 50% found that school connectedness protected against suicide. Most included studies did not control for notable variables in their final models, such as sleep, impulsivity, substance use, or depression. No studies examined moderators of school connectedness and suicide.

CONCLUSIONS

School connectedness is somewhat protective of suicidality, and more protective of suicidal ideation than suicide attempts. Researchers should examine the construct of school connectedness among modern youth to better understand school connectedness and suicide.

Sexual harassment, sexual assault, violence, self-esteem, and the role of LGBTQ-specific parental support in a sample of Latinx sexual and gender minority youth

INTRODUCTION

Oftentimes as result of racism, cissexism, and heterosexism, many Latinx and sexual and gender minority (SGM) youth are victims of sexual harassment, sexual assault, and violence. These experiences of victimization are in part related to increased negative mental health outcomes such as decreased self-esteem. Some research links LGBTQ-specific parental support to mental health outcomes among Latinx SGM youth, yet, no research has explored the role of LGBTQ-specific parental support with self-esteem among Latinx SGM youth.

METHODS

In a sample of 1,012 Latinx SGM youth (ages 13-17), we assessed: (a) associations between sexual harassment, sexual assault, and violence and self-esteem, (b) association between LGBTQ-specific parental support and self-esteem, and (c) whether LGBTQ-specific parental support moderated the relation between sexual harassment, sexual assault, and violence and self-esteem. Main effect and moderation analyses examined interactions between LGBTQ-specific parental support with sexual harassment, sexual assault, and violence on self-esteem.

RESULTS

Latinx SGM youth experienced low levels of LGBTQ-specific parental support and various degrees of sexual harassment, sexual assault, and violence. Also, transgender and nonbinary/genderqueer Latinx youth experienced lower self-esteem than their Latinx cisgender counterparts. Increased LGBTQ-specific parental support was related to increased self-esteem. We also identified a significant interaction between sexual harassment, sexual assault, and violence and LGBTQ-specific parental support, such that parental support was more protective at low levels rather than high levels of sexual harassment, sexual assault, and violence among Latinx SGM youth.

CONCLUSIONS

Findings add to a growing body of research about the importance of LGBTQ-specific parental support for Latinx SGM youth, and the need to examine culturally appropriate approaches to understand parent-child relationship among these communities.

Examining the integrated model of the interpersonal-psychological theory of suicide and intersectionality theory among Black male adolescents

INTRODUCTION

Guided by Opara et al.'s (2022), Integrated Model of the Interpersonal Psychological Theory of Suicide and Intersectionality Theory, the current study examined contextual stressors experienced disparately by Black youth (racial discrimination, poverty, and community violence) as moderators of the association between individual motivating factors for suicidal thoughts and behaviors (perceived burdensomeness, thwarted belongingness, and hopelessness) and active suicidal ideation.

METHOD

Participants were 457 Black adolescent boys (mean age = 15.31, SD = 1.26) who completed self-report surveys.

RESULTS

As predicted, the association between perceived burdensomeness and active suicidal ideation was significantly moderated by economic stress. In addition, the association between peer belongingness and suicidal ideation was significantly moderated by racial discrimination, but there were no moderating effects for school belongingness. Finally, the association between hopelessness and suicidal ideation was significantly moderated by both racial discrimination and witnessing community violence.

CONCLUSION

These findings highlight the need for research, interventions, and policy work devoted to using integrated approaches of individual and socioeconomically relevant patterns of suicidal thoughts and behaviors to support Black youth exposed to various forms of structural oppression.

Policy solutions to eliminate racial and ethnic child health disparities in the USA

Societal systems act individually and in combination to create and perpetuate structural racism through both policies and practices at the local, state, and federal levels, which, in turn, generate racial and ethnic health disparities. Both current and historical policy approaches across multiple sectors-including housing, employment, health insurance, immigration, and criminal legal-have the potential to affect child health equity. Such policies must be considered with a focus on structural racism to understand which have the potential to eliminate or at least attenuate disparities. Policy efforts that do not directly address structural racism will not achieve equity and instead worsen gaps and existing disparities in access and quality-thereby continuing to perpetuate a two-tier system dictated by racism. In Paper 2 of this Series, we build on Paper 1's summary of existing disparities in health-care delivery and highlight policies within multiple sectors that can be modified and supported to improve health equity, and, in so doing, improve the health of racially and ethnically minoritised children.

Mental Health and Gender Affirmation of Black and Latine Transgender/Nonbinary Youth Compared to White Peers Prior to Hormone Initiation

PURPOSE

To compare baseline mental health symptoms and gender affirmation between Black/Latine versus White transgender/nonbinary youth (BLTY vs. WTY) and examine relationships between gender affirmation and mental health symptoms, and whether associations differed by race/ethnicity subgroup.

METHODS

Baseline data were analyzed from the gender-affirming hormone cohort of the Trans Youth Care United States Study-a 4-clinic site, observational study. Mental health symptoms assessed included depression, suicidality, and anxiety. Gender affirmation measures included the parental acceptance subscale from the perceived Parental Attitudes of Gender Expansiveness Scale-Youth Report; non-affirmation, internalized transphobia, and community connectedness subscales from the Gender Minority Stress and Resilience Measure-Adolescent; and self-reported living full time in affirmed gender. Fisher exact tests and independent sample t tests compared mental health symptoms and gender affirmation between subgroups. Logistic regression analyses evaluated associations between gender affirmation and mental health symptoms. Interaction analyses assessed differences in associations between subgroups.

RESULTS

The sample (mean age 16 years, range 12-20 years) included 92 BLTY (35%) and 170 WTY (65%). Subgroups had comparable prevalence of depression and anxiety symptoms. WTY had higher prevalence of lifetime suicidality (73% vs. 59%; p = .02). There were no differences in gender affirmation. Among the whole sample, higher parental acceptance decreased odds of depression symptoms. Not living in affirmed gender increased odds of depression symptoms. Higher non-affirmation and internalized transphobia increased odds of depression and anxiety symptoms and suicidality. Associations did not vary by subgroup.

DISCUSSION

BLTY and WTY had comparable mental health symptoms. For both subgroups, gender affirmation decreased odds of those symptoms.

Beyond Race, Sex, and Gender: Mental Health Considerations of Transgender Youth of Color, Intersex Youth, and Nonbinary Youth

This article explores how race, sex, and gender are better thought of as a continuum rather than binary categories. Starting with a discussion of intersectionality, we examine the importance of ethnic-racial identity and explore unique cultural considerations for working with Black, Latinx, and AAPI transgender and nonbinary youth. We then examine intersex youth and variations of sex development, as well as specific challenges they face. Finally, we explore nonbinary gender identities and the importance of individually tailoring affirming interventions. For all sections, we highlight the strengths and resilience of the youth and offer clinical recommendations for child and adolescent providers.

State-Level Policies and Health Outcomes in U.S. Transgender Adolescents: Findings from the 2019 Youth Risk Behavior Survey

Purpose: Policies have been shown to bear a considerable influence on transgender health. The few studies that have examined policy-related health outcomes in adolescent transgender populations have rarely included policies that directly affect them. Our study explores associations between four state-level policies and six health outcomes in a sample of transgender adolescents. Methods: Our analytic sample consisted of adolescents residing in 14 states that used the 2019 Youth Risk Behavior Survey's optional gender identity question in their surveys (n = 107,558). Chi-square analyses were performed to examine differences between transgender and cisgender adolescents in demographic variables and suicidal ideation, depression status, cigarette use, binge drinking, grades in school, and perceptions of school safety. Multivariable logistic regression models were run for transgender adolescents only to examine associations between policies and health outcomes, adjusting for demographics. Results: Transgender adolescents comprised 1.7% (n = 1790) of our sample. Compared with cisgender adolescents, transgender adolescents were more likely to experience adverse health outcomes in chi-square analyses. Multivariable models indicated that transgender adolescents who lived in a state that had explicit transgender guidance in their antidiscrimination laws were less likely to experience depressive symptoms, and those who lived in a state with positive or neutral athlete guidance were less likely to report past 30-day cigarette use. Conclusion: Our study is one of the first to show protective associations between affirming transgender-specific policies and health outcomes in transgender adolescents. Findings could have important implications for policymakers and school administrators.

Psychological distress, self-harm and suicide attempts in gender minority compared with cisgender adolescents in the UK

BACKGROUND

Few population-based studies have compared the mental health of gender minority and cisgender adolescents.

AIMS

To compare reports of psychological distress, behavioural and emotional difficulties, self-harm and suicide attempts between gender minority and cisgender adolescents.

METHOD

Data came from the Millennium Cohort Study (n = 10 247), a large nationally representative birth cohort in the UK. At a 17-year follow-up, we assessed gender identity, psychological distress (Kessler K6 scale), behavioural and emotional difficulties (parent and child reports on the Strengths and Difficulties Questionnaire), self-harm in the previous year, suicide attempts, substance use, and victimisation including harassment and physical and sexual assaults. Multivariable modified Poisson and linear regression models were used. Attenuation after the inclusion of victimisation and substance use was used to explore mediation.

RESULTS

Of the 10 247 participants, 113 (1.1%) reported that they were a gender minority. Gender minority participants reported more psychological distress (coefficient 5.81, 95% CI 4.87-6.74), behavioural and emotional difficulties (child report: coefficient 5.60; 95% CI 4.54-6.67; parent/carer report: coefficient 2.60; 95% CI 1.47-3.73), self-harm including cutting or stabbing (relative risk (RR) 4.38; 95% CI 3.55-5.40), burning (RR 3.81; 95% CI 2.49-5.82), taking an overdose (RR 5.25; 95% CI 3.35-8.23) and suicide attempts (RR 3.42; 95% CI 2.45-4.78) than cisgender youth. These associations were partially explained by differences in exposure to victimisation.

CONCLUSIONS

Gender minority adolescents experience a disproportionate burden of mental health problems. Policies are needed to reduce victimisation and services should be adapted to better support the mental health of gender minority adolescents.

Prevalence of self-inflicted injuries among transgender and gender diverse adolescents and young adults compared to their peers: an examination of interaction with mental health morbidity

PURPOSE

Compare occurrence of self-inflicted injuries among transgender and gender diverse (TGD) youth to that of their cisgender peers while accounting for mental health diagnoses.

METHODS

Review of electronic health records from three integrated health care systems identified 1087 transfeminine and 1431 transmasculine adolescents and young adults. Poisson regression was used to calculate prevalence ratios comparing the proportion of TGD participants with at least one self-inflicted injury (a surrogate for suicide attempt) before index date (first evidence of TGD status) to the corresponding proportions in presumed cisgender male and female referents matched on age, race/ethnicity, and health plan. Interactions between gender identities and mental health diagnoses were assessed on multiplicative and additive scales.

RESULTS

TGD adolescents and young adults were more likely to have a self-inflicted injury, various mental health diagnoses, and multiple mental health diagnoses than their cisgender peers. The prevalence of self-inflicted injuries among TGD adolescents and young adults was high even in the absence of mental health diagnoses. Results were consistent with positive additive interaction and negative multiplicative interaction.

CONCLUSIONS

Universal suicide prevention efforts for all youth, including those with no mental health diagnoses, and more intensive suicide prevention efforts for TGD adolescents and young adults and those with at least one mental health diagnosis are warranted.

Innovations and Opportunities in Care for Black Mothers and Birthing People

In recent years, there has been increased attention given to how racism fuels health inequities, including the inadequacy of prenatal care (PNC) that Black women and Black birthing people receive. This increase of attention has brought notable advancements in research, practice, and policy that intend to better understand and address these systemic inequities within the health care system. This review aims to provide an overview of promising developments in the study of Black mothers' and birthing people's experiences in PNC and delivery, to detail current research surrounding interventions to improve quality and mitigate bias in obstetric care, and to offer ways in which legislation can support such strategies targeting the root causes of inequities in care.

A rapid realist review of universal interventions to promote inclusivity and acceptance of diverse sexual and gender identities in schools

Universal interventions to promote inclusivity and acceptance of diverse sexual and gender identities in schools could help to prevent mental health problems in this population. We reviewed evidence and developed programme theories to explain which universal interventions work, for whom, in which contexts and why. We conducted a rapid realist review and extracted data in context-mechanism-outcome configurations, to develop and refine programme theories. We included 53 sources and identified five intervention themes: student pride clubs, inclusive antibullying and harassment policies, inclusive curricula, workshops and staff training. Here, we show that these interventions could work by reducing discrimination, bullying and marginalization. Interventions appear to work best when school staff are trained and the school climate is supportive and may be less effective for boys, gender minority students and bisexual students. Our findings provide guiding principles for schools to develop interventions and should encourage primary research to confirm, refute or refine our programme theories.

Latine Transgender/Gender Diverse Adolescents: Protective Factors Against Emotional Distress

Purpose: Latine transgender/gender diverse (TGD) adolescents may be at increased risk of emotional distress due to structural oppression affecting their intersecting nondominant identities. Multiple protective factors may buffer emotional distress among Latine TGD adolescents. We studied how these protective factors relate to emotional distress, comparing Latine with non-Latine TGD students. Methods: We conducted a cross-sectional analysis of the 2019 Minnesota Student Survey, which included 3861 TGD and gender questioning (GQ) youth (10.9% Latine) in grades 8, 9, and 11 across Minnesota. We used multiple logistic regression with interaction terms to examine associations between protective factors (school connectedness, family connectedness, and internal assets) and emotional distress (depressive symptoms, anxiety symptoms, self-harm, suicidal ideation, and suicide attempt) between Latine TGD/GQ students and non-Latine TGD/GQ students. Results: There was a significantly higher rate of suicide attempts in Latine TGD/GQ students (36.2%) compared with non-Latine TGD/GQ students (26.3%, χ2 = 15.53, p < 0.001). In unadjusted models, school connectedness, family connectedness, and internal assets were associated with lower odds of all five indicators of emotional distress. In fully adjusted models, family connectedness and internal assets remained associated with significantly lower odds of all five indicators of emotional distress; these protective associations were similar across all TGD/GQ students regardless of Latine identity. Conclusion: Higher rates of suicide attempts in Latine TGD/GQ youth emphasize the need to better understand protective factors in youth with multiple nondominant social identities and identify programming that supports well-being. Family connectedness and internal assets can protect against emotional distress among both Latine and non-Latine TGD/GQ youth.

Intersectional microaggressions, depressive symptoms, and the role of LGBTQ-specific parental support in a sample of Latinx sexual and gender minority youth

INTRODUCTION

Latinx and sexual and gender minority (SGM) youth experience higher incidents of racism, cissexism, and heterosexism in the forms of overt discrimination and microaggressions. These experiences could in part explain increased negative mental health outcomes, such as depressive symptoms. Evidence points to the possibility that LGBTQ-specific parental support buffers the effects of intersectional microaggressions on depressive symptoms among Latinx SGM youth.

METHODS

In a sample of 1292 Latinx SGM youth (ages 13-17), we assessed: a) the association between LGBTQ-specific parental support and depressive symptoms, b) the associations between three forms of intersectional microaggressions and depressive symptoms, and c) whether parental LGBTQ-specific parental support moderated the relationship between three forms of intersectional microaggressions and depressive symptoms. Main effect and moderation analyses examined interactions between LGBTQ-specific parental support with each of the three forms of intersectional microaggressions on depressive symptoms.

RESULTS

We found that Latinx transgender youth experienced higher intersectional microaggressions compared to their cisgender counterparts and that Latinx SGM youth who reported lower LGBTQ-specific parental support experienced higher depressive symptoms. We also identified a significant interaction between intersectional microaggressions and LGBTQ-specific parental support, suggesting that parental support was more protective at low rather than high levels of intersectional microaggressions.

CONCLUSIONS

Findings suggest a need for future work examining culturally appropriate approaches to foster a supportive parent-child relationship among Latinx SGM youth and their parental figures.

The Role of School and Community Involvement in the Psychosocial Health Outcomes of Black and Latinx LGBTQ Youth

PURPOSE

Lesbian, gay, bisexual, transgender, and queer-identified (LGBTQ) youth of color face poorer psychosocial health outcomes than their non-LGBTQ peers. Research suggests school-based and community activities promote psychosocial health for LGBTQ youth, but study samples are predominantly White. This study tested whether school enrollment and seven community activities were associated with LGBTQ community connectedness, happiness, and health among Black and Latinx LGBTQ youth.

METHODS

This study used a subsample of Black and Latinx LGBTQ adolescents and young adults (N = 472) from the Social Justice Sexuality project. Mean differences in study variables were examined across intersectional racial/gender identity categories. Multiple regression analyses assessed the association of school enrollment and community activities with psychosocial health outcomes, accounting for covariates.

RESULTS

Social activities for LGBTQ people (ß = 0.19) and LGBTQ people of color (POC; ß = 0.15) were associated with greater LGBTQ connectedness. While moderate religious services attendance (ß = -0.13) was associated with lower LGBTQ connectedness, high attendance was associated with greater happiness (ß = 0.13) and health (ß = 0.12). Social activities for LGBTQ-POC (ß = 0.13) were also associated with better health. School enrollment was not significantly associated with any outcomes and Latinx transgender and diverse youth had the lowest happiness and health.

DISCUSSION

Social activities for LGBTQ people and LGBTQ-POC may play a role in the social connectedness and health of Black and Latinx LGBTQ youth, while frequent religious service attendance may support health and happiness. Schools and faith institutions should ensure their institutions are welcoming to LGBTQ youth. Public health workers might facilitate the involvement and inclusion of LGBTQ youth, while policy should support funding for community activities.

Gender Felt Pressure, Affective Domains, and Mental Health Outcomes among Transgender and Gender Diverse (TGD) Children and Adolescents: A Systematic Review with Developmental and Clinical Implications

Although capable of mobilizing significant resilience factors to face stigma and discrimination, transgender and gender diverse (TGD) children and adolescents tend to suffer from more adverse mental health outcomes compared to their cisgender counterparts. The minority stressors that this population faces are mainly due to the gender-based pressure to conform to their assigned gender. This systematic review was aimed at assessing the potential mental health issues that affect the TGD population. The literature search was conducted in three databases; namely, Scopus, PubMed, and Web of Science, based on the PRISMA guidelines. The 33 articles included in the systematic review pointed out how TGD children and adolescents experience high levels of anxiety and depression, as well as other emotional and behavioral problems, such as eating disorders and substance use. Resilience factors have been also pointed out, which aid this population in facing these negative mental health outcomes. The literature review highlighted that, on the one hand, TGD individuals appear to exhibit high levels of resilience; nonetheless, health disparities exist for TGD individuals compared with the general population, which are mainly attributable to the societal gender pressure to conform to their assigned gender. Considerations for research and clinical practice are provided.

Transgender and other gender diverse adolescents with eating disorders requiring medical stabilization

BACKGROUND

Despite the high prevalence of eating disorders in gender diverse adolescents, little is known about the characteristics of gender diverse youth with eating disorders who require inpatient medical stabilization. The primary objective of this study was to describe the medical, anthropometric, and psychiatric characteristics of gender diverse adolescents hospitalized for eating disorders and compare these characteristics to cisgender peers hospitalized for eating disorders. The secondary objective was to evaluate percent median body mass index as one marker of malnutrition and treatment goal body mass index as a recovery metric between patients' birth-assigned sex and affirmed gender using standardized clinical growth charts.

METHODS

A retrospective chart review was conducted of 463 patients admitted to an inpatient eating disorders medical unit between 2012 and 2020. To compare medical, anthropometric, and psychiatric data between gender diverse and cisgender patients, chi-square/Fisher's exact and t-tests were used. Clinical growth charts matching the patients' birth-assigned sex and affirmed gender identity were used to assess percent of median body mass index and treatment goal body mass index.

RESULTS

Ten patients (2.2%) identified as gender diverse and were younger than cisgender patients [13.6 (1.5) years vs. 15.6 (2.7) years, p = 0.017]. Gender diverse patients were hospitalized with a higher percent median body mass index compared to cisgender peers [97.1% (14.8) vs. 87.9% (13.7), p = 0.037], yet demonstrated equally severe vital sign instability such as bradycardia [44 (8.8) beats per minute vs. 46 (10.6) beats per minute, p = 0.501], systolic hypotension [84 (7.1) mmHg vs. 84 (9.7) mmHg, p = 0.995], and diastolic hypotension [46 (5.8) mmHg vs. 45 (7.3) mmHg, p = 0.884]. Gender diverse patients had a higher prevalence of reported anxiety symptoms compared to cisgender patients (60% vs. 28%, p = 0.037).

CONCLUSIONS

Gender diverse patients demonstrated complications of malnutrition including vital sign instability despite presenting with a higher weight. This is consistent with a greater proportion of gender diverse patients diagnosed with atypical anorexia nervosa compared to cisgender peers. Additionally, psychiatric comorbidities were present among both groups, with a larger percentage of gender diverse patients endorsing anxiety compared to cisgender patients.

Experiences of discrimination or violence and health outcomes among Black, Indigenous and People of Colour trans and/or nonbinary youth

AIMS

Identify the relationship between experiences of discrimination or violence and health outcomes for transgender and nonbinary Black, Indigenous and People of Colour (BIPOC) compared to their white trans and nonbinary peers.

DESIGN

A national online survey, the 2019 Canadian Trans and Nonbinary Youth Health Survey, was conducted among youth ages 14-25, in English and French.

METHODS

Participants were recruited from November 2018 to May 2019 (N = 1519). BIPOC youth comprised 25.7% of the sample (n = 390). Questions about six types of discrimination (e.g. racism and sexism) and violence (physically threatened or injured), plus foregone health care, self-harm and suicidality were drawn from existing validated measures. Analyses involved cross-tabulations with chi-square tests and logistic regressions.

RESULTS

Trans and non-binary BIPOC reported significantly higher prevalence of suicide attempts (24.9% vs. 19.5%) and violence victimization compared to white youth. They had significantly higher odds of self-harm and foregone health care when experiencing discrimination by ethnicity or culture. All types of violence were significantly associated with higher odds of foregone physical health care, self-harm, suicide ideation and suicide attempt.

CONCLUSION

In Canada, trans and nonbinary youth who are BIPOC face disparities in health outcomes and experiences of violence and discrimination compared to white trans and nonbinary youth.

IMPACT

Nurses should assess for violence exposure and discrimination among trans and/or nonbinary youth of colour, and promote health equity by advocating for policies to reduce violence and discrimination, including racism, for trans and nonbinary young people.

Syndemic relationship of depressive symptoms, substance use, and suicidality in transgender youth: a cross-sectional study using the U.S. youth risk behavior surveillance system

PURPOSE

Syndemics are co-occurring epidemics that cluster within populations due to shared socio-structural factors and are often in populations with intersecting forms of vulnerability. Suicide, depression, and substance use all disproportionately affect transgender and gender diverse (TGD) youth. In this study, we test a syndemic model of the relationship between these three mental health conditions in the context of economic deprivation and interpersonal discrimination.

METHODS

We used data on substance use, depressive symptoms, suicidality, and social-structural factors from 2680 TGD youth captured in the 2017 and 2019 survey waves of the Youth Risk Behavior Surveillance System. We used a latent class analysis (LCA) to identify groups with distinct patterns of self-reported substance use and depressive symptoms, and regression models to characterize the relationship between substance-use, depressive symptoms, class membership, social-structural factors, and suicidality.

RESULTS

A three-class LCA solution identified a subset of student respondents in a "high use" latent class characterized by high self-reported substance use frequency and depressive symptoms compared with other classes. Online bullying (aOR: 1.58; 95% CI: 1.28-1.95) and housing insecurity (aOR: 8.78; 95% CI: 4.35-17.71) were associated with increased odds of "high use" class membership relative to the "no use" class membership. "High use" class membership was associated with increased odds of suicidal ideation (aOR: 2.26; 95% CI: 1.75-2.94), plans (aOR: 2.59; 95% CI: 2.01-3.36), and attempts (aOR: 6.85; 95% CI: 3.17-15.68).

CONCLUSION

The co-occurrence of substance use and depressive symptoms is associated with socio-structural factors and may drive risk for suicidality among TGD youth. Meaningful suicide prevention efforts that address disproportionate risk in this population must be attentive to and mitigate the shared determinants of mood symptoms and substance use behavior.

Mental health in transgender individuals: a systematic review

Several lines of evidence indicate the prevalence of mental health disorders in Transgender (TG) individuals is higher than that of cisgender individuals or the general population. In this systematic review, we aim to propose a summary of some of the most significant research investigating mental health disorders' prevalence among this population. We performed a double-blind systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting (PRISMA) on PUBMED/MEDLINE and SCOPUS, specifically using peer-reviewed articles examining the mental health status of transgender (TG) individuals. This review did not exclude any research based on publication date. The last search was performed in February 2022. The employed search strategy led to the selection of 165 peer-reviewed articles. The majority of these papers presented a cross-sectional design with self-reported diagnoses and symptoms, signaling a significant prevalence of mental health disorders amongst TG Individuals. Of the reviewed articles, 72 examined the prevalence of mood and anxiety disorders; 8 examined eating disorders; 43 examined the prevalence of suicidal or self-harm ideation or behaviors; 5 papers examined the prevalence of trauma and stress-related disorders; 10 examined the frequency of personality disorders; 44 examined substance use disorders; and 9 papers examined the prevalence of autism spectrum disorder. Finally, 22 studies reported on the prevalence of TG individuals diagnosed with co-morbid mental health disorders or unspecified mental disorders. Our findings coincide with existing research, which indicates TG individuals do experience a higher prevalence of mental health disorders than that of the general population or cisgender individuals. However, further research is needed to address the existing gaps in knowledge.

Associations between minority stress, depression, and suicidal ideation and attempts in transgender and gender diverse (TGD) individuals: Systematic review and meta-analysis

Minority stress theory posits that transgender and gender diverse (TGD) individuals exhibit greater rates of depression and suicidality due to internal (proximal) and external (distal) stressors related to their TGD identity. Yet, the magnitude of the relationship between minority stress processes and mental health outcomes has not been quantitatively summarized. The current research meta-analyzed the relationship between minority stress constructs and depression, suicidal ideation, and suicide attempt. Results from 85 cross-sectional quantitative studies indicate that distal stress, expectations of rejection, internalized transphobia, and concealment are significantly associated with increased depression, suicidal ideation, and suicide attempt. Greater effect sizes were observed for expectations of rejection and internalized transphobia when compared to distal stress and concealment. Future research on the relationship between minority stress, depression, and suicide would benefit from longitudinal designs and more diverse and representative samples of TGD individuals.

Association between First Sexual Intercourse and Sexual Violence Victimization, Symptoms of Depression, and Suicidal Behaviors among Adolescents in the United States: Findings from 2017 and 2019 National Youth Risk Behavior Survey

The objective of this study was to investigate the association between first sexual intercourse and sexual violence victimization, symptoms of depression, and suicidal ideation among sexually active adolescents in the United States. Data for this study came from the U.S. 2017 and 2019 iterations of the National Youth Risk Behavior Survey. An analytic sample of 6252 adolescents aged 14–18 years old (49.5% female) who reported ever having sexual intercourse was analyzed using Poisson regression. The outcome variables investigated in this study were sexual violence victimization, symptoms of depression, suicidal ideation, a suicide plan, and suicide attempts, and the main explanatory variables were age at first sexual intercourse and forced sexual intercourse. We also analyzed differences by gender and race. Of the 6252 adolescents who reported ever having sexual intercourse, 7.1% had their first sexual intercourse before age 13, and 14.8% experienced forced sexual intercourse. About 16% of adolescents experienced sexual violence during the past year, 42.6% reported symptoms of depression, 23.9% experienced suicidal ideation, 19.3% made a suicide plan, and 11.1% attempted suicide during the past year. In the regression analysis, early sexual intercourse was significantly and positively associated with suicidal ideation (relative risk (RR) = 1.15, 95% Confidence Interval (CI) = 1.02–1.30), suicide plan (RR = 1.18, 95% CI = 1.00–1.38), and suicide attempts (RR = 1.36, 95% CI = 1.15–1.61). Controlling for the effects of covariates, history of forced sexual intercourse was positively associated with the five outcomes examined with the relative risk ranging between 1.59 and 6.01. Findings of this study suggest that history of early or forced sexual intercourse is associated with poor mental health outcomes among adolescents and underscores the importance of developing interventions that offer psychological support in reducing the adverse impact of early sexual intercourse and forced sexual intercourse on adolescent health.

Take the T out, put the T in: Gender-affirming hormones in youth

BACKGROUND

An increasing number of adolescents are seeking gender care at clinics and hospital programs, and requesting gender-affirming hormonal treatment. The interventions can either include suppression of testosterone and introduction of estrogen, or suppression of estrogen and introduction of testosterone.

AIMS

This review article focuses on the psychosocial experiences of youth who have completed their endogenous puberty and are now requesting one of these two forms of gender-affirming hormonal treatment. We investigate the comparative profiles of these two subgroups of transgender/gender-expansive youth.

MATERIALS AND METHODS

Review of research data, established standards of care and practice guidelines, and clinical observations.

RESULTS

Differences and similarities are noted and discussed in several realms: gender-related experiences prior to receiving hormonal treatment; the relationship between the physical changes and psychological experiences that accompany the introduction of testosterone or suppression of testosterone with replacement with estrogen; the intrapersonal and interpersonal implications of the treatment; considerations of fertility preservation for future family building; the role of the family in the decision-making process prior to starting a course of hormone therapy; and the capacity of youth to make informed decisions about these partially irreversible medical interventions.

DISCUSSION

Medical providers who offer gender-affirming hormonal care to youth should work with the family and allied professionals to assure that the youth's gender health is enhanced, barriers to care are removed, and mental health risks are reduced, whether the T is coming out or going in.

CONCLUSION

The cohort of youth who come to medical providers after completing puberty, and request gender-affirming hormones in the form of increases or reductions in T have a great deal in common, and also extensive variation among them.