Self-injury among trans individuals and matched controls: prevalence and associated factors

Daily and Momentary Associations Between Gender Minority Stress and Resilience With Alcohol Outcomes

BACKGROUND AND PURPOSE

Minority stressors have been linked with alcohol use among transgender and gender diverse (TGD); however, no ecological momentary assessment studies have examined daily links between minority stress and alcohol use specifically among TGD. This study examined gender minority stressors and resilience as predictors of same-day or momentary alcohol-related outcomes. Feasibility and acceptability of procedures were evaluated.

METHODS

Twenty-five TGD adults (mean age = 32.60, SD = 10.82; 88% White) were recruited Canada-wide and participated remotely. They completed 21 days of ecological momentary assessment with daily morning and random surveys (assessing alcohol outcomes, risk processes, gender minority stressors, resilience), and an exit interview eliciting feedback.

RESULTS

Gender minority stress had significant and positive within-person relationships with same-day alcohol use (incidence risk ratio (IRR) = 1.12, 95% confidence interval [CI] [1.02, 1.23]), alcohol-related harms (IRR = 1.14, 95% CI [1.02, 1.28]), and coping motives (IRR = 1.06, 95% CI [1.03, 1.08]), as well as momentary (past 30-min) alcohol craving (IRR = 1.32, 95% CI [1.18, 1.47]), coping motives (IRR = 1.35, 95% CI [1.21, 1.51]), and negative affect (IRR = 1.28, 95% CI [1.20, 1.36]). Gender minority stress indirectly predicted same-day drinking via coping motives (ab = 0.04, 95% CI [0.02, 0.08]). Resilience was positively associated with same-day alcohol use (IRR = 1.25, 95% CI [1.03, 1.51]) but not harms.

CONCLUSIONS

TGD adults may use alcohol to cope with gender minority stress, which can increase the risk for alcohol-related harms. Interventions are needed to eliminate gender minority stressors and support adaptive coping strategies.

Risk and protective factors for self-harm thoughts and behaviours in transgender and gender diverse people: A systematic review

Background

Self-harm (any self-injury or -poisoning regardless of intent) is highly prevalent in transgender and gender diverse (TGD) populations. It is strongly associated with various adverse health and wellbeing outcomes, including suicide. Despite increased risk, TGD individuals' unique self-harm pathways are not well understood. Following PRISMA guidelines we conducted the first systematic review of risk and protective factors for self-harm in TGD people to identify targets for prevention and intervention.

Methods

We searched five electronic databases (PubMed, PsychInfo, Scopus, MEDLINE, and Web of Science) published from database inception to November 2023 for primary and secondary studies of risk and/or protective factors for self-harm thoughts and behaviours in TGD people. Data was extracted and study quality assessed using Newcastle-Ottawa Scales.

Findings

Overall, 78 studies published between 2007 and 2023 from 16 countries (N = 322,144) were eligible for inclusion. Narrative analysis identified six key risk factors for self-harm in TGD people (aged 7-98years) were identified. These are younger age, being assigned female at birth, illicit drug and alcohol use, sexual and physical assault, gender minority stressors (especially discrimination and victimisation), and depression or depressive symptomology. Three important protective factors were identified: social support, connectedness, and school safety. Other possible unique TGD protective factors against self-harm included: chosen name use, gender-identity concordant documentation, and protective state policies. Some evidence of publication bias regarding sample size, non-responders, and confounding variables was identified.

Interpretation

This systematic review indicates TGD people may experience a unique self-harm pathway. Importantly, the risk and protective factors we identified provide meaningful targets for intervention. TGD youth and those assigned female at birth are at increased risk. Encouraging TGD people to utilise and foster existing support networks, family/parent and peer support groups, and creating safe, supportive school environments may be critical for self-harm and suicide prevention strategies. Efforts to reduce drug and alcohol use and experiences of gender-based victimisation and discrimination are recommended to reduce self-harm in this high-risk group. Addressing depressive symptoms may reduce gender dysphoria and self-harm. The new evidence presented in this systematic review also indicates TGD people may experience unique pathways to self-harm related to the lack of social acceptance of their gender identity. However, robust longitudinal research which examines gender-specific factors is now necessary to establish this pathway.

The Role of Family Support and Dyadic Adjustment on the Psychological Well-being of Transgender Individuals: An Exploratory Study

Introduction

This study aimed to measure dyadic adjustment, social support, and psychological well-being.

Methods

A research protocol composed of the Dyadic Adjustment Scale, the Outcome Questionnaire 45.2, and the Multidimensional Scale of Perceived Social Support was administered to a sample of 109 Italian transgender individuals.

Results

Higher levels of global psychological distress, symptom severity, and interpersonal relationship distress were associated with lower levels of family support and dyadic adjustment. In addition, transgender women and younger transgender individuals reported higher levels of interpersonal relationship distress.

Conclusions

The results indicate that the support and acceptance of one's partner and family of origin play a crucial role in promoting well-being. It represents an important protective factor with respect to negative psychological health outcomes.

Policy Implications

The findings emphasize the need to develop specific clinical and social practices for transgender individuals and their families. Building family and partner-centered policies and programs is particularly important to enable transgender individuals to avoid paying the emotional and psychological costs associated with rejection and non-acceptance.

Gender-Affirming Care of Transgender and Gender-Diverse Youth: Current Concepts

Increasing numbers of transgender and gender-diverse (TGD) youth, from early puberty through late adolescence, are seeking medical services to bring their physical sex characteristics into alignment with their gender identity-their inner sense of self as male or female or elsewhere on the gender spectrum. Numerous studies, primarily of short- and medium-term duration (up to 6 years), demonstrate the clearly beneficial-even lifesaving-mental health impact of gender-affirming medical care in TGD youth. However, there are significant gaps in knowledge and challenges to such care. Long-term safety and efficacy studies are needed to optimize medical care for TGD youth.

Social Support as a Buffer of the Association between Sexual Assault and Trauma Symptoms Among Transgender and Gender Diverse Individuals

The prevalence of experiencing sexual assault is alarmingly high among Transgender and Gender Diverse people (TGD; people whose gender identities and/or expressions are not traditionally associated with their sex assigned at birth) and is associated with various mental health sequalae. Perceived social support has been shown to abate the negative outcomes of sexual assault among cisgender individuals, yet little is known about this association among TGD people, especially which provider of support (i.e., family, friends, or significant others) may be most beneficial. To that end, 191 TGD adults were recruited through Amazon's Mechanical Turk to examine perceived social support as a potential moderator of the association between sexual assault victimization and post-sexual assault trauma symptomology. Results showed an interaction trending toward significance between sexual assault and support from a significant other. Decomposition of this interaction demonstrated that sexual assault was associated with post-assault trauma symptoms when support from a significant other was low (ß = .25, p < .05) but not high (ß = .10, p = .089). The interaction between sexual assault and perceived social support was not significant for perceived support from friends (p = .133) or family (p = .954). Findings highlight the need for additional research on perceived social support as a potential buffering mechanism between sexual assault and post-assault symptomology in TGD people.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

Resilience among LGBTQIA+ youth in out-of-home care: A scoping review

BACKGROUND

Research on the experiences of LGBTQIA+ youth in out-of-home care has mainly focused on these youth's adversities and the resulting negative impact on their wellbeing. Little is known about the ways through which LGBTQIA+ youth in out-of-home care are resilient to these adversities. To date, a review study on resilience in this population is lacking.

OBJECTIVE

To map and synthesize the existing research on resilience among LGBTQIA+ children and youth in out-of-home care. Specific goals were to summarize and analyze 1) the general characteristics of the existing studies, and 2) the resilience resources found at the individual, relational, sociocultural, and ecological levels.

METHODS

We carried out a scoping review examining empirical published academic literature.

RESULTS

The 14 studies included in this scoping review indicated that resilience studies among LGBTQIA+ youth in out-of-home care are mainly qualitative, cross-sectional, US-based, and were centered on gay youth. Studies suggested that resilience resources were mostly focused at the socio/relational level (e.g., foster family acceptance) with fewer studies at the individual (e.g., LGBTQ positive identity), and community levels (e.g., LGBTQ centers). Importantly, no studies explored the interaction of resilience resources across these different domains.

CONCLUSIONS

Resilience among LGBTQIA+ youth in out-of-home care remains understudied and the results of this scoping review point to specific research gaps. Recommendations are provided for research, practice, and policy.

Self-harm and suicidality among LGBTIQ people: a systematic review and meta-analysis

Research evidence has consistently documented a higher risk of suicidality in the Lesbian, Gay, Bisexual, Transgender, Intersex, and Queer (LGBTIQ) population. This systematic review and meta-analysis aimed to report a detailed description of research data regarding the risk of Attempted Suicide (SA), Suicide Ideation (SI), and Non-Suicidal Self-Injury (NSSI) behaviours for LGBTIQ people and their subgroups. Medline, Scopus, PsycINFO, and EMBASE were searched for studies reporting a comparative estimation of SA, SI, and NSSI rates among LGBTIQ population and the general population (i.e. heterosexual/cisgender), without restrictions on participants' age and setting for the enrolment. Pooled analyses were based on odds ratios (ORs, with 95% CIs), estimated through inverse variance models with random effects. Fifty studies were selected for the quantitative synthesis and included fifty samples involving 3.735.601 controls and 87.252 LGBTIQ people. LGBTIQ people reported an increased risk of SA (OR:4.36[95%CI:3.32;5.71]), SI (OR:3.76[95%CI:3.02;4.69]), and NSSI (OR:4.24[95%CI:3.23;5.55]). Among LGBTIQ subgroups, the Bisexual group has shown the highest risk of suicidality (SA, OR:6.71; SI, OR:5.04; NSSI, OR: 5.03), followed by the Lesbian-Gay for attempted suicide (SA, OR:6.03), and the Transgender-Intersex-Queer for suicide ideation and non-suicidal self-injury (SI and NSSI, OR:3.42). The quality of the evidence ranged from low to moderate. Our findings have shown that LGBTIQ people report a higher risk of suicidality compared with their cisgender/heterosexual peers. This evidence may contribute to the public awareness on LGBTQI mental health needs and suggest supportive strategies as well as preventive interventions (e.g. supportive programs, counselling, and destigmatizing efforts) as parts of a tailored health-care planning aimed to reduce psychiatric morbidity and mortality in this at-risk population.

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.

Examining the Mental Health Presentations of Treatment-Seeking Transgender and Gender Nonconforming (TGNC) Youth

Recent research suggests that transgender and/or gender nonconforming (TGNC) youth present with heightened levels of mental health problems compared to peers. This study seeks to examine the mental health needs of a large sample of treatment-seeking TGNC youth by comparing them to cisgender males and females. Participants were 94,804 children and youth ages 4-18 years (M = 12.1, SD = 3.72) who completed the interRAI Child and Youth Mental Health Instrument (ChYMH) or Screener (ChYMH-S) at participating mental health agencies in the Ontario, Canada. Overall, the mental health presentations of TGNC youth were similar to cisgender females but at higher acuity levels. TGNC youth showed significantly higher levels of anxiety, depression, social disengagement, positive symptoms, risk of suicide/self-harm, and were more likely to report experiencing emotional abuse, past suicide attempts, and a less strong, supportive family relationship than cisgender females and males. Clinical implications of these findings are discussed.

Challenges in the care of transgender and gender-diverse youth: an endocrinologist's view

An increasing number of transgender and gender-diverse (TGD) youth (early pubertal through to late adolescent, typically 9-10 through to 18 years of age) are seeking medical services to bring their physical sex characteristics into alignment with their gender identity - their inner sense of self as male or female or somewhere on the gender spectrum. Compelling research has demonstrated the clear mental health - even life-saving - benefits of gender-affirming care, but current clinical practice guidelines and standards of care are based on only several short-term and a few medium-term outcomes studies complemented by expert opinion. Nevertheless, although the relative paucity of outcomes data raises concerns, the stance of not intervening until more is known is not a neutral option, and large observational studies evaluating current models of care are necessary and are now underway. This Review highlights key advances in our understanding of transgender and gender-diverse youth, the challenges of providing gender-affirming care, gaps in knowledge and priorities for research.

Anxiety and Depression Among Transgender People: Findings from a Cross-Sectional Online Survey in Russia

Purpose: As we still do not know enough about the mental health concerns of gender minority people in Russia, there is a need to initiate research on these issues. We aimed to examine the frequency of anxiety and depression symptoms in a Russian sample of transgender people. Methods: The study consisted of a structured online survey and was conducted throughout November 2019. The Hospital Anxiety and Depression Scale was used for online screening of anxiety and depression symptoms. A total of 588 transgender adults living in all Federal Districts of Russia (mean age 24.0 ± standard deviation 6.7) was included in the final analysis. Results: It was found that 45.1% (n = 265) and 24.0% (n = 141) of transgender people had clinically significant levels of anxiety and depression, respectively. No statistically significant differences in the prevalence of anxiety and depression were found among those who identified as a transgender man, a transgender woman, or other transgender identities. The anxiety and depression mean scores in the sample were statistically significantly higher than in the general Russian population (p < 0.001). No statistically significant differences were found in the level of depression and anxiety symptoms among respondents in Moscow, St. Petersburg, and other Russian cities. Conclusions: We found high rates of clinical symptoms of depression and anxiety among transgender people, consistent with international research. The study highlights the need for further research on the psychological well-being and mental health of transgender people, and the availability of psychiatric care to transgender people living in Russia.

Prevalence and Risk Factors for Nonsuicidal Self-Injury in Transgender and Gender-Expansive Youth at a Rural Gender Wellness Clinic

Purpose: Transgender and gender-expansive (TGE) populations are at increased risk for nonsuicidal self-injury (NSSI). Rural TGE populations are understudied and underserved in terms of mental health services. The purpose of this study was to determine lifetime prevalence of NSSI among TGE youth at a rural gender wellness clinic and identify demographic and clinical characteristics associated with NSSI. Methods: The Gender Wellness Center Pediatric Patient Registry, a comprehensive database of 185 TGE youth ≤25 years of age, provided an estimate of the lifetime prevalence of NSSI. Univariate logistic regression models were utilized to test associations between patient demographic and clinical characteristics and NSSI. Variables that met the threshold for significance in the univariate analyses (p<0.05) were entered into a multivariate logistic regression model. All statistical analyses were conducted in SAS v.9.4. Results: Prevalence of NSSI in the sample was 36.8% (n=68). In unadjusted logistic regression models, risk factors for NSSI included female assigned sex at birth, transmasculine spectrum gender identity, history of mood disorder, history of suicidal ideation (SI) or attempt, and history of abuse (p<0.05). In the adjusted model, variables significantly associated with NSSI included female assigned sex at birth, history of mood disorder, and history of SI or attempt. Conclusion: NSSI was highly prevalent in this sample of rural TGE youth, confirming the need for screening and early interventions that target the unique vulnerabilities of TGE youth. The complex interplay of sex assigned at birth, mood disorders, and NSSI requires further research.

Differences in mental health symptom severity and care engagement among transgender and gender diverse individuals: Findings from a large community health center

Mental health disparities among transgender and gender diverse (TGD) populations have been documented. However, few studies have assessed differences in mental health symptom severity, substance use behavior severity, and engagement in care across TGD subgroups. Using data from the electronic health record of a community health center specializing in sexual and gender minority health, we compared the (1) severity of self-reported depression, anxiety, alcohol use, and other substance use symptoms; (2) likelihood of meeting clinical thresholds for these disorders; and (3) number of behavioral health and substance use appointments attended among cisgender, transgender, and non-binary patients. Participants were 29,988 patients aged ≥18 who attended a medical appointment between 2015 and 2018. Depression symptom severity (F = 200.6, p < .001), anxiety symptom severity (F = 102.8, p < .001), alcohol use (F = 58.8, p < .001), and substance use (F = 49.6, p < .001) differed significantly by gender. Relative to cisgender and transgender individuals, non-binary individuals are at elevated risk for depression, anxiety, and substance use disorders. Gender was also associated with differences in the number of behavioral health (χ2 = 51.5, p < .001) and substance use appointments (χ2 = 39.3, p < .001) attended. Engagement in treatment among certain gender groups is poor; cisgender women and non-binary patients assigned male at birth were the least likely to have attended a behavioral health appointment, whereas transgender men and cisgender women had attended the lowest number of substance use appointments. These data demonstrate the importance of (1) assessing gender diversity and (2) addressing the barriers that prevent TGD patients from receiving affirming care.

The relationship of the UPPS model of impulsivity on bulimic symptoms and non-suicidal self-injury in transgender youth

OBJECTIVE

This brief report examined the relationship of negative urgency (the tendency to act rashly in response to negative emotional states), (lack of) perseverance, (lack of) premeditation, and sensation seeking in association with non-suicidal self-injury (NSSI) and symptoms of bulimia nervosa (BN) in a sample of treatment-seeking transgender (TG) youth.

METHOD

Eighty-six TG youth with a mean age of 17 (sd = 3.2) agreed to participate in the study. The majority of our sample identified as TG male (n = 60) with 20 participants identifying as TG female and 6 identifying as non-binary. The racial ethnic breakdown of our sample was 8.2% Black, 8.2% Multi-racial, 1.2% Native American, and 82.4% White. Over ¼ of our sample endorsed at least one episode of objective binge eating in the last 28 days and 62% endorsed a history of NSSI.

RESULTS

Negative urgency was significantly associated with the odds of NSSI, objective binge eating, and general eating disorder symptoms. Lack of premeditation was significantly related to the odds of NSSI only. No other factors were significantly associated with NSSI or symptoms of BN.

CONCLUSIONS

Negative urgency appears to be an important personality construct in understanding increased risk for NSSI and BN symptoms in transgender youth.

Suicidality, self-harm, and their correlates among transgender and cisgender people living in Aotearoa/New Zealand or Australia

BACKGROUND

Transgender people experience high rates of suicidality and self-harm. Past research has established a range of correlates of suicidality/self-harm among transgender people but little is known about whether these correlates are similar for transgender and cisgender people.

AIMS

The aim of this study was to test whether a range of potential demographic and psychosocial correlates of suicidality/self-harm hold for both transgender and cisgender people living in Aotearoa/New Zealand and Australia.

METHODS

An online survey was completed by 700 adults living in Aotearoa/New Zealand (n = 328) or Australia (n = 372). Targeted advertising was used to recruit transgender respondents (n = 392) and cisgender respondents (n = 308). Participants completed questions about demographics, discrimination (the Everyday Discrimination Scale), distress (the Kessler-10 scale), social support (the Multi-Dimensional Scale of Perceived Social Support), resilience (the Brief Resilience Scale), suicidality (the Suicidal Ideation Attributes Scale and other questions about ideation/attempts), and self-harm (the Deliberate Self-Harm Inventory).

RESULTS

Lifetime suicidal ideation, lifetime suicide attempts, and lifetime self-harm were more common among transgender participants. Discrimination was associated with lifetime suicide attempts and lifetime self-harm, particularly for transgender participants. Distress was consistently associated with recent suicidality and self-harm for transgender participants. Younger cisgender participants were more likely to report lifetime self-harm. Recent suicidal ideation was associated with lower social support among transgender participants but with lower resilience among cisgender participants.

DISCUSSION

These findings reaffirm and expand on past research on suicidality/self-harm among transgender or cisgender people and demonstrate the relevance of tackling discrimination and distress experienced by transgender people. In addition, the findings highlight the importance of meeting additional social support needs among transgender people to help prevent suicide and self-harm.

Trans, gender diverse and non-binary adult experiences of social support: A systematic quantitative literature review

Background: Trans, gender diverse and non-binary (TGDNB) adults experience significant health disparities relative to their cisgender peers. While social support is a known health-protective factor within the general population, no systematic reviews of TGDNB experiences of social support exist. Aim: To systematically review prior research of social support for TGDNB adults. We sought to assess the defining characteristics of the research, the participants and the research findings, mapping emerging trends across disciplines. Methods: Six electronic databases (PubMed, MEDLINE, CINAHL, Web of Science, LGBT Life and PsycNet) were searched for literature pertaining to TGDNB adults, social support, and health or well-being published in the past decade. Results: The findings illustrate a predominance of USA-based quantitative research that measures social support of friends, family and a singular intimate partner. The majority of participants were white, binary-identified transgender women and TGDNB people living in metropolitan settings. Social support was commonly reported as a protective factor, with TGDNB peer support the most frequently reported correlate of health and well-being for TGDNB adults. Discussion: The results suggest standardized inventories do not capture the emic nature of social support for TGDNB adults. A key opportunity lies in an inductive, hypothesis-forming approach to the study of what is socially supportive for TGDNB adults. In turn, this knowledge will enable the appropriate measurement, implementation and interpretation of social support studies.

Prevalence and correlates of non-suicidal self-injury among lesbian, gay, bisexual, and transgender individuals: A systematic review and meta-analysis

The current review presents a meta-analysis of the existing empirical literature on the prevalence of non-suicidal self-injury (NSSI) among lesbian, gay, bisexual, and transgender (LGBT) individuals, as well as on correlates of NSSI within sexual and gender minority populations. Eligible publications (n = 51) were identified through a systematic search of PsycINFO, MEDLINE, and Embase, supplemented by a search of references of prior reviews on this topic. NSSI prevalence rates were quite elevated among sexual (29.68% lifetime) and gender (46.65% lifetime) minority individuals compared to heterosexual and/or cisgender peers (14.57% lifetime), with transgender (46.65% lifetime) and bisexual (41.47% lifetime) individuals being at greatest risk. Even among these group findings, sexual minority youth emerged as an especially vulnerable population. Moreover, current evidence suggests these rates and differences between LGBT and heterosexual and/or cisgender peers have not declined over time. These findings may in some measure be due to the existence of LGBT-specific risk correlates combined with general risk correlates being more severe among sexual and gender minority populations. Additional research, particularly employing a longitudinal design, is needed in this area to advance efforts to reduce risk for NSSI among sexual and gender minority individuals.

Non-suicidal self-injury, suicide ideation, and past suicide attempts: Comparison between transgender and gender diverse veterans and non-veterans

BACKGROUND

Transgender and gender diverse (TGD) individuals, especially veterans, experience elevated rates of non-suicidal self-injury (NSSI) and suicide related behaviors compared to gender majority individuals. Research has yet to compare TGD veterans to non-veterans or look at correlates of NSSI and related behaviors to suicide related outcomes. This study examines prevalence and suicide related correlates of NSSI among TGD veterans and TGD non-veterans.

METHOD

Data analyzed in the were part of the Trans Lifeline Mental Health Survey. Both TGD veterans (N = 313) and non-veterans (N = 3,972) completed an online, cross-sectional survey that included self-report measures of NSSI, suicidal ideation (SI), and suicidal attempt (SA) along with lifetime hospitalization and avoidance of care due to NSSI.

RESULTS

Results of this paper indicate that prevalence of NSSI, SI, and SA are elevated in both the TGD veterans and non-veteran subpopulations. Further, veterans compared to non-veterans have a lower prevalence of NSSI but higher prevalence of hospitalization when self-harm is inflicted, reflecting more healthcare utilization or increased severity of NSSI episodes. Additionally, veterans were less likely to avoid care due to NSSI. Further, veteran status seemed to be a protective factor against demographic differences that increased rates of NSSI history in non-veteran TGD individuals.

LIMITATIONS

The limitations of this study include its cross-sectional study design, one question assessing SA, and few TGD male veterans.

CONCLUSION

NSSI is an important risk factor in future suicide related outcome such as SI and SA. Further, differences in healthcare utilization among TGD veterans and non-veterans are apparent.

Self-harm prevalence and ideation in a community sample of cis, trans and other youth

Background: Trans youth have been reported to have high rates of self-harm, depression and bullying, and find it difficult to seek support. However, much of this research comes from gender identity clinics; non-clinical samples and those who reject gender binaries remain under-researched. Aims: This study investigated the experiences of a community school-based sample of Trans, identifying youth, Other, and cis-gendered adolescents in relation to their experiences of low mood, bullying, associated support, self-harm ideation and peer-related self-harm. Methods: An online survey was completed by 8440 13-17 year olds (3625 male, 4361 female, 227 Other, and 55 Trans). Results: Trans and Other students had significantly higher rates of self-harm ideation and peer self-harm, in comparison to cis-gendered students. These Trans and Other students reported significantly higher rates of bullying and self-reported depression and significantly less support from teachers and staff at school, in fact these students did not know where to go to access help. Discussion: This community sample confirms findings of high rates of self-harm ideation, self-reported depression and bullying for Trans youth as previously reported in clinic-based samples. However, by accessing a community sample, the salience of the category "Other" was established for young people today. While Other and Trans identified students both struggled to find support, those who identified as Trans were more likely to have been bullied, and have experienced self-reported depression and thoughts of self-harm. Thus, those who identify as transgender represent a high-risk group that needs targeted support within schools and by statutory and nonstatutory community services. Unpacking the category of Other would be beneficial for future research, as well as exploring resilience within this group and intersecting identities such as sexuality, Autism, or experiences such as earlier abuse.

Risk and protective factors for mental health morbidity in a community sample of female-to-male trans-masculine adults

BACKGROUND

Trans-masculine (TM) individuals, who are assigned female sex at birth and identify along the masculine gender spectrum, face mental health disparities relative to cisgender people. Limited research has sought to explore the multi-level risk and protective factors associated with mental health morbidity for TM populations.

METHODS

Between August 2015-September 2016, 150 TM adults were enrolled in a one-time biobehavioral health study. A survey assessed socio-demographics, past 12-month everyday discrimination, lifetime intimate partner violence (IPV), resilience (using the Brief Resilience Scale), and other factors. Bivariate and multivariable logistic regression analyses examined associations between participant characteristics and four mental health statuses: post-traumatic stress disorder (PTSD), depression, anxiety, and non-suicidal self-injury (NSSI).

RESULTS

In this sample (76.7% had a binary gender identity, i.e., man or transgender man; 74.7% were white, 70.0% were under age 30 years), 42.2% had PTSD based on past 30-day symptoms; 25.7% had depression based on past 7-day symptoms; 31.1% had anxiety based on past 7-day symptoms; and 31.3% had engaged in NSSI within the past 12-months. Results from multivariable models: 1) PTSD: unemployment, lifetime IPV and past 12-month discrimination were each associated with increased odds of PTSD, while having a partner was associated with the reduced odds of PTSD. 2) Depression: lower educational attainment and past 12-month discrimination were each associated with the increased odds of depression, while greater resilience was associated with the reduced odds of depression. 3) Anxiety: low annual household income and past 12-month discrimination were each associated with the increased odds of anxiety, while resilience was associated with the reduced odds of anxiety. 4) NSSI: past 12-month discrimination was associated with the increased odds of past 12-month NSSI, while higher age and greater resilience was associated with the reduced odds of NSSI (all p-values < 0.05).

CONCLUSIONS

Unemployment, low income, limited education, everyday discrimination, and violence were risk factors for poor mental health, while being in a relationship, higher age, and personal resilience were protective against mental health morbidity. Findings highlight the need for interventions to address the individual, interpersonal, and societal factors that may be driving poor mental health in this population.

Autistic Traits in Treatment-Seeking Transgender Adults

The present study aimed to compare prevalence of autistic traits measured by the self-reported autism spectrum quotient-short (AQ-short) in a transgender clinical population (n = 656) matched by age and sex assigned at birth to a cisgender community sample. Results showed that transgender and cisgender people reported similar levels of possible autistic caseness. Transgender people assigned female were more likely to have clinically significant autistic traits compared to any other group. No difference was found between those assigned male. High AQ scores may not be indicative of the presence of an autism spectrum condition as the difference between groups mainly related to social behaviours; such scores may be a reflection of transgender people’s high social anxiety levels due to negative past experiences.

Stigma, gender dysphoria, and nonsuicidal self-injury in a community sample of transgender individuals

We investigated rates of nonsuicidal self-injury (NSSI) and correlates of past-year NSSI among transgender people to better understand factors contributing to this health disparity. A community-based sample of 332 transgender people participated in quantitative in-person interviews. The mean age of participants was 34.56 years (SD = 13.78, range = 16-87). The sample was evenly divided between transfeminine spectrum (50.3%) and transmasculine spectrum identities (49.7%) and was diverse in race/ethnicity. We evaluated associations between sociodemographic characteristics, stigma, hypothesized resilience factors, and identity variables with past-year NSSI. 53.3% of participants reported ever having self-injured in their lifetime. Past-year NSSI was reported by 22.3% of the sample and did not significantly differ based on gender identity. In logistic regression models, past-year NSSI was associated with younger age and felt stigma (perceived or anticipated rejection), but not enacted stigma (actual experiences of discrimination), and with gender dysphoria. Efforts to address the high rates of NSSI among transgender people should aim to reduce felt stigma and gender dysphoria, and promote transgender congruence. Future research using a developmental approach to assess variations in NSSI across the life course and in relation to transgender identity development may illuminate additional processes that affect NSSI in this population.

Quality of life of treatment-seeking transgender adults: A systematic review and meta-analysis

The study aims to systematically extract and analyse data about Quality of Life (QoL) in the transgender population. A systematic literature search and meta-analysis were conducted using the MEDLINE, EMBASE, PubMed, and PsycINFO databases, up to July 2017. Only English language quantitative studies, in adults, which reported the means for validated QoL measures were included. Random-effect meta-analysis was adopted to pool data and estimate the 95% Confidence Intervals (CI). From 94 potentially relevant articles, 29 studies were included within the review and data extraction for meta-analysis was available in 14 studies. The majority of the studies were cross-sectional, lacked controls and displayed moderate risk of bias. Findings from the systematic review suggested that transgender people display poor QoL, independent of the domain investigated. Pooling across studies showed that transgender people report poorer mental health QoL compared to the general population (-0.78, 95% CI = -1.08 to -0.48, 14 studies). However, meta-analysis in a subgroup of studies looking at QoL in participants who were exclusively post-CHT found no difference in mental health QoL between groups (-0.42, 95% CI = -1.15 to 0.31; 7 studies). There was insufficient data for a pre-treatment subgroup. Evidence suggests that transgender people have lower QoL than the general population. Some evidence suggests that QoL improves post-treatment. Better quality studies that include clearly defined transgender populations, divided by stage of gender affirming treatment and with appropriate matched control groups are needed to draw firmer conclusions.

Levels of depression in transgender people and its predictors: Results of a large matched control study with transgender people accessing clinical services

BACKGROUND

Depression is a serious disorder which significantly impacts wellbeing and quality of life. Studies exploring mental wellbeing in the transgender population are mostly limited by small, non-homogenous samples and lack of matched controls. This study aimed to address these limitations and explore depression rates in a large sample of transgender people, compared with matched controls from the general population, as well as factors predicting depression in those taking cross-sex hormone treatment (CHT) compared to those not.

METHODS

Transgender individuals (n = 913) completed a measure of depression, measures which predict psychopathology (self-esteem, victimization, social support, interpersonal problems), and information regarding CHT use. Participants were matched by age and experienced gender with adults from the general population who had completed the measure of depression.

RESULTS

Individuals were categorized as having no, possible or probable depressive disorder. Transgender individuals not on CHT had a nearly four-fold increased risk of probable depressive disorder, compared to controls. Older age, lower self-esteem, poorer interpersonal function and less social support predicted depressive disorder. Use of CHT was associated with less depression.

LIMITATIONS

Participants were attending a national gender identity service and therefore represent only a sub-group of transgender people. Due to the cross-sectional design, longitudinal research is required to fully confirm the finding that CHT use reduces depression.

CONCLUSION

This study confirms that non-treated transgender individuals have an increased risk of a depressive disorder. Interventions offered alongside gender affirming treatment to develop interpersonal skills, increase self-esteem and improve social support may reduce depression and prepare individuals for a more successful transition.

A comparison of mental health symptomatology and levels of social support in young treatment seeking transgender individuals who identify as binary and non-binary

Background : Previous research has consistently reported high rates of mental health symptomatology and lower social support in young treatment seeking transgender individuals. However, these studies have failed to distinguish between transgender people who identify within the gender binary and those who identify as non-binary. Aims : This study aimed to compare levels of mental health symptomatology (anxiety, depression, and non-suicidal self-injury behavior) and social support of treatment seeking non-binary transgender young individuals with those self-identified as binary transgender young individuals. All participants attended a national transgender health service in the UK during a 2-year period. Measures : Age and gender identity descriptors were collected, as well as clinical measures of anxiety and depression (Hospital Anxiety and Depression Scale), self-esteem (The Rosenberg Self-Esteem Scale), non-suicidal self-injury (Non-Suicidal Self-Injury: Treatment Related), and social support (Multidimensional Scale of Perceived Social Support). Results : A total of 388 young people, aged 16-25 years, agreed participation; 331 (85.3%) identified as binary and 57 (14.7%) as non-binary. Analysis of the data showed the non-binary group experienced significantly more anxiety and depression and had significantly lower self-esteem than the binary group. There were no significant differences between groups in the likelihood of engaging in non-suicidal self-injury behavior or levels of social support. Conclusions : Non-binary identifying treatment seeking transgender youth are at increased risk of developing anxiety, depression, and low self-esteem compared to binary transgender youth. This may reflect the even greater barriers and feelings of discrimination that may be faced by those whose identity does not fit the notion of binary gender that is pervasive in how society views both cis- and transgender populations.

The Role of Distal Minority Stress and Internalized Transnegativity in Suicidal Ideation and Nonsuicidal Self-Injury Among Transgender Adults

Transgender people are at elevated risk for nonsuicidal self-injury (NSSI) and suicidal ideation compared to the general population. Transgender (trans) refers to a diverse group of people who experience incongruence between their gender identity and sex assigned at birth. The present study is guided by the minority stress model and the psychological mediation framework, which postulate that sexual minority groups experience elevated stress as a result of anti-minority prejudice, contributing to negative mental health outcomes. This study utilized these theories to investigate the role of internalized transnegativity-internalization of negative societal attitudes about one's trans identity-in the relationships of distal trans stress to suicidal ideation and NSSI. A U.S. national sample of trans adults (N = 237) completed a battery of online measures. Structural equation modeling (SEM) was used to compare models with mediation and moderation effects. Results suggested that internalized transnegativity acts as both a mediator and a moderator in the relationship between distal trans stress and suicidal ideation. Log likelihood comparisons suggested moderation models had the superior fit for these data. Results suggest that clinical interventions should directly target individuals' internalized transnegativity as well as societal-level transnegativity.

How well do various types of support buffer psychological distress among transgender and gender nonconforming students?

Background: Transgender and gender nonconforming (TGNC) individuals experience an increased prevalence of many psychological disorders, leading many to reach out for support from family, friends, mental health professionals, and religious or community networks. Nonetheless, experiences seeking support are often negative, and many psychotherapists report feeling underprepared to work with TGNC clients. To better understand the experiences of TGNC individuals and better equip psychotherapists in their work with TGNC clients, we investigate which sources of support most successfully buffer psychological distress among TGNC individuals. Aims: This study aims to identify differences in levels of various types of support (social, family, religious, and living-situation) between cisgender and TGNC individuals and examine how these types of support may or may not buffer psychological distress among TGNC individuals. Method: We used a United States national sample of 3,090 students (1,030 cisgender men; 1,030 cisgender women; 349 transgender; 681 endorsing another gender identity) from the Center for Collegiate Mental Health 2012-2015 database which provided basic demographic information through the Standardized Data Set. Psychological distress was measured through the Counseling Center Assessment of Psychological Symptoms 34-item questionnaire. Results: TGNC individuals reported more distress, less family support, more social support, and less frequent religious affiliation than cisgender men and women. Family and social support emerged as the strongest predictors of distress for both TGNC and cisgender individuals. Though religious affiliation and living on-campus buffered distress among cisgender students, they did not buffer distress among TGNC students. Conclusion: Our study highlights disparities in distress and support between TGNC and cisgender individuals. We found that although religious affiliation and on-campus living are beneficial for cisgender students, neither systematically buffers distress for TGNC students. These findings illustrate the impact minority stress and systemic discrimination may have on TGNC individuals and provide suggestions for therapeutic intervention in work with TGNC individuals.

Targeted Victimization and Suicidality Among Trans People: A Web-Based Survey

Purpose: The aim of this study was to investigate the associations between a series of empirically known risk and protective factors and suicidality among trans people in Sweden.

Methods: Participants were self-selected anonymously to a web-based survey conducted in 2014. Univariable and multivariable logistic regression analyses were performed to assess associations between contributing factors and suicide ideation in the past 12 months and lifetime suicide attempts.

Results: The analysis included 796 trans individuals, between 15 and 94 years of age, who live in Sweden. A total of 37% of respondents reported that they have seriously considered suicide during the past 12 months and 32% had ever attempted a suicide. Offensive treatment during the past three months and lifetime exposure to trans-related violence were significantly associated with suicidality. Less satisfaction with contacts with friends and acquaintances and with one's own psychological wellbeing were associated with suicide ideation in the past 12 months. Lack of practical support was associated with lifetime suicide attempts.

Conclusions: Our findings show that suicidality is directly correlated with trans-related victimization. Preventing targeted victimization is, therefore, a key preventive intervention against this elevated suicidality.

The buffering role of social support on the associations among discrimination, mental health, and suicidality in a transgender sample

INTRODUCTION

Per the minority stress framework, trans individuals often experience psychological distress given the unique stress engendered by gender identity-related discrimination. Prior research has identified social support as particularly important for psychological distress and has suggested that social support may moderate this relationship. AIMS: The purpose of the current study was to explore the patterns of connections among discrimination, mental health, and suicidal ideation in trans individuals, and whether social support moderates these relationships.

METHODS

Participants (N = 78) completed measures of these constructs as part of a national online survey.

RESULTS

A series of simultaneous multiple regressions found that harassment/rejection discrimination was a unique positive predictor of mental health symptoms and suicidal ideation, with depression positively predicting suicidal ideation. A mediational model indicated that the association between harassment/rejection discrimination and suicidal ideation was fully mediated by depression. Three moderated meditational models were run, and one yielded a significant interaction, such that discrimination predicted suicidal ideation most strongly when participants had low social support from a significant other in comparison to moderate or high support. Further, conditional direct effects identified that discrimination led to ideation only for individuals with low support from friends or a significant other but not for those with moderate or high support.

CONCLUSIONS

Helping trans individuals cope with harassment and rejection, particularly by drawing on social support, may promote better mental health, which could help reduce suicidality in this population.

Non-suicidal self-injury and suicidality in trans people: A systematic review of the literature

Literature has described high levels of mental health problems among trans people, such as depression, resulting in increased levels of non-suicidal self-injury (NSSI) behaviour and suicidality (suicidal thoughts, suicide attempts and suicide rates). With the aim of systematically reviewing the available literature in this field, this study identifies 31 papers that explore the rates of NSSI and suicidality in trans people. From reviewing the literature, it was revealed that trans people have a higher prevalence of NSSI and suicidality compared to the cisgender (non-trans) population. There appear to be some gender differences within these rates, with trans men at a greater risk for NSSI behaviour. Prevalence rates differ depending on the different stages of transition, but they are still overall greater than the cisgender population. The study concludes that trans individuals are at a greater risk of NSSI behaviour and suicidality than the cisgender population, and discusses risk factors and the need to develop effective preventative interventions.

Risk Factors for Non-Suicidal Self-Injury Among Trans Youth

INTRODUCTION

Previous research has reported high levels of non-suicidal self-injury (NSSI) in trans populations and younger age has been identified as a risk factor.

AIMS

To explore the prevalence of NSSI in a large group of young trans people and to identify risk factors for this group.

MAIN OUTCOME MEASURES

Sociodemographic variables and measurements of NSSI (Self-Injury Questionnaire), psychopathology (Symptom Checklist-90-Revised), self-esteem (Rosenberg Self-Esteem Scale), victimization (Experiences of Transphobia Scale), interpersonal functioning (Inventory of Interpersonal Problems), and social support (Multidimensional Scale of Perceived Social Support).

METHODS

Two hundred sixty-eight young people attending a national gender clinic completed questionnaires assessing presence and frequency of NSSI and levels of general psychopathology, depression, anxiety, interpersonal problems, self-esteem, social support, transphobia, and information on hormone treatment.

RESULTS

A lifetime presence of NSSI was identified in 46.3% of patients and 28.73% reported currently engaging in NSSI (within at least the past few months). Analyses showed that those with a lifetime presence of NSSI had significantly greater general psychopathology, lower self-esteem, had suffered more transphobia, and experienced greater interpersonal problems than those without NSSI. Findings were similar when comparing current with non-current NSSI. Overall, natal male patients reported less social support than natal female patients, but current NSSI was more common in natal female patients. Regression analyses confirmed that natal female gender and greater general psychopathology predicted current and lifetime NSSI. Further analyses confirmed that general psychopathology itself could be predicted by transphobic experiences, low self-esteem, and interpersonal problems, but not by the use of cross-sex hormones.

CONCLUSION

These findings confirm that NSSI is common in trans youth and emphasize the need for interventions that decrease transphobia, increase social support, and help trans youth navigate their relationships with others to decrease psychopathology and NSSI.