A new, large cohort study of transgender or gender nonconforming youth—the Study of Transition, Outcomes, and Gender—showed that people who first presented as transgender or gender nonconforming before their 18th birthday have a higher prevalence of mental health conditions, including anxiety, depression, and attention-deficit disorders compared with their cisgender counterparts.
Mental healthcare is an important priority for transgender and gender nonconforming children, who may experience distress related to gender dysphoria, compounded by stress resulting from prejudice and discrimination. Existing literature on this population, mostly from small, specialized, clinic-based studies, has shown a high prevalence of mental health diagnoses and self-reported emotional and behavior problems among transgender and gender nonconforming youth, but the existing literature typically involves small sample sizes and lacks information on individuals who have either not sought or have had no access to care.
A new, large cohort study of transgender or gender nonconforming youth—the Study of Transition, Outcomes, and Gender (STRONG)1—showed that people who first presented as transgender or gender nonconforming before their 18th birthday have a higher prevalence of mental health conditions, including anxiety, depression, and attention deficit disorders compared with cisgender counterparts.
STRONG, designed as an electronic medical record (EMR)-based retrospective and prospective cohort study of members at 3 Kaiser Permanente sites in Georgia, Northern California, and Southern California, in partnership with the Emory University Rollins School of Public Health, identified a cohort of 588 transfeminine and 745 transmasculine children and adolescents, and each individual in the cohort was matched to 10 cisgender male or female children or adolescents. The researchers calculated the prevalence of mental health conditions for patients at any time in their lives and within 6 months of the index date (the date of first evidence of gender nonconforming status) among the transgender and gender nonconforming cohort, and compared the findings with those of the cisgender referents.
Across all diagnostic categories, prevalence of mental health conditions was higher among transgender or gender nonconforming youth than for the matched cisgender group. Common diagnoses included attention-deficit disorders (transfeminine 15%, transmasculine 16%) and depressive disorders (transfeminine 49%; transmasculine 62%). Prevalence ratios for a history of self-inflicted injury in adolescents 6 months prior to the index date ranged from 18 (95% CI, 4.4-82) to 144 (95% CI, 36-1248), and the prevalence ratios for suicidal ideation ranged from 25 (95% CI, 14-45) to 54 (95% CI, 18-218).
The authors wrote that these results support the findings from previous research, and demonstrate that, among this population, mental health conditions are common and often severe, as evidenced by diagnoses associated with hospitalization. Children to present as transgender or gender nonconforming should be thoroughly and immediately evaluated for mental health needs, and also provided with gender identity support.
Writing in an accompanying commentary,2 Stanley Ray Vance Jr, MD, and Stephen M. Rosenthal, MD, warned that stress associated with adverse childhood experiences—including mental health conditions—can have both an immediate and a lifelong negative impact on health.
“Understanding the types of trauma and adverse experiences for which LGBTQ and gender nonconforming youth are at risk could be crucial for screening of risk factors and providing appropriate services,” wrote Vance and Rosenthal.
But even before such risk factors can be addressed, providers must create clinical environments that allow youth to feel comfortable disclosing their gender identity and be confident in their ability to identify this population appropriately in order to provide them with potentially life-saving support.
1. Becerra-Culqui TA, Liu Y, Nash R, et al. Mental health of transgender and gender nonconforming youth compared with their peers. [published online April 16, 2018]. J Pediatr. doi: 10.1542/peds.2017-3845.
2. Vance SR, Rosenthal SM. A closer look at the psychosocial realities of LGBTQ youth. [published online April 16, 2018]. J Pediatr. doi: 10.1542/peds.2018-0361.