High Burden of Mental Health Problems, Substance Use, Violence, and Related Psychosocial Factors in Transgender, Non-Binary, and Gender Diverse Youth and Young Adults

INTRODUCTION

Transgender and gender diverse (TGD) people are a group for whom their sex assigned at birth differs from their gender identity (James et al., 2016). The TGD population is diverse and includes transgender women (individuals assigned male at birth who identify as women), transgender men (individuals assigned female at birth who identify as men), as well as individuals whose gender identity is non-binary (e.g., gender nonconforming, genderqueer people) or who do not identify with a gender. A small but growing literature has examined the health of TGD people, and data suggest that TGD people are at substantially elevated risk for various negative health outcomes compared to cisgender people (i.e., individuals whose sex assigned at birth matches their gender identity) (e.g., James et al., 2016). Further, evidence from samples of high school students and youth suggests these disparities are already present by adolescence (e.g., Eisenberg et al., 2017; Perez-Brumer, Day, Russell, & Hatzenbuehler, 2017). Less is known about the health of non-binary individuals (Connolly, Zervos, Barone, Johnson, & Joseph, 2016), as the majority of the existing research base on TGD health either focuses on transgender-identified individuals alone or combines transgender and non-binary individuals into a single group (for exceptions, see Aparicio-Garcia, Diaz-Ramiro, Rubio-Valdehita, Lopez-Nunez, & Garcia-Nieto, 2018; Tabaac, Sutter, Wall, & Baker, 2018; Thorne et al., 2018). The goal of this study was to characterize the health of a heterogeneous sample of TGD youth, as well as to add to the growing literature by examining differences between different gender identities in the prevalence of health outcomes and related psychosocial variables.

Research on the health of TGD youth, including adolescents, emerging adults, and young adults, is particularly important, because these are the developmental periods in which mental health problems (e.g., depression, suicidality) escalate sharply (Thapar, Collishaw, Pine, & Thapar, 2012) and various health-related risk behaviors are at their highest, including alcohol, marijuana, and illicit drug use (Bachman et al., 2002). Psychosocial stressors (e.g., lack of social support, violence) have particularly profound effects during these developmental periods, as youth during these stages are transitioning from living at home to more independent adulthood, leaving them particularly vulnerable to the impact of stress (Arnett, 2000).

Although the research base is growing, relatively few studies have attempted to estimate the health status of TGD communities in the United States (Grant, 2011; James et al., 2016; Landers & Kapadia, 2017; Meyer, Brown, Herman, Reisner, & Bockting, 2017). Existing community-based studies have found elevated rates of discrimination, violence, and victimization in TGD compared to cisgender people (Aparicio-Garcia et al., 2018; Grant, 2011; James et al., 2016; Reisner et al., 2015; White Hughto, Reisner, & Pachankis, 2015), and more recent population-based studies of TGD youth have replicated these findings (Coulter, Bersamin, Russell, & Mair, 2018; Day, Perez-Brumer, & Russell, 2018; Eisenberg et al., 2017; Gower et al., 2018; Meyer et al., 2017). In fact, evidence suggests that between 50-90% of TGD people will experience verbal harassment or disrespect related to their gender identity in their lifetime, and at least 25% will experience physical assault or violence due to their perceived gender identity (Clements-Nolle, Marx, & Katz, 2006; Freese, Ott, Rood, Reisner, & Pantalone, 2018; Grant, 2011; James et al., 2016; McCann & Brown, 2017). The 2015 U.S. Transgender Survey (USTS) (James et al., 2016), a large non-representative survey of the health and wellbeing TGD adults (N = 27,715), assessed a wide array of experiences of discrimination and violence and found troublingly high rates. First, 77% of respondents reported having experienced verbal or physical abuse at school (i.e., during K-12 years), and 50% of those who were out to their family experienced at least one form of rejection from that family during childhood or adulthood. Further, nearly half (46%) were verbally harassed in the past year because of being TGD, and 47% had been sexually assaulted in their lifetime (James et al., 2016).

The persistent marginalization experienced by many TGD people is likely in large part responsible for elevated rates of risk behavior engagement and negative health outcomes observed in TGD populations (Hendricks & Testa, 2012). Compared to cisgender people, TGD individuals are more likely to use tobacco, alcohol, or other substances to cope with stress, and these findings have been described with both community samples (Freese et al., 2018; Grant, 2011; James et al., 2016) and population-based datasets (Coulter et al., 2018; Day, Fish, Perez-Brumer, Hatzenbuehler, & Russell, 2017; Eisenberg et al., 2017; Meyer et al., 2017). Indeed, 29% of USTS respondents reported illicit drug use in the past month, which is three times the rate of the general population (James et al., 2016). With regard to mental health, 39% of USTS respondents endorsed serious psychological distress in the past month, compared to only 5% of the general population, and among youth the rate was even higher (53%) (James et al., 2016). Indeed, depression and anxiety have repeatedly been found to be elevated in TGD communities (Connolly et al., 2016; Eisenberg et al., 2017; Freese et al., 2018; Grant, 2011; James et al.,2016; Khobzi Rotondi, 2012; Thorne et al., 2018), and suicidal ideation and attempts are at epidemic levels (Gower et al., 2018; Perez-Brumer et al., 2017): 82% have considered suicide at some point in their life; 48% have seriously considered killing themselves in the past year; and 40% reported a lifetime suicide attempt (nine times the rate in the general population) (James et al., 2016). Mental health problems are also common in clinical samples of youth referred for treatment of gender dysphoria (e.g., Bechard, VanderLaan, Wood, Wasserman, & Zucker, 2017), but gender-affirming treatment significantly improves health and well-being in TGD youth (Connolly et al., 2016; de Vries, Steensma, Doreleijers, & Cohen-Kettenis, 2011).

While existing studies have highlighted the important disparities in health outcomes between TGD and cisgender people, most of this research has examined TGD people as a single group. This approach assumes that all identities within the TGD population experience psychosocial stressors and resulting health outcomes uniformly, which is unlikely given the diverse identities and experiences within this population. Several exceptions point to important differences between non-binary, transgender, and cisgender people (Aparicio-Garcia et al., 2018; James et al., 2016; Thorne et al., 2018). For example, the USTS found higher rates of serious psychological distress among non-binary people compared to transgender women and men, while transgender men reported higher rates of lifetime suicide attempts (James et al., 2016). Similarly, Thorne et al. (2018) found that non-binary people reported more symptoms of depression and anxiety than transgender women and men. The USTS also found that transgender women of color (including Black and Latina women) were at particularly high risk for various experiences of violence (James et al., 2016), but, in contrast, Aparicio-Garcia et al. (2018) found that harassment and lack of social support were more common among non-binary compared to transgender people. Given the limited existing research in this area, it is critically important to replicate these initial findings, as well as to examine more fine-grained differences in health outcomes and related risk factors across various gender identities, including comparisons between non-binary, transgender, and cisgender people.

The current study aimed to fill this gap in the literature by utilizing data from two large, unique community cohorts of sexual and gender minority youth and young adults in the Chicago area. These analyses add two unique contributions to the literature. First, we examined the prevalence of health outcomes in a sample of youth that spans multiple developmental periods during which youth are vulnerable to negative health outcomes, including adolescence, emerging adulthood, and young adulthood. Second, we analyzed differences in health between various gender identities. To do this, we conducted two sets of analyses to characterize TGD experiences with mental health, substance use, and related psychosocial risk factors: (1) we examined mean differences in all outcome variables between transgender men, transgender women, non-binary assigned female at birth (AFAB) youth, and non-binary assigned male at birth (AMAB) youth, and (2) we examined differences between TGD youth and their cisgender sexual minority peers from their cohort of origin (i.e., TGD AFAB youth vs. cisgender sexual minority women; TGD AMAB youth vs. cisgender sexual minority men) on all previously noted outcome variables. Because of the limited research examining differences in health and psychosocial experiences between gender identities within the TGD youth population, we made no a priori hypotheses about gender identity differences in the prevalence of the outcome variables examined in the present study. However, we anticipated that TGD youth would report significantly worse scores on all health and related variables compared to their cisgender sexual minority peers.

METHODS

RESULTS

DISCUSSION

The current study found high rates of various negative health outcomes and related psychosocial risk factors in a sample of TGD youth derived by combining data from the baseline visit of two existing cohort studies of sexual and gender minority adolescents, emerging adults, and young adults. In most cases, these health outcomes and negative psychosocial experiences were significantly elevated in TGD youth compared to their cisgender sexual minority peers in the cohort studies from which these participants were drawn. While rates of negative health outcomes and risk factors were high among all TGD gender identity groups, many of these outcomes were highest among TGD AMAB youth, including transgender women and non-binary AMAB youth, indicating that these youth may be at even higher risk for adverse health outcomes across multiple domains.

Consistent with prior literature (Coulter et al., 2018; Day et al., 2018; Eisenberg et al., 2017), TGD youth in this sample experienced high rates of negative psychosocial experiences, including lack of social support, sexual and gender minority-based victimization, and violence. First, TGD youth in this study reported that they received the least amount of support from families, compared to friends and significant others, which aligns with findings from the U.S. Transgender Survey (USTS) (James et al., 2016). Indeed, the mean response for perceived family support across all TGD individuals in this study indicated that participants “neither agreed nor disagreed” that they received support from their families. Transgender women reported the lowest rates of both friend and significant other support compared to all other groups, and both transgender women and non-binary AMAB youth reported significantly lower social support from family and peers compared to cisgender sexual minority male youth.

Given the clear link between lack of social support (particularly from families) and negative health outcomes in sexual and gender minority samples (Coulter et al., 2018; McConnell, Birkett, & Mustanski, 2015; Newcomb, Heinz, & Mustanski, 2012; Ryan, Huebner, Diaz, & Sanchez, 2009), these differences may help to explain why, in general, TGD AMAB youth in this sample reported higher rates of most negative health outcomes relative to TGD AFAB youth. More work should be conducted to understand how various forms of support interact with one another to confer risk for or buffer against negative health outcomes. For example, it remains unclear whether the presence of strong friend or significant other support reduces the risk of negative health outcomes in the context of having a rejecting or unsupportive family or if having one supportive parent or family member compensates for lack of support for others in the family. Recent data from a sample of LGBTQ youth found that the influence of family support on mental health became less important over time among those youth who had high levels of peer support (McConnell, Birkett, & Mustanski, 2016), but this sample had a small proportion of TGD youth so results were not disaggregated by gender identity.

With regard to sexual and gender minority-based victimization and violence, TGD AMAB youth endorsed substantially higher rates than both TGD AFAB and cisgender sexual minority male youth. However, we must emphasize that reported rates of victimization in the past six months were unacceptably high for all youth. For example, approximately half of transgender women and non-binary AMAB youth reported at least one instance of victimization in the past six months, compared to about a third of transgender men and cisgender sexual minority male youth, and less than a quarter of non-binary AFAB youth and cisgender sexual minority female youth. These findings are consistent with the USTS, which found that 46% had been verbally harassed in the past year, and 9% had been physically attacked, because of being TGD (James et al., 2016). Furthermore, more than one third of both transgender women and non-binary AMAB youth in our sample reported experiencing some type of CSA in their lifetime, and nearly one third of transgender women reported ever experiencing penetrative CSA. Similarly, non-binary AMAB youth were the most likely to report having a traumatic experience in their lifetime, though reports of traumatic events were high across all groups. More specifically, 82.1% of non-binary AMAB youth reported at least one lifetime traumatic event, compared to 78% of non-binary AFAB youth, 72.4% of transgender women, and 59.1% of transgender men. Given the long-term effects of CSA and other violent experiences on mental health (e.g., depression, suicidality) and engagement in risk behaviors (substance use, sexual risk behaviors) (Lloyd & Operario, 2012; Maniglio, 2009), there is a clear need for both structural and individual interventions to prevent the occurrence of these experiences, in concert with individual interventions to help TGD youth cope with the effects of CSA when it does occur.

Based on the high rates of victimization, CSA, and other traumatic experiences, it is not surprising that TGD youth in this sample reported high rates of mental health problems and substance use (Maniglio, 2009). Consistent with prior work (Eisenberg et al., 2017; Perez-Brumer et al., 2017), analyses revealed very high rates of depression and suicidality, and in most cases these rates were significantly higher among TGD youth compared to their cisgender sexual minority peers. With regard to depression, the mean score for non-binary AFAB youth fell within the range indicative of moderate depression, while the means for non-binary AMAB youth and transgender men fell within mild depression range; these mean scores are substantially higher than the measure norm for the general population (Pilkonis et al., 2011). Transgender women had significantly lower scores for depression. However, the majority of transgender women in this sample were Black, and some data suggest that Black sexual and gender minority youth have lower rates of depression than White youth (Burns, Ryan, Garofalo, Newcomb, & Mustanski, 2015; Mustanski et al., 2019). Consistent with prior reports (Perez-Brumer et al., 2017), and with data from the USTS that 82% of respondents reported lifetime suicidal ideation and 40% reported a lifetime suicide attempt (James et al., 2016), suicidality was at epidemic levels in this sample. Half of non-binary AMAB youth, and approximately one third of transgender men and non-binary AFAB youth, reported past six month suicidal ideation. Further, more than 10% of transgender women and non-binary AMAB youth reported a suicide attempt in the past six months alone. These findings indicate that non-binary youth are at particularly high risk for depression and suicidal ideation, which is consistent with one recent report (Thorne et al., 2018), and TGD AMAB youth (both transgender women and non-binary AMAB youth) are at very high risk for suicide attempt. For comparison, the 2016 National Survey on Drug Use and Health (NSDUH) reported much lower rates of suicidal ideation (8.8%), planning (2.9%), and attempt (1.8%) among 18-25 year olds in the general population during the past 12 months (Substance Abuse and Mental Health Services Administration, 2017). Given these disturbingly high rates, there is a shocking lack of funded research on suicidality in sexual and gender minority populations, which is a clear area of need.

Prior reports have documented substantial disparities in cigarette smoking, alcohol use, and illicit drug use between cisgender heterosexual youth and both cisgender sexual minorities (Corliss et al., 2014; Newcomb, Birkett, Corliss, & Mustanski, 2014; Talley, Hughes, Aranda, Birkett, & Marshal, 2014) and TGD youth (Coulter et al., 2018; Day et al., 2017; Eisenberg et al., 2017). Substance use was also strikingly high in this sample, particularly among transgender women and non-binary AMAB youth, including problematic alcohol use (24.1% and 42.8% at moderate to high risk for current alcohol use disorder, respectively), hazardous marijuana use (34.5% and 39.3%, respectively), current cigarette smoking (41.4% and 21.4%, respectively), and past six month stimulant use (20.7% and 14.3%, respectively). In most cases, these rates are substantially higher than those reported by large population-based studies of youth and adults (Pickens, Pierannunzi, Garvin, & Town, 2018; Substance Abuse and Mental Health Services Administration, 2017). For example, the 2016 NSDUH reported that among 18-25 year olds, 9.4% were daily smokers, 10.1% were heavy drinkers, and 2.2% had used stimulants in the last month. While these findings may not be directly comparable in all cases, they point to vast disparities in substance use between cisgender and TGD youth.

It is important to note that the cisgender sexual minority men in the RADAR cohort reported substance use at similar rates to those of the TGD AMAB youth, which is consistent with prior research reporting high levels of alcohol and illicit drug use among young sexual minority men (e.g., Newcomb, Ryan, Greene, Garofalo, & Mustanski, 2014). Nevertheless, these high rates of use point to critically important targets for health promotion and HIV prevention. As documented in these analyses, TGD youth experience frequent stressors related to their gender and/or sexual orientation identities, and both general and minority stressors have been linked to substance use in sexual and gender minority samples (Hatzenbuehler, 2009; Hendricks & Testa, 2012; Meyer, 2003). Further, many of the social environments attended by young gay and bisexual men, and presumably transgender women and non-binary AMAB youth, are venues in which drinking and drug use may occur (e.g., bars, clubs), which may lead to more permissive substance use norms among some youth and thus higher rates of use in these populations. Thus, the combination of experiencing stressors related to sexual and/or gender identity and more permissive social norms likely contribute to the very high rates of substance use observed in this study.

Synthesizing across study findings, we observed several noteworthy patterns. First, TGD AMAB youth, including both transgender women and non-binary AMAB youth, reported worse outcomes on nearly all indicators of health and psychosocial risk factors compared to TGD AFAB youth, with the exception of depressive symptoms and suicidal ideation. The elevated rates of negative health outcomes and associated risk factors among TGD AMAB youth were also consistently higher than those reported by their cisgender sexual minority male peers, which means that TGD AMAB youth may be at disproportionate risk compared to all other groups of TGD and sexual minority youth observed in this study. Given the high rates of various psychosocial risk factors, including lack of social support, victimization, traumatic experiences, and CSA among TGD AMAB youth, it is perhaps not surprising that these youth also reported the most substance use and the highest rates of suicide attempt.

While this study did not examine the mechanisms driving these differences in health outcomes between TGD AMAB and AFAB youth, it indicates that some stressors or contextual factors may be unique to, or more elevated among, TGD youth who are assigned male at birth. Based on the limited existing literature, TGD AMAB youth may be more likely to experience poverty, have lower educational attainment and employment, experience more gender-based violence, and have higher likelihood of participation in sex work, even compared to TGD AFAB youth and cisgender sexual minority youth (Brennan et al., 2012; White Hughto et al., 2015). All of these factors may contribute to a particularly high burden of stress in these youth and consequently very high rates of negative health outcomes. Much more work needs to be done to understand the specific vulnerabilities associated with these troubling findings, as well as to understand the unique stressors and experiences of varied gender identities within the TGD population.

Another particularly important finding emerging from these data is that non-binary youth, particularly those assigned male at birth, often experienced comparable or worse rates of negative health outcomes and related risk behaviors than their transgender and cisgender peers. Consistent with recent evidence (Thorne et al., 2018), both AFAB and AMAB non-binary youth reported the highest rates of depression (though these scores did not significantly differ from those of transgender men). Further, non-binary AMAB youth reported the most alcohol-related problems and traumatic experiences, as well as a staggeringly high rate of past six month suicidal ideation. Regrettably, the majority of the already limited research on TGD health has focused on people who identify as transgender, and in particular on transgender women (Connolly et al., 2016; Reisner et al., 2016), though several recent studies are notable exceptions (Aparicio-Garcia et al., 2018; Tabaac et al., 2018; Thorne et al., 2018). This lack of attention to non-binary youth may reflect the invisibility of these identities in health-related research or a misinformed belief that these youth are at lower risk for negative health outcomes than their transgender peers. Our data indicate that non-binary youth may be at even higher risk for some negative health outcomes compared to transgender youth in some cases, so it is clear that more research is needed to understand the unique needs of non-binary youth, which in itself is a diverse group of various different gender identities and expressions.

Finally, the effect sizes for differences in health and related outcomes were generally larger when examining differences within the TGD population compared to the differences between TGD youth and the cisgender sexual minority youth for their respective cohorts of origin. In some cases, TGD youth were more similar in their health outcomes to the cisgender sexual minority youth of their same sex assigned at birth than they were to TGD youth of a different sex assigned at birth. For example, TGD AMAB youth were more similar in their substance use behaviors to cisgender sexual minority male youth than they were to TGD AFAB youth, and TGD AFAB youth were more similar to cisgender sexual minority female youth in their perceived social support. This is not to say that, in general, TGD youth are more similar to their cisgender sexual minority peers with the same sex assigned at birth. Instead, these differences highlight the marked diversity within the TGD population in experiences with health and psychosocial factors that must be attended to in research and intervention development.

This study is not without limitations. First, these data were cross-sectional, so we are unable to make conclusions about what may be driving observed rates of, and differences in, health-related outcomes. There is an urgent need for longitudinal cohort studies with large enough samples of TGD individuals to examine health trajectories over time, as well as temporal ordering of predictors of health outcomes to more confidently draw causal inference. As we continue to follow these cohorts over time, we will be well-poised to answer some of these longitudinal questions. Related, our sample had low representation of certain gender identities, which meant that we had to collapse across some identities (e.g., various non-binary identities) when examining group differences. This sample was recruited as part of two community-based cohort studies. While community cohorts allow for the collection of variables nuanced to the experiences of TGD people (e.g., sexual and gender minority-based victimization), population-based studies allow for greater generalizability of findings. Importantly, very few population-based datasets have collected data on gender identity, making such analyses exceedingly rare. We urge various agencies who conduct population-based research on health outcomes to include questions assessing gender identity and sexual orientation identities in order to provide more generalizable estimates of health issues.

With regard to analyses, we acknowledge that the large number of analyses conducted in this study increased the likelihood of Type I error. However, if we were to use a more stringent criterion for significance (i.e., p < .01) to account for this possibility, the majority of the observed differences would remain significant, and those that would lose significance are those with relatively low base rates of endorsement. If we were to apply this correction to analyses, the differences between TGD groups in traumatic experiences and CSA would become non-significant (with the exception of penetrative CSA). Further, the differences between TGD AMAB youth and cisgender sexual minority male youth in certain indicators of CSA, as well as suicide planning, would become non-significant. Finally, the observed differences between TGD AFAB youth and cisgender sexual minority female youth in victimization and lifetime traumatic events would become non-significant.

Despite these limitations, the present data provide novel information about the health of transgender and gender diverse youth, as well as their experiences with various psychosocial risk factors that have implications for the onset and maintenance of health issues. Further, this study is one of the first to examine differences in health-related variables between groups of TGD youth, including transgender women, transgender men, non-binary AMAB youth and non-binary AFAB youth. Taken together, these findings indicate that TGD youth are at high risk for negative health outcomes, likely due to their experience of various psychosocial risk factors (e.g., lack of social support, victimization, violence). Within this population, those youth assigned male at birth, including both transgender women and non-binary AMAB youth, reported the most elevated rates of nearly all negative health outcomes and related psychosocial variables. These findings point to a dire need for more research on the mechanisms driving these effects, as well as work on both individual-level and structural interventions to mitigate the vast health disparities experienced by TGD youth.