Risk and Resilience Factors for Mental Health among Transgender and Gender Nonconforming (TGNC) Youth: A Systematic Review

The impact of physical activity on adolescent mental health status: the mediating effect of school adaptation

Objective

This study was designed to examine the mental health status of Chinese adolescents, investigate the effects of adolescent physical activity on mental health status, and verify the mediating effect of school adaptation.

Methods

A survey and analysis were conducted on 9,701 high school students in Shandong Province using the Physical Activity Questionnaire for Adolescents (PAQ-A), the School Social Behavior Scale-2 (SSBS-2), and the Symptom Checklist-90 (SCL-90) self-rating scale. The overall status of adolescent mental health was analyzed, regression modeling along with structural equation modeling was used to test whether school adaptation played a mediating role.

Results

The structural equation model was validated as a good fit (GFI = 0.950, RMSEA = 0.048, CFI = 0.972, NFI = 0.970, SRMR = 0.077). Physical activity was significantly and positively correlated with mental health status (β = -0.691, p < 0.001), school adaptation (β = 1.153, p < 0.001), and school adaptation was significantly and positively correlated with mental health status (β = -0.287, p < 0.001). The direct effect of physical activity on mental health status was 0.011 and the indirect effect of physical activity on school adaptation and school adaptation on mental health status was 0.024.

Conclusion

Physical activity was positively related to mental health status, with physical activity significantly and positively predicting mental health status; school adaptation was significantly and positively related to physical activity and mental health status, with school adaptation mediating between physical activity and mental health status.

Intentions to Use PrEP Among a National Sample of Transgender and Gender-Expansive Youth and Emerging Adults: Examining Gender Minority Stress, Substance Use, and Gender Affirmation

Transgender and gender-expansive young people, ages 13-24 years, experience disproportionate HIV risk yet are among those with the lowest US PrEP uptake rates (< 10%). Factors influencing PrEP outcomes for this population are poorly understood. This study examines the effects of gender minority stressors, gender affirmation, and heavy substance use on their PrEP outcomes using data from the CDC's 2018 START study (N = 972). A conceptual model integrating the gender minority stress and gender affirmation models was developed, mapping relevant START items onto it. Structural equation modeling (Mplus-8.9) was used to examine factors related to their PrEP intentions. Most participants were 18-24 (68%), trans-female (46%), white (45%), and reported heavy substance use (40%). Medical discrimination increased internalized transphobia (b = 0.097, SE = 0.034, p = 0.005) and perceived stigma (b = 0.087, SE = 0.034, p = 0.010). Family rejection increased perceived stigma (b = 0.181, SE = 0.032, p < 0.001) and heavy substance use (b = 0.260, SE = 0.053, p < 0.001). Perceived stigma also increased heavy substance use (b = 0.106, SE = 0.037, p = 0.004). Perceived stigma (b=-0.085, SE = 0.027, p = 0.002) and heavy substance use (b=-0.161, SE = 0.031, p < 0.001) decreased PrEP intentions, while gender affirmation increased them (b = 0.045, SE = 0.019, p = 0.020). A 1-point increase in gender affirmation reduced heavy substance use risk by -0.179 (SE = 0.030, p < 0.001) in the presence of family rejection and by -0.074 (SE = 0.041, p = 0.074) when perceived stigma was present. This study underscores heavy substance use as a potential barrier to PrEP uptake for transgender/gender-expansive youth. Future research could explore how gender affirmation acts as a protective factor against the negative impact of family rejection and perceived stigma on heavy substance behaviors among these populations.

Cyberbullying Victimization Among Transgender and Gender-Questioning Early Adolescents

OBJECTIVE

To determine the association between transgender or gender-questioning identity and cyberbullying victimization in a diverse national sample of early adolescents in the United States.

METHODS

We analyzed cross-sectional data from the Adolescent Brain Cognitive Development Study (year 3, 2019-2021, 11-14 years old, 48.8% female, 47.6% racial and ethnic minority). Logistic regression analyses were conducted to estimate the associations between transgender or gender-questioning identity and lifetime cyberbullying victimization, adjusting for sociodemographic confounders.

RESULTS

In a sample of 9989 adolescents (1.0% transgender, 1.1% gender-questioning), both transgender (odds ratio [OR] 2.24, 95% confidence interval [CI] 1.22-4.10) and gender-questioning (OR 1.91, 95% CI 1.05-3.47) adolescents had greater odds of cyberbullying victimization compared to their cisgender peers. There was no evidence of significant effect modification of the association between transgender identity and cyberbullying victimization by sex assigned at birth.

CONCLUSIONS

Transgender and gender-questioning early adolescents experience higher rates of cyberbullying victimization than their cisgender peers. Future research could investigate the risk and protective factors for cyberbullying in gender minority adolescents.

Prevalence, severity and risk factors for mental disorders among sexual and gender minority young people: a systematic review of systematic reviews and meta-analyses

Evidence suggests heightened prevalence and severity of mental disorders among sexual minority (SM) and gender minority (GM) young people. Several risk factors have been associated with these disparities. A systematic review of systematic reviews and meta-analysis was conducted to provide a comprehensive overview of the literature and to determine the field's current position. MEDLINE, PsycInfo, Scopus and Web of Science were searched in March 2022 and updated January 2024. Eligibility criteria were systematic reviews or meta-analyses assessing contemporaneous prevalence, severity and/or risk factors of mental disorders among SM or GM young people aged 25 and under. 42 reviews were included, all of which were low quality. The prevalence of depression among SM was 26% (95% CI 21-32%), and among GM was 46% (95% CI 36-56%). Greater depression severity was found among SM compared to heterosexual young people, with a significant albeit small effect size (Hedges' g = 0.38, 95% CI = 0.25 to 0.50); effect sizes were similar when separating by gender. GM also reported greater symptom severity compared to cisgender young people. Other mental disorders were more prevalent compared to those reported in the general population, and of greater severity compared to heterosexual/cisgender young people. Several proximal and distal risk factors were focused upon within the systematic reviews identified. Past systematic reviews consistently indicate a heightened risk of mental disorders among SM and GM young people. Services need to be aware of these disparities and adapt their care accordingly.

The rise of anti-trans laws and the role of public health advocacy

The recent surge in anti-trans laws and policies in Canada and the United States has important public health implications, particularly for trans and gender-expansive (TGE) youth. This legislation has the potential to exacerbate minority stress experienced by TGE youth, who already experience higher rates of depression, anxiety, and suicide than their cisgender peers. Social gender affirmation, including respecting affirmed names and pronouns, can reduce the risk of adverse mental health outcomes in TGE youth. However, recent laws requiring parental consent for affirmed names and pronouns in schools can cause additional distress and harm for TGE youth, especially those who lack family support. Public health professionals have a critical role to play in countering the harmful effects of anti-trans legislation by better understanding TGE youth and their needs, advocating for trans rights, supporting trans-led community organizations, and strengthening trans-affirming mental health services.

Predictors, patterns, and correlates of moderate-severe psychological distress among New York City College Students during Waves 2-4 of COVID-19

The COVID-19 pandemic may have exacerbated mental health conditions by introducing and/or modifying stressors, particularly in university populations. We examined longitudinal patterns, time-varying predictors, and contemporaneous correlates of moderate-severe psychological distress (MS-PD) among college students. During 2020-2021, participants completed self-administered questionnaires quarterly (T1 = 562, T2 = 334, T3 = 221, and T4 = 169). MS-PD reflected Kessler-6 scores ≥ 8. At T1 (baseline), most participants were cisgender women [96% vs. 4% transgender/gender non-conforming (TGNC)]. MS-PD prevalence was over 50% at all timepoints. MS-PD predictors included low self-rated health and perceptions of local pandemic control, verbal/physical violence experience, food insecurity, cohabitation dynamics, geographic location, and loneliness. Unique MS-PD correlates encompassed drug use and TGNC identity. Trajectories comprised Persistently (40%), Highly (24% MS-PD twice/thrice), Minimally (15% MS-PD once), and Never (21%) Distressed. Persistently Distressed students had low social support and self-rated health; high food insecurity, drug use, physical/verbal violence experience, need-based financial aid, and TGNC representation; and fluctuating self-rated health amid increasing COVID-19 symptomatology. In this sample, MS-PD prevalence was high, persistent, and associated with financial, behavioral, structural, experiential, and intra- and inter-personal factors. Given its complexity, improving and preserving college students' mental health necessitates comprehensive, multi-component activities to change adjustable stressors while attenuating the adverse effects of immutable influences.

The Workplace Experiences of Transgender and Gender Diverse Employees: A Systematic Literature Review Using the Minority Stress Model

Transgender and gender diverse (TGD) employees encounter unique challenges in the workplace that are not shared with the rest of the working population. In this study, we conducted a systematic review of 58 empirical studies on the workplace experiences of TGD individuals published in peer-reviewed journals between 2000 and 2022. Using the Minority Stress Model as a theoretical framework, we classified the literature based on (a) the challenges that TGD employees face when navigating their gender identity at work, (b) the outcomes of minority stress processes, and (c) the mechanisms to ameliorate the impact of minority stressors. Findings suggest that TGD employees are exposed to various distal and proximal stress processes that negatively impact work outcomes and mental health, including discrimination or expectations of rejection. A key protective factor both at the organizational and interpersonal level is support, including inclusive policy development and coworker support. At the intrapersonal level, adaptive coping strategies and an integrated minority identity can countervail the impact of minority stressors. Future research should further examine intrapersonal variables while leveraging broader intersectional and international samples. Practitioners are advised to proactively and continuously review their nondiscrimination policies and practices to promote employee wellbeing and positive work outcomes.

Early mental health intervention and supported self-care for LGBTQ+ young people in the UK: a mixed-methods study

Background

Lesbian, gay, bisexual, trans, queer/questioning, plus young people have a higher risk of poor mental health in comparison to cisgendered heterosexual young people, and they underutilise mental health services and support. In addition, there is a paucity of research conducted in United Kingdom examining mental health early intervention provision for lesbian, gay, bisexual, trans, queer/questioning, plus young people.

Objectives

To produce a model of what works for early intervention mental health support for lesbian, gay, bisexual, trans, queer/questioning, plus young people and increase understanding of lesbian, gay, bisexual, trans, queer/questioning, plus young people's access to, navigation of, and engagement with mental health support.

Method

This was a multi-methods theory-led case study evaluation with three distinct stages: (1) a meta-narrative review of existing literature to develop a theoretical framework to explain effective mental health support for lesbian, gay, bisexual, trans, queer/questioning, plus young people; (2) an online and offline service mapping exercise to locate current mental health early intervention support for lesbian, gay, bisexual, trans, queer/questioning, plus young people in the United Kingdom in order to produce a service typology; and (3) a theory-led case study evaluation of 12 case study sites selected from the service typology produced in stage 2, to establish the components of appropriate quality, early intervention mental health support for lesbian, gay, bisexual, trans, queer/questioning, plus young people.

Results

Stage 1 produced an interdisciplinary theoretical framework indicating that early intervention mental health support for lesbian, gay, bisexual, trans, queer/questioning, plus youth must prioritise addressing normative environments that marginalise youth, lesbian, gay, bisexual, trans, queer/questioning, plus identities and mental health problems. Stage 2 mapping found 111 services, the majority in urban settings in England. There was an absence of mainstream National Health Service support that specifically addressed the needs of lesbian, gay, bisexual, trans, queer/questioning, plus young people. The majority of lesbian, gay, bisexual, trans, queer/questioning, plus youth mental health support was provided by voluntary/community organisations. Stage 3 case study evaluation found that an intersectional, youth-rights approach is the most appropriate way to deliver early intervention mental health support for lesbian, gay, bisexual, trans, queer/questioning, plus young people. Youth rights should underpin mental health support to address the multiple marginalisation, isolation and stigmatisation that lesbian, gay, bisexual, trans, queer/questioning, plus young people may experience and to enable them to make informed independent decisions about their own bodies and lives, and for the right to freedom of safe self-expression to be upheld. The model that we have produced contains 13 principles that are necessary to the provision of mental health support, and to improve access to, engagement with, and navigation of mental health services.

Conclusions

In the United Kingdom, a rights-based approach to mental health service provision is not prominent. In addition, at the time of writing, lesbian, gay, bisexual, trans, queer/questioning, plus young people are facing active legislative and policy attacks on their human rights. This study provides the first large-scale theory-led evaluation of early intervention mental health support for lesbian, gay, bisexual, trans, queer/questioning, plus young people with common mental health problems. The resulting intersectional, youth-rights approach provides evidence on ways of improving lesbian, gay, bisexual, trans, queer/questioning, plus young people's mental health. Further research on the implementation of an intersectional, youth-rights approach to early intervention mental health support for lesbian, gay, bisexual, trans, queer/questioning, plus young people with mental health problems is required.

Study registration

This study is registered as PROSPERO CRD42019135722.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/09/04) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 47. See the NIHR Funding and Awards website for further award information.

Sleep health among youth outside of the gender binary: Findings from a national Canadian sample

OBJECTIVES

Sleep is important for adolescent health. The unique needs of suprabinary youth (youth with gender identities outside of the gender binary), along with the growing number of youth with these identities, underscores the need to better understand sleep health within this population. The current study's objectives were to (1) examine differences in sleep health between suprabinary and binary youth and (2) explore how social support, peer victimization, and technology use accounted for these differences.

METHODS

Data were drawn from the 2017/2018 Health Behavior in School Aged Children Survey. Adolescents (individuals ages 14 to 17, n = 10,186), indicated whether they were suprabinary (n = 182) or binary (n = 10,004), and completed measures of sleep health (difficulty falling asleep, difficulty staying awake, weekday and weekend sleep length), covariates (age, family affluence, race/ethnicity, depressive symptoms), as well as variables that may account for differences between suprabinary and binary youth (family, friend, and teacher support, as well as peer victimization, and technology use before bed).

RESULTS

Suprabinary youth reported worse sleep health on all outcomes, and differences persisted for both difficulty falling asleep and weekday sleep hours accounting for covariates. Significant indirect effects between suprabinary status were observed across all sleep outcomes for family support and school climate. Indirect effects for sleep quality were also observed via peer victimization.

CONCLUSIONS

Findings support the relevance of looking at basic health processes like sleep to better understand how the stressors associated with suprabinary status impact health outcomes among this vulnerable population.

Gender Minority Stressors and Psychological Distress Among Chinese Transgender and Gender Diverse People: Variable-Centered, Person-Centered, and Psychological Network Approaches

Mental health disparities in transgender and gender diverse (TGD) populations call for more research examining gender minority stressors (GMS) as antecedents to their psychological distress, especially for the long-underrepresented groups living in conservative societies towards gender minorities. Furthermore, some questions remain underexamined, including the relative, independent influences of various GMS on TGD people's mental well-being (i.e., uniqueness of each stressor); how these stressors would configurate with each other in distinctive patterns to characterize subgroups of TGD people (i.e., beyond-average heterogeneity); and how these stressors would constitute a psychological network and vary in their centrality in that network (i.e., holistic complexity). To narrow such gaps, we examined the links between GMS and TGD people's psychological distress, using survey data collected in 2023 from 410 Chinese TGD people (Meanage = 22.33 years, SD = 4.27; 306 transgender, 70 non-binary/gender-queer/gender-fluid, 26 agender/gender-neutral, 3 intersex, and 5 others). We approached such links from three perspectives. First, variable-centered analyses indicated that while different GMS were considered simultaneously, internalized transphobia, preoccupation with gender dysphoria, and gender-related victimization were uniquely associated with psychological distress. Second, person-centered analyses yielded a 3-profile solution. Psychological distress varied systematically across profiles. Last, network analyses revealed a 3-cluster structure: Distal, Proximal Internal, and TGD-Specific Stressors. Preoccupation with gender dysphoria was the most central node. These findings contribute to a more nuanced understanding of the implications of GMS for TGD people's mental well-being. GMS related to internal struggles with gender identity might be among the central intervention targets to prevent/reduce TGD people's psychological distress.

State of the Science: Gender-Affirming Care for Transgender and Gender Diverse Youth

Gender-affirming care is a framework that has developed over the past two decades and has experienced a rapid proliferation of empirical evidence. Given increased attention to transgender and gender diverse (TGD) youth in sociocultural spheres, there is a need to examine the current evidence base for effective gender-affirming mental health treatment. In this State of the Science review, we highlight general treatment frameworks that best support TGD youth and families in a variety of contexts, using gender-affirming psychosocial approaches. We use groupings of presenting concerns for TGD youth and families outlined by Coyne et al. (2020) to highlight differing mental health support needs, emphasizing the need for individual, contextually-based care models that consider aspects of gender-related marginalization and resilience. We further discuss needs for care access and equity and need for further attention in future research and intervention approaches.

Psychosocial support interventions for children and adolescents experiencing gender dysphoria or incongruence: a systematic review

BACKGROUND

National and international guidelines recommend that psychosocial support should be a key component of the care offered to children and adolescents experiencing gender dysphoria/incongruence. However, specific approaches or interventions are not recommended.

AIM

To identify and summarise evidence on the outcomes of psychosocial support interventions for children and adolescents (age 0-18) experiencing gender dysphoria/incongruence.

METHODS

Systematic review and narrative synthesis. Database searches (MEDLINE; EMBASE; CINAHL; PsycINFO; Web of Science) were performed in April 2022, with results assessed independently by two reviewers. Peer-reviewed articles reporting the results of studies measuring outcomes of psychosocial support interventions were included. Quality was assessed using the Mixed Methods Appraisal Tool.

RESULTS

Ten studies were included. Half were conducted in the US, with others from Australia, Canada, New Zealand and the UK. Six were pre-post analyses or cohort studies, three were mixed methods, and one was a secondary analysis of intervention data from four trials. Most studies were of low quality. Most analyses of mental health and psychosocial outcomes showed either benefit or no change, with none indicating negative or adverse effects.

CONCLUSIONS

The small number of low-quality studies limits conclusions about the effectiveness of psychosocial interventions for children/adolescents experiencing gender dysphoria/incongruence. Clarity on the intervention approach as well as the core outcomes would support the future aggregation of evidence. More robust methodology and reporting is required.

PROSPERO REGISTRATION NUMBER

CRD42021289659.

Community Advisory Boards as a Form of Community-Engaged Research for Gender Diverse Youth

Gender diverse youth are incredibly resilient but face significant stigma and marginalization. In this article, we argue that in the face of these challenges, researchers must work collaboratively with gender diverse youth and caregivers to identify and address the most important issues affecting them. We use our Navigating Gender Together Project as an example of using community advisory boards in community-engaged research. Although community engagement requires more resources, it overwhelmingly enriches research and increases its relevance for the community. Relevant, evidence-based research is critical in supporting gender diverse youth and their families.

An exploratory study of stressors, mental health, insomnia, and pain in cisgender girls, cisgender boys, and transgender and gender diverse (TGD) youth

INTRODUCTION

Transgender and gender-diverse (TGD) youth experience more stressors and are therefore at a higher risk of health problems compared with their cisgender peers. The aim of this study was to investigate the prevalence of TGD youth in a general population sample and to explore a wide variety of health-related factors. We investigate differences in stressors and health outcomes between TGD youth and cisgender girls and boys and the influence of stressors and demographic factors on health outcome in the whole group.

METHODS

Cross-sectional survey data from a Swedish school-based study were used (N = 3,067, M = 17.8 years). Those who had reported their gender identity as "other" or other than their assigned gender (N = 41) were compared with cisgendered girls (n = 1,544) and boys (n = 1,482). Regression models in the whole group explored if demographics and stressors statistically predicted health outcomes.

RESULTS

In comparison with cisgender girls and boys, TGD youth (1.3% of the whole sample) reported a higher prevalence of self-harm and pain problems. Both TGD youth and cisgender girls more frequently reported insomnia, social anxiety, depressive symptoms, pain, and stressors compared with cisgender boys. When only demographic variables were entered, but not when stressors were added to the model, being TGD magnified the odds of depressive symptoms, sub-diagnostic social anxiety, and pain problems. Stressors magnified the odds of reporting health problems for the whole group.

CONCLUSION

TGD youth generally reported more stressors, which negatively influence health outcomes. Results are important for professionals who meet TGD youth.

Transgender lives at the population level: Evidence from Danish administrative data

This paper provides the first rigorous account of the diverse characteristics of transgender individuals at the population level, using data from Danish population registers. We observe three transgender subpopulations within the same national setting: all who changed thier legal sex (T-Legal, n = 1,995), all who have been assigned trans-related diagnostic codes (T-ICD, n = 1,594), and those who self-identified as transgender in a representative survey (T-Survey, n = 197, weighted n = 44,958). Results show significant differences in the subpopulations' backgrounds, family, education and labour market characteristics, and healthcare use. These differences extend beyond comparisons with the general population to great variations between each of the transgender subpopulations. Individuals with legal sex changes, and particularly those with trans-related diagnostic codes, face substantial disadvantages across various outcomes. Compared to the general population and the T-Survey subpopulation, the T-Legal subpopulation and the T-ICD subpopulation have significantly higher numbers of psychiatric hospital visits, lower educational attainment, lower annual earnings, and reduced employment rates, also when controlling for background characteristics. Earnings and employment rates remained significantly lower also when controlling for educational attainment. Our results show that the strategy chosen to identify trans individuals in population data has a great impact on the characteristics observed, and that trans individuals captured by surveys do not necessarily represent all transgender individuals, including those who seek to medically or legally transition. Furthermore, our results indicate that high numbers of trans individuals observed in surveys do not necessarily correspond to high demands for gender-affirming treatments or legal sex change. Finally, we show that transgender individuals who seek gender-affirming healthcare constitute a distinct and significantly disadvantaged group, also compared to other trans subpopulations.

Understanding Risk of Chronic Pain Development and Related Mental Health Disparities Among Transgender People: A Review of Current Literature and Future Directions

Biomedical and clinical research has traditionally focused on binary sex assignments as opposed to gender identity. This oversight has resulted in other gender minority populations being understudied. As a result, there is limited literature on chronic pain and mental health in transgender populations. These socially vulnerable individuals may be at increased risk for chronic pain development and related mental health disorders. Transgender individuals experience higher rates of social stigma and discrimination than their cisgender counterparts, and these factors have been linked to an increased prevalence of chronic pain, depression, and stress. Beyond chronic pain and mental health research, large overall health disparities and differences exist for transgender people compared with their cisgender peers. Therefore, it is crucial to include transgender individuals, as well as other gender minority people, in research in order to fully understand the impact of gender minority status on pain and quality of life. PERSPECTIVE: This review explores the intersectional impact of stress and mental health on chronic pain development and the unequal risk for transgender individuals. Promoting inclusion of gender minority individuals in research is a critical step to understanding the factors contributing to minority stress.

Mental health and timing of gender-related events among transgender and gender-diverse children and adolescents seeking gender-affirming consultation and care

Transgender and gender-diverse (TGD) youth encounter unique challenges affecting their mental health, largely related to societal stigma and gender dysphoria. Limited research considers the specific needs of TGD youth. This study examined demographic and developmental factors, including the ages at which gender-related events occur, and their relationship to mental health among TGD youth seeking gender-affirming consultation and care (GACC). We examined the medical records of 674 TGD children and adolescents, comparing demographics, gender-related events, and mental health across gender groups. The total sample comprised 261 patients assigned male at birth, and 413 patients assigned female at birth. Non-binary individuals reported higher rates of psychopathology compared to binary transgender patients, with transgender boys exhibiting higher rates than transgender girls. Seeking GACC at a more advanced pubertal stage and older age was associated with an increased likelihood of psychopathology. Later recollection of first gender incongruence memory was correlated with higher rates of depression and anxiety. Finally, socioeconomic status was linked to GACC healthcare-seeking behaviors. These findings underscore the importance of recognizing the diverse experiences and needs of TGD youth seeking GACC services, highlighting that early identification and access to care may be crucial for improving mental health outcomes.

A Narrative Synthesis Review of Legislation Banning Gender-Affirming Care

Purpose of Review

In recent years, there has been a drastic increase in legislation across US states that aims to ban gender-affirming care (GAC) for transgender and nonbinary (trans) youth. We synthesized the literature on bans on GAC, its impacts on medical and mental health providers, trans communities, particularly trans youth and their caregivers (e.g., parents/families), and provided recommendations for future research and advocacy.

Recent Findings

We highlight several adverse impacts of legislation banning GAC, including: an increase in professional tensions for medical and mental health providers that work with trans youth and worse mental health outcomes for trans youth and their caregivers due to loss of autonomy in accessing evidence-based GAC.

Summary

Bans on GAC undermine evidenced-based practices and are resulting in negative health effects for trans communities and youth. Research evidence highlights the need to examine effects of bans at the intersections of gender identity, socioeconomic status, race, and ethnicity.

Mental Health Needs, Barriers, and Receipt of Care Among Transgender and Nonbinary Adolescents

PURPOSE

Transgender and nonbinary youth disproportionately experience adverse mental health outcomes compared to cisgender youth. This study examined differences in their mental health needs and supports, barriers to care, and receipt of mental health care.

METHODS

This study examined cross-sectional data from 43,339 adolescents who completed the California Healthy Kids Survey, 4% (n = 1,876) of whom identified as transgender and/or nonbinary. Chi-square test and t-test were used to compare mental health needs and supports, resilience, and barriers to and receipt of care experienced by transgender and nonbinary youth compared to cisgender youth.

RESULTS

Transgender and nonbinary youth were significantly more likely to experience chronic sadness/hopelessness (74% vs. 35%) and consider suicide (53% vs. 14%) and less likely to report resilience factors (school connectedness: mean score 3.12 vs. 3.52). Transgender and nonbinary youth were significantly less likely to be willing to talk to teachers/adults from school (12% vs. 18%) or parents/family members (21% vs. 43%), but more willing to talk to counselors (25% vs. 19%) regarding mental health concerns. Transgender and nonbinary youth were significantly more likely to select being afraid (48% vs. 20%), not knowing how to get help (44% vs. 30%), or concern their parents would find out (61% vs. 36%) as barriers to seeking mental health care, yet reported slightly higher odds of receiving care when needed (odds ratio: 1.2).

DISCUSSION

Transgender and nonbinary youth are more likely to report mental health concerns and barriers to seeking care than cisgender youth. Increasing access to care is critical for this population.

Understanding Family Support for Transgender Youth: Impact of Support on Psychosocial Functioning

PURPOSE

This study investigated the association between positive and negative family support and psychosocial outcomes among transgender and gender diverse (TGD) youth.

METHODS

A retrospective analysis was performed using psychological data collected from 175 TGD youth (aged 13-18 years) at time of hormone readiness assessment within a multispecialty gender clinic between May 2021 and February 2023. As part of this assessment process, TGD youth provided responses to a variety of measures, including the Youth Self-Report and the Family Environment Scale.

RESULTS

Negative family support scales were more strongly associated with more outcomes than positive support scales. The exclusion and abuse, viewing gender expression as morally wrong, and trying to change gender scales were each associated with significantly higher Youth Self-Report T-scores for internalizing problems (βs = 6.86, 6.26, 5.56, all p < .01), externalizing problems (βs = 4.58, 4.42, 4.19, all p < .02), and total problems (βs = 6.70, 6.45, 5.34, all p < .02). The explicit care and support scale was associated with significantly lower T-scores for externalizing problems (β = -3.54 p = .02) and total problems (β = -3.35, p = .04). Overall support was also associated with higher T-scores in internalizing problems (b = -2.90, p = .02), externalizing problems (β = -2.40, p = .03), and total problems (β = -2.79, p = .03).

DISCUSSION

Family support plays a critical role in the psychosocial wellbeing of TGD youth. TGD youth reporting positive family support reported fewer mental health concerns, less experiences of nonaffirmation, and lower levels of internalized transphobia. TGD youth reporting negative family support were found to have an increased risk of suicidal ideation.

Discovering sources of resilience among homeless LGBTQ+ youth in out-of-home care in Israel: An ecological framework

BACKGROUND

LGBTQ+ youth in out-of-home care experience multiple stressors due to being a minority group, in out-of-home care, and rejected by their families. Therefore, they tend to be vulnerable.

OBJECTIVE

The purpose of this study is to explore the sources of the resilience of homeless LGBTQ+ youth in out-of-home care in the Israeli context. The research question was: What are the experiences, perceptions, and constructions of "resilience" among LGBTQ+ youth who aged out of out-of-home care for homeless LGBTQ+ youth in Israel?

METHODS

The study employed a critical constructivist grounded theory approach. Thirty-one in-depth semi-structured interviews were conducted with LGBTQ+ youth aged 16 to 32 (average age of 21.5) and analyzed.

RESULTS

The data analysis presents the sources of resilience according to four levels. (1) The individual level refers to self-acceptance, faith and hope, and creativity and productiveness. (2) The interpersonal level refers to friends and peer groups, educational institutions, employment environments, professionals, and LGBTQ+ out-of-home care services. (3) The macro level refers to public visibility of the LGBTQ+ community and financial support. (4) Finally, the chrono level refers to the development of rights and recognition over time.

CONCLUSIONS

An ecological model was implemented to conceptualize resilience among LGBTQ+ youth in out-of-home care in Israel. This multidimensional model was used to construct resilience sources that could assist in overcoming adversities among these youth. Implications for practice and future research are discussed.

"We did more than survive": lessons learned from studies of risk and resilience of young people growing up with HIV and mental health needs

Despite advances in HIV-treatment, adolescents and young adults (AYA) with HIV (AYAHIV) face myriad challenges. They are less likely than children and older adults to be virally suppressed and are at higher risk for mental health conditions compared to their peers who do not have HIV. AYA are also developing in the context of numerous biomedical, neurocognitive, and psychosocial developmental changes. Normative challenges during this time can be exacerbated by HIV and can result in significant physical and mental health problems. Yet, many AYAHIV have shown resilience with positive assets and resources and few health or mental health problems. Historically research has had a risk-focused approach to understanding AYAHIV needs. This paper discusses the rationale for a shift from a risk-focused only approach to one that examines AYAHIV needs from both a risk and resilience perspective. This paper presents: (1) epidemiological data on AYAHIV; (2) conceptual models for understanding both risk (e.g., poverty, stress, trauma, limited resources) and resilience/protective factors (e.g., family and peer support, future orientation, problem-solving skills); (3) global data examining risk and protective factors for physical and mental health challenges; and (4) promising interventions that incorporate elements of resilience to improve overall outcomes among AYAHIV.

Prevalence, severity and risk factors of psychiatric disorders amongst sexual and gender diverse young people during the COVID-19 pandemic: A systematic review

Before the COVID-19 pandemic, the prevalence and severity of psychiatric disorders among sexual and gender diverse (SGD) young people was greater than in their heterosexual/cisgender peers. We systematically reviewed literature examining the prevalence, severity, and risk factors for psychiatric disorders among SGD young people aged 25 and under during the pandemic. Four databases (MEDLINE, PsycInfo, Scopus and Web of Science) were searched. Eligibility criteria were studies assessing prevalence rates, mean symptomology scores and risk factors of psychiatric disorders using contemporaneous screening measures or diagnosis. Thirteen studies of mixed quality were identified. Most studies indicated SGD young people were at high risk of experiencing several psychiatric disorders including depressive and generalised anxiety disorder compared to the general population. This group also experienced more severe symptomology of various psychiatric disorders compared to their heterosexual/cisgender peers. Risk factors included those specific to the pandemic along with factors that led to greater risk before the pandemic. This systematic review has indicated evidence of heightened risk of psychiatric disorders among SGD young people during the COVID-19 pandemic. It is important for clinicians to acknowledge the needs of SGD young people, working with them to co-develop more inclusive care as they deal with the pandemic's fallout.

Adolescent neurocognitive development and decision-making abilities regarding gender-affirming care

Recently, politicians and legislative bodies have cited neurodevelopmental literature to argue that brain immaturity undermines decision-making regarding gender-affirming care (GAC) in youth. Here, we review this literature as it applies to adolescents' ability to make decisions regarding GAC. The research shows that while adolescence is a time of peak risk-taking behavior that may lead to impulsive decisions, neurocognitive systems supporting adult-level decisions are available given deliberative processes that minimize influence of short-term rewards and peers. Since GAC decisions occur over an extended period and with support from adult caregivers and clinicians, adolescents can engage adult-level decision-making in this context. We also weigh the benefits of providing GAC access during adolescence and consider the significant costs of blocking or delaying GAC. Transgender and non-binary (TNB) adolescents face significant mental health challenges, many of which are mitigated by GAC access. Further, initiating the GAC process during adolescence, which we define as beginning at pubertal onset, leads to better long-term mental health outcomes than waiting until adulthood. Taken together, existing research indicates that many adolescents can make informed decisions regarding gender-affirming care, and that this care is critical for the well-being of TNB youth. We highlight relevant considerations for policy makers, researchers, and clinicians.

Changes in Gender Dysphoria, Interpersonal Minority Stress, and Mental Health Among Transgender Youth After One Year of Hormone Therapy

PURPOSE

Cross-sectional studies have identified a strong link between interpersonal minority stress and mental health among transgender youth. However, very little is known about how experiences of minority stress change over time and how these changes relate to mental health. Further, few quantitative studies have examined the extent to which changes in gender dysphoria drive the improvements witnessed in mental health following gender-affirming medical treatment.

METHODS

Transgender youth (N = 115; age 12-18) completed measures of interpersonal minority stress (e.g., family and peer support, parent support of gender, victimization), body dissatisfaction, and mental health (e.g., depression, anxiety, psychosocial functioning) at baseline and one year after initiating medical treatment with a multidisciplinary gender-affirming program.

RESULTS

Significant reductions in body dissatisfaction, victimization, depression, and anxiety were found along with improvements in parent gender-related nonaffirmation and psychosocial functioning. Higher levels of baseline family support, parent gender-related acceptance, and lower levels of baseline victimization were associated with better mental health at one-year follow-up. Reductions in body dissatisfaction were also associated with fewer symptoms of depression and better psychosocial functioning and follow-up.

DISCUSSION

Results provide further confirmation of the broad, short-term benefits of gender-affirming hormone therapy and highlight the importance of monitoring youth's experience of dysphoria while receiving treatment. Results also continue to highlight the importance of family support and suggest some forms of minority stress improve over time; however, the relationship between short-term changes in minority stress and mental health may be more complex.

Development of Gender Non-Contentedness During Adolescence and Early Adulthood

Adolescence is an important period for the development of gender identity. We studied the development of gender non-contentedness, i.e., unhappiness with being the gender aligned with one's sex, from early adolescence to young adulthood, and its association with self-concept, behavioral and emotional problems, and adult sexual orientation. Participants were 2772 adolescents (53% male) from the Tracking Adolescents' Individual Lives Survey population and clinical cohort. Data from six waves were included (ages 11-26). Gender non-contentedness was assessed with the item "I wish to be of the opposite sex" from the Youth and Adult Self-Report at all six waves. Behavioral and emotional problems were measured by total scores of these scales at all six waves. Self-concept was assessed at age 11 using the Global Self-Worth and Physical Appearance subscales of the Self-Perception Profile for Children. Sexual orientation was assessed at age 22 by self-report. In early adolescence, 11% of participants reported gender non-contentedness. The prevalence decreased with age and was 4% at the last follow-up (around age 26). Three developmental trajectories of gender non-contentedness were identified: no gender non-contentedness (78%), decreasing gender non-contentedness (19%), and increasing gender non-contentedness (2%). Individuals with an increasing gender non-contentedness more often were female and both an increasing and decreasing trajectory were associated with a lower global self-worth, more behavioral and emotional problems, and a non-heterosexual sexual orientation. Gender non-contentedness, while being relatively common during early adolescence, in general decreases with age and appears to be associated with a poorer self-concept and mental health throughout development.

Delivering transgender-specific knowledge and skills into health and allied health studies and training: a systematic review

Many transgender individuals face inequities, discrimination, and sometimes even a lack of transgender-specific knowledge in health care settings. Educational curricula can address such disparities and help future health professionals to become more knowledgeable, confident, and well-prepared for addressing the needs of transgender individuals. This systematic review aims to summarize current training interventions about care of transgender individuals for health and allied health students, and to analyse the effects of the respective intervention. A total of six databases (Pubmed, MEDLINE, Scopus, Web of Science, Embase and SciSearch) were screened for original articles published between 2017 and June 2021. Search terms and eligibility criteria were pre-specified, and after a structured selection process 21 studies were included into further analysis. Extracted data contained information on general study properties, population, design, program format and outcomes of interest. A narrative synthesis was used to summarize detected results. Study quality was assessed for each individual study. A self-developed 18-item checklist combining criteria of two prior published tools was used to assess overall quality of quantitative studies. For qualitative studies a 10-item checklist by Kmet et al. [HTA Initiat, 2004] was applied. Eligible studies were designed for multiple health or allied health profession students, and varied widely regarding program format, duration, content, and assessed outcomes. Almost all (N = 19) interventions indicated improvements in knowledge, attitude, confidence and comfort levels or practical skills concerning care for transgender clients. Major limitations included the lack of long-term data, validated assessment tools, control groups and comparative studies. Training interventions contribute to prepare future health professionals to deliver competent and sensitive care and which may improve the prospective experienced health care reality of transgender individuals. However, currently there is no common consensus about best practice of education. Additionally, little is known about whether detected effects of training interventions translate into noticeable improvements for transgender clients. Further studies are warranted to assess the direct impact of specific interventions in the light of the respective target populations.

Mental Health of Homicidally Bereaved Individuals: A Systematic Review of Post-Homicide Factors

Experiencing the homicide of a loved one has a substantial impact on the mental health of family members and friends who must survive their loved one's tragic death. This systematic review aims to synthesize the current findings on post-homicide factors and identify the factors most frequently related to the mental health of homicidally bereaved individuals (HBI). Four databases were searched (PsycINFO, SCOPUS, Sociological Abstract, PubMed). The selection of studies was based on a peer review process conducted by two independent researchers to ensure interrater reliability. The articles were screened to ensure the presence of homicidally bereaved adults, resulting in a total of 35 eligible papers to be considered in the current review. Factors were organized into categories, with the criminal justice system-related factors (n = 18), social factors (n = 17), and coping factors (n = 13) being the most prevalent. This review identifies clinical avenues for preventing distress and fostering the well-being of HBI.

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.

Affirming Care for Transgender and Gender-Diverse Youth

ABSTRACT

Nurses play a critical role in providing gender-affirming care for transgender and gender-diverse youth. With heightened debate about the clinical care for transgender and gender-diverse youth in the national and global spotlight, now more than ever before nurses must equip themselves with the knowledge and the evidence spanning more than 4 decades that support the clinical use of gender-affirming care for youth and young adults. By exploring gender development and gender-affirming care approaches through the lifespan perspective, this review provides an up-to-date discussion about best practices and clinical implications for providing equitable care for transgender and gender-diverse youth from birth to childhood and through adolescence developmental phases. A transgender and gender-diverse youth's future willingness to access health care is dependent on how positive their interactions are with their care team at this sensitive moment in their life. Nurses must not let political rhetoric impede their practice and ethical guidelines to provide competent, skilled, and unbiased care. Knowledgeable, informed, and empowered nurses can provide life-saving care to transgender and gender-diverse youth and their families.

Caregiver perspectives on receiving gender-affirming care with their transgender and gender diverse adolescents via telemedicine

Telemedicine may help improve access to gender-affirming care for transgender and gender diverse (TGD) adolescents. Parents or guardians (i.e., caregivers) of TGD adolescents play a critical role in supporting TGD adolescents in accessing this care. The purpose of this study was to explore caregivers' perspectives regarding their adolescent receiving pediatric gender-affirming care via telemedicine to help providers and health systems optimize this modality for future care delivery. Caregivers (n=18) of TGD adolescents ages 14-17 participated in semi-structured, individual interviews that were transcribed and analyzed qualitatively. Caregivers cited participating in visits from their home environment, decreased anxiety, COVID safety, ability to have more family members attend, no transportation demands, and effective delivery of care as advantages of telemedicine. Disadvantages included dysphoria or discomfort with self-image, impersonal provider-patient interactions, video teleconferencing fatigue, difficulty with portal navigation, connectivity issues, and lack of privacy. Caregivers largely deferred to their child's preference regarding the choice of visit modality, but many reported a preference for the first to be conducted in-person, and follow-up and less complex visits via telemedicine. Health systems should consider these perspectives as they adapt telemedicine infrastructure to better meet the needs of patients and their families.

Patterns and practices of parenting transgender children: A brief Comparative study

The practices of parents raising children with trans* life experiences influence their subsequent social adjustment. The aim of the study was to identify potential differences in parenting patterns and practices between two groups, one comprising families with transgender children and the other group comprising families with cisgender children. Twenty-eight adults and 15 children and adolescents from Bogotá, Colombia, participated. We performed descriptive, nonparametric comparative, and Bayesian comparative analyses for independent samples. We used a frequentist inferential comparative method with the Mann-Whitney U test with an effect size based on rank-biserial correlation, which revealed no statistically significant difference values. Bayesian comparisons showed minimal evidence in favor of the null hypothesis in all comparisons performed, except for the Behavioral Control or Regulation variable. The main finding of this study suggests that parents of children with trans* life experiences may not be addressing their specific needs, which could lead to a lack of understanding of their situation and support in their transition process.

Minority stress and mental health in European transgender and gender diverse people: A systematic review of quantitative studies

The current study aimed at systematically reviewing evidence on the relationships between gender minority stress and mental health outcomes among European transgender and gender diverse (TGD) individuals. A systematic search was conducted in PsycINFO, PubMED, Scopus, and Google Scholar. It was based on Boolean operators to combine terms related to minority stress, TGD identities, and mental health. Thirty studies were identified as eligible. The results confirmed that gender minority stress factors are significantly related with mental health problems among European TGD individuals. Distal stressors were identified as strongly associated with poorer mental health, with gender-related discrimination emerging as the most documented risk factor. The significant role of proximal stressors was also highlighted, with some mediation analyses detecting an indirect effect on mental health. However, identity concealment appeared unrelated to mental health outcomes. Resilience-promoting factors buffering the impact of stressors were also identified, including self-esteem, pride, transitioning, and social support. Conversely, data on community connectedness as a source of resilience were inconclusive. The studies reviewed have several limitations, including lack of longitudinal designs, sampling bias, variability in measurement methods, and unaccounted ethnic variables. Research and clinical recommendations in this field are reported.

A systematic review and qualitative research synthesis of the lived experiences and coping of transgender and gender diverse youth 18 years or younger

Background

Research on the daily experiences of transgender and gender diverse (TGD) youth 18 years or younger is limited, making it essential to gain a comprehensive understanding of their internal and external experiences related to gender identity.

Aim

This systematic review and qualitative research synthesis fills this research gap by examining the lived experiences and coping of TGD youth, including prepubertal children.

Methods

The review was pre-registered according to PROSPERO on the Open Science Framework and followed the ENTREQ reporting guidelines. A Qualitative research synthesis, according to Howell Major and Savin-Baden, was conducted.

Results

Seventeen peer-reviewed articles published between 2000 and 2023 fulfilled inclusion criteria and quality assessment. Synthesized themes were: (1) "Navigating gender identity", with two sub-themes, Meaning-making and Considering visibility (2) "Navigating relations", with four sub-themes: Longing for belonging, Supportive actions, Lack of safety and Coping inside out (3) "Navigating society with two sub-themes Inclusion and exclusion and Beyond control. Our findings demonstrate that TGD youth view gender identity as fluid and benefit from a supportive environment that facilitates genuine exploration. Coping strategies develop intricately, influenced by multifaceted factors.

Discussion

Unlike previous research on the negative effects of minority stress, our review underscores the cumulative impact of subtle daily stressors on TGD youth's well-being, highlighting the significance of an environment where gender is not a constant concern. By shedding light on these dynamics, this synthesis contributes to a comprehensive understanding of TGD youth's perspectives for professionals and a broader audience.

Evaluation of a codesigned group cognitive-behavioural therapy intervention for trans young people (TAG TEAM): protocol for a feasibility trial and a subsequent pilot RCT

INTRODUCTION

Trans young people are at a higher risk of mental health difficulties such as depression, anxiety and suicidality than their cisgender peers, due in part to their experiences of minority stress. This protocol describes a feasibility trial and subsequent pilot randomised controlled trial (RCT) of a codesigned group cognitive-behavioural therapy intervention for trans young people, named Trans Adolescent Group ThErapy for Alleviating Minority stress (TAG TEAM).

METHODS AND ANALYSIS

To evaluate TAG TEAM, we will conduct a feasibility trial followed by a pilot RCT with trans young people aged 14-16 years who have been referred to the Royal Children's Hospital Gender Service in Melbourne, Australia. In the feasibility trial, we aim to enrol 32 participants who will be randomised at a 1:1 ratio to either in-person or online intervention arms. Participants will be assessed at baseline and post-treatment, with a nested qualitative evaluation post-treatment. Primary outcomes are the feasibility and acceptability of the intervention and the study design and associated procedures, including comparison of the in-person and online delivery modes. In the subsequent pilot RCT, we aim to enrol 64 participants who will be randomised at a 1:1 ratio to an intervention or waitlist control arm, with delivery mode determined by the feasibility trial. Participants will complete assessments at baseline, post-treatment and 3-month follow-up. Primary outcomes are the feasibility and acceptability of the RCT study design. In both the feasibility trial and pilot RCT, participants will complete assessments related to mood, anxiety, suicidality, quality of life, minority stress, family support and social transition. Quantitative data will be analysed using descriptive statistics. Qualitative data will be analysed using thematic and interpretive analysis.

ETHICS AND DISSEMINATION

The Royal Children's Hospital Human Research Ethics Committee has approved this study (#91162). Informed consent will be obtained in writing from all participants and a legal guardian. Findings will inform the development of a full-scale RCT to evaluate the efficacy of TAG TEAM and will be disseminated through conferences and peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12623000302651, ACTRN12623000318684.

Cognitive and Developmental Profiles Associated with Self-Reported Sexual and Gender Minority Stigmatization Among Binary Transgender Adolescents

OBJECTIVE

Sexual and gender minority (SGM) stigmatization is a key factor related to transgender adolescent mental health. While previous research has focused on direct associations between stigmatization and mental health, the present study of transgender youth, equitably recruited across the autism spectrum, examines cognitive and developmental factors in relation to the self-report of experienced and perceived SGM stigmatization.

METHOD

65 binary transgender adolescents (43% transfeminine; ages 13-21 years) were intentionally recruited across the spectrum of autism traits from no traits to full criteria autism. Participants completed measures of autism-related social differences, cognitive abilities, and self-reported directly experienced and perceived SGM stigma. Autism-related social differences, cognitive abilities, and age were studied in relation to both SGM stigma factors.

RESULTS

Autism-related social differences were negatively associated with level of directly experienced SGM stigma but unassociated with perceived stigma. Greater cognitive ability was positively associated with level of perceived SGM stigma, but unassociated with report of directly experienced stigma. Older age was positively associated with level of perceived SGM stigma. There was a statistical trend toward older age positively associated with level of directly experienced stigma.

CONCLUSIONS

The present study identifies candidate cognitive and developmental influences on self-reported SGM stigmatization among transgender adolescents, evenly recruited across the autism spectrum. The factors which may impact the perception and experience of stigmatization have been notably under-explored in the mental health field. The examination of these individual characteristics may allow for more precise predictive models for research with transgender youth, and ultimately, in clinical care.

Gender non-conformity in childhood and adolescence and mental health through to adulthood: a longitudinal cohort study, 1995-2018

BACKGROUND

Few studies have examined associations between gender non-conformity (GNC) in childhood or adolescence and mental health outcomes later in life. This study examined associations between (1) GNC and mental health over multiple time points in childhood and adolescence, and (2) GNC in childhood and/or adolescence and mental health in adulthood.

METHOD

Second generation participants from the Raine Study, a longitudinal cohort from Perth, Western Australia. Data were collected between 1995 and 2018, comprising seven waves: ages 5 (N = 2236), 8 (N = 2140), 10 (N = 2048), 14 (N = 1864), 17 (N = 1726), 22 (N = 1236) and 27 (N = 1190) years. History of GNC, v. absence of this history, was based on responses to item 110 from the Child Behaviour Checklist (CBCL)/Youth Self Report (YSR) ('wishes to be of opposite sex'). The CBCL/YSR were used to measure internalising and externalising symptoms. Items 18 ('deliberate self-harm [DSH] or attempts suicide') and 91 ('talks/thinks about killing self') were used as measures of suicidal ideation (SI) and DSH. For adults, Depression, Anxiety and Stress Subscales and Kessler Psychological Distress Scale assessed mental health.

RESULTS

Child and adolescent GNC was associated with elevated internalising and externalising behaviours and increased odds of DSH. A history of GNC was also associated with vulnerability for severe psychological distress in adulthood in some symptom scales.

CONCLUSION

GNC over the child and adolescent period is associated with significant emotional and behavioural difficulties, and psychological distress. A history of GNC in childhood and/or adolescence also predicts poorer mental health in adulthood on multiple symptom domains.

Childhood and Adolescence Gender Role Nonconformity and Gender and Sexuality Diversity in Young Adulthood

Importance

Sexuality- and gender-diverse youth experience disproportionate health and social adversity. Accurate early-life indicators are important for development of supportive approaches.

Objective

To examine whether commonly used items measuring childhood conformity to gender roles are associated with sexual orientation in young adulthood.

Design, Setting, and Participants

This single-center, prospective cohort study (the Raine Study) assessed 2868 children of 2900 women who were recruited during pregnancy from August 1, 1989, to April 30, 1992, with follow-up ongoing. The Achenbach System of Empirically Based Assessment (ASEBA) Child Behavior Checklist, Teacher Report Form, and Youth Self-Report tools were used to survey parents, teachers, and youths to examine gender diversity among the participating youths. Parents were followed up at years 5, 8, 10, 14, and 17, adolescents at years 14, 17, and 27, and teachers at years 10 and 14. Data were analyzed from August 1, 2020, to July 31, 2023.

Exposures

Parent and teacher report that a child "behaves like the opposite sex" (gender role behavior), and parent and self-report that a child "wishes to be the opposite sex" (gender role wish), in response to assessment items.

Main Outcome Measures

Year 27 self-reported sexual identity, attraction, and behavior.

Results

Of the 2868 children in the original birth cohort, 1154 (40.2%) participated in the year 27 follow-up, of whom 608 (52.7%) were recorded female at birth and 546 (47.3%) were recorded male at birth. Of these, 582 who were recorded female at birth continued to identify as female (cisgender) (95.7%), and 515 recorded male at birth continued to identify as male (cisgender) (94.3%); 47 (4.1%) did not complete the questionnaire. Of cisgender participants, 76 of 605 women (12.6%) and 52 of 540 men (9.6%) had a diverse sexual identity, 204 of 605 women (33.8%) and 77 of 540 men (14.3%) were same-gender attracted, and 100 of 605 women (18.6%) and 39 of 540 men (7.2%) had ever engaged in same-gender sexual behavior. Across all follow-ups, after adjusting for gender, nonconforming gender role behavior was consistently associated with diverse sexual identity and behavior (adjusted odds ratio [aOR] for identity, 2.8; 95% CI, 1.9-4.2; behavior aOR, 2.4; 95% CI, 1.6-3.5). Self-reported gender role wish was consistently associated with diverse sexual orientation (identity aOR, 2.3; 95% CI, 1.4-3.8; attraction aOR, 1.7; 95% CI, 1.1-2.5; behavior aOR, 1.9; 95% CI, 1.2-2.9).

Conclusions and Relevance

In this cohort study, ASEBA gender role nonconformity was associated with diverse sexual orientation, beginning in early childhood. Findings suggest that the ASEBA measures should not be used to infer sexual orientation or gender diversity in clinical or research settings; asking direct questions may provide more accurate data.

A scoping review of research literature on eating and body image for transgender and nonbinary youth

BACKGROUND

Transgender and nonbinary (TGNB) adolescents and young adults are underrepresented in the literature on eating disorders and body image-related problems, despite increased mental health disparities and emerging research showing high associations between gender dysphoria, body image, and eating disorders among TGNB youth.

AIMS

The scoping review was designed to critically examine the research on TGNB adolescents and young adults who experience eating and body image related problems as well as clinical studies on treatment approaches and effectiveness.

METHOD

Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) was used for reporting this scoping review. The electronic databases of MEDLINE and PsychInfo were used for searching subject terms. Inclusion criteria for studies required the quantitative measurement or qualitative exploration of body image or eating for transgender minor children, adolescents, or young adult samples (18 to 25 years old) and address differences in eating/body-related problems by age. The relevant data was extracted and narratively summarized.

RESULTS

49 studies were identified, data extracted, and analyzed. Increased prevalence of eating disorders and body image problems were identified for TGNB youth. Body-gender congruence through gender affirming social and medical interventions (e.g., hormone therapy) were noted as significant for alleviating body image problems and facilitating eating disorder treatment. Family and social factors were not well understood in the literature and a need for increased study of TGNB youth from varied racial/ethnic, neurodiverse, and within specific identities (e.g., nonbinary) and families and cultural contexts is still needed.

CONCLUSIONS

Future research should consider the use of developmental and family theories for guiding inclusion of salient social factors influencing eating patterns, body image, and treatment outcomes. In addition, more studies are needed with those from minoritized racial and ethnic groups, neurodiversity, and varied gender identities (e.g., nonbinary and gender queer) for identifying important differences.

A scoping review of resilience among transition-age youth with serious mental illness: tensions, knowledge gaps, and future directions

INTRODUCTION

The study of resilience among transition-age youth (aged 16-29 years) living with serious mental illness (SMI) has provided a promising new direction for research with the capacity to explore individuals' strengths and resources. However, variability in how resilience is defined and measured has led to a lack of conceptual clarity. A comprehensive synthesis is needed to understand current trends and gaps in resilience research among this population. The purpose of the current study was to map how resilience has been conceptualized and operationalized among transition-age youth with SMI, explore resilience factors and outcomes that have been studied, and recommend areas for future research.

METHODS

A six-stage scoping review methodology was used to systematically identify relevant empirical literature across multiple databases (MEDLINE, EMBASE, PsycINFO, AMED, CINAHL, Scopus), addressing transition-age youth diagnosed with SMI and resilience. Topic consultation and reaction meetings were conducted to gather feedback from transition-age youth with SMI, researchers, and clinicians during the review process to enhance the applicability of the review findings. A meta-narrative approach was used to organize included studies into research traditions (i.e., paradigms of inquiry with similar storylines, theoretical and methodological orientations). Resilience factors and outcomes, and the consultative meetings, were analyzed using content analysis.

RESULTS

Twenty-four studies met inclusion criteria (14 quantitative, 9 qualitative, 1 mixed-method). Four research traditions were identified, each contributing a unique storyline which conceptualized and operationalized resilience in slightly different ways: Stress Adaptation, Person-Environment Interactions, Recovery-Focused, and Critical and Cultural Perspectives. Resilience factors and outcomes were most commonly evaluated at the individual-level or within the immediate environment (e.g., personal characteristics, social support networks). Limited research has explored the influence of macro-level systems and health inequalities on resilience processes. Results from the consultative meetings further demonstrated the importance of health services and sociocultural factors in shaping processes of resilience among youth.

CONCLUSION

The present results may be used to inform future work, as well as the development of age-appropriate, strengths-based, and resilience-oriented approaches to service delivery. Interdisciplinary and intersectional research that prioritizes community and youth engagement is needed to advance current understandings of resilience among transition-age youth with SMI.

Protocol for a systematic review of substance use and misuse prevalence and associated factors among transgender and non-binary youth living in the USA

BACKGROUND

Transgender and gender non-binary (TNB) youth living in the USA report elevated levels of substance use compared with their cisgender counterparts, with previous literature pointing to minority stressors as some of the factors that could facilitate such elevated levels. Yet, substance use and misuse prevalence and associated modifiable factors among TNB youth are not fully known. The current paper details the protocol for a systematic review aimed at (1) identifying substance use and misuse prevalence among TNB youth (ages <25) and related demographic disparities (based on racial, ethnic and gender identity, and sexual orientation), (2) examining factors associated with substance use and misuse among TNB youth and (3) examining protective factors against substance use and misuse among TNB youth.

METHODS AND ANALYSIS

Systematic searches will be conducted across four databases: PubMed, LGBTQ+ Source, CINAHL and PsycInfo to identify quantitative, qualitative and mixed-methods peer-reviewed research publications. An exhaustive list of keywords and corresponding MeSH (Medical Subject Headings) terms representing the concepts of 'TNB' (the population of interest) and 'substance use and misuse' (outcome) will be employed. Identified records will be initially screened via a review of titles and abstracts. Full text of the remaining records will be reviewed corresponding to the inclusion and exclusion criteria. Extracted data will be synthesised in table and narrative format. A meta-analysis will be considered contingent on the existence of sufficient data. Methodological quality and risk of bias of studies will be assessed.

ETHICS AND DISSEMINATION

This review does not require approval from the Institutional Review Board as it involves no interactions with human subjects. We will disseminate our findings via peer-reviewed manuscripts and academic conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42023394985.

Gender Affirmation-Related Information-Seeking Behaviors in a Diverse Sample of Transgender and Gender-Diverse Young Adults: Survey Study

BACKGROUND

Of the 1.6 million transgender and gender-diverse (TGD) people in the United States, approximately 700,000 are youth aged 13-24 years. Many factors make it difficult for TGD young people to identify resources for support and information related to gender identity and medical transition. These range from lack of knowledge to concerns about personal safety in the setting of increased antitransgender violence and legislative limitations on transgender rights. Web-based resources may be able to address some of the barriers to finding information and support, but youth may have difficulty finding relevant content or have concerns about the quality and content of information they find on the internet.

OBJECTIVE

We aim to understand ways TGD young adults look for web-based information about gender and health.

METHODS

In August 2022, 102 young adults completed a 1-time survey including closed- and open-ended responses. Individuals were recruited through the Prolific platform. Eligibility was restricted to people between the ages of 18-25 years who identified as transgender and were residents of the United States. The initial goal was to recruit 50 White individuals and 50 individuals who identified as Black, indigenous, or people of color. In total, 102 people were eventually enrolled.

RESULTS

Young adults reported looking on the internet for information about a broad range of topics related to both medical- and social-gender affirmation. Most participants preferred to obtain information via personal stories. Participants expressed a strong preference for obtaining information from other trans people.

CONCLUSIONS

There is a need for accessible, expert-informed information for TGD youth, particularly more information generated for the transgender community by members of the community.

Stigma and HIV Treatment Outcomes Among Transgender Women Sex Workers in the Dominican Republic

Trans women experience multiple forms of intersecting stigma due to trans identity, HIV, and sex work, which can negatively affect their health. There is limited understanding of the relationships between stigma and HIV care and treatment outcomes. We assessed associations between multiple forms and types of stigma and HIV treatment outcomes among trans women who conduct sex work in Santo Domingo, Dominican Republic using cross-sectional survey data. Most participants had received HIV care (91%) and were currently taking anti-retroviral therapy (ART) (84%). Only 64% were virally suppressed. Nearly one-third (32%) had interrupted ART at some point; those who had never interrupted ART were more likely to be suppressed. Drug use was associated with ART interruption. Higher enacted HIV stigma was associated with current ART use. Higher enacted HIV stigma and higher anticipated sex work stigma were associated with ART adherence. Higher trans stigma was associated with being virally suppressed. Findings highlight the importance of addressing multiple forms of stigma at the individual and clinic levels to improve and sustain viral suppression. Future research is needed to assess if unexpected associations between stigma and HIV outcomes reflect processes of resilience. Future research is also needed to assess the pathways between drug use, ART interruption, and viral suppression among trans women.

Resilience mediates the effect of peer victimization on quality of life in Chongqing adolescents: from a perspective of positive childhood experiences

Background

Peer victimization is a harmful experience that contributed to one's psychological problems, physical health deterioration, and so on. Quality of life (QoL) is an important indicator of adolescent health assessment. To identify potential pathways of positive experiences in preventing peer victimization's detrimental effects and then provide intervention ideas for adolescent health, this study was conducted to examine the relationship between peer victimization and QoL in Chongqing adolescents and discover whether resilience plays a mediating role and positive childhood experiences (PCEs) act as a moderating role in the relationship.

Methods

Data were the first follow-up of a cohort study conducted in four complete middle schools in two districts of Chongqing, China. Self-designed peer victimization items, the Connor-Davidson Resilience Scale, the Adolescent Quality of Life Scale, and the Benevolent Childhood Experiences Scale were used. We investigated the differences and correlations in peer victimization, QoL, and resilience between the two PCEs groups. Mplus version 8.3 was used to analyze the mediating role of resilience and the moderating role of PCEs in peer victimization and QoL.

Results

Peer victimization, resilience, and QoL differed between the two PCEs groups (P < 0.001). Peer victimization negatively correlated with QoL and resilience, while resilience positively correlated with QoL (P < 0.001). In the models with total QOL as the dependent variable, the indirect effect was -0.431 (8.08% of the total effect) in the low-PCEs group vs. -2.077 (41.97% of the total effect) in the high-PCEs group. In the models with four dimensions of QOL as the dependent variable, the indirect effects ranged from -0.054 to -0.180 (6.07-12.95% of the total effects) in the low-PCEs group and from 0.295 to -0.823 in the high-PCEs group (35.89-68.76% of the total effects). Both total and indirect effects were significant (P < 0.05). In addition, the differences in indirect effects were significant between the two PCEs groups (P < 0.05), while differences in total and direct effects were almost not apparent.

Conclusion

Resilience partially mediated the effect of peer victimization on QoL in Chongqing adolescents, and PCEs moderated this mediation. Schools, families, and society should focus on resilience intervention and prioritize the enhancement of PCEs for improving adolescent QoL.

The influence of minority stress-related experiences on mental wellbeing for trans/gender-diverse and cisgender youth: a comparative longitudinal analysis

Trans and gender-diverse (TGD) adolescents are likely to experience poorer mental health and wellbeing than their cisgender peers. Minority stress theory has developed as a possible explanation for some of this disadvantage: factors such as increased bullying and discrimination lead to excess stress and reduced wellbeing. However, the evidence base remains limited. This study drew on secondary data analysis of the #BeeWell longitudinal cohort over 2 years (N = 26 042, aged 12-13 at time one, T1). We report two unregistered hypotheses relating to T1 (autumn 2021) data which was available at the time of stage-one submission: H1, mean differences in T1 wellbeing; H2, mean differences in T1 minority-related stressors. These are followed by two registered hypotheses relating to T2 (autumn 2022) data: H3, replication of T1 mean differences in T2 wellbeing; H4, predictions were made about the strength of the association between T1 minority-related stressors, controlling for sexuality and T2 wellbeing across T1 gender identity groups. At both time points cis-females, TGD and those who preferred not to say their gender had lower wellbeing than cis-males (CM), with the largest effect evident for the TGD group. TGD adolescents also showed the largest disadvantage (mean difference) compared with CM for minority stressors. Counter to H4 and minority stress theory, gender was not found to moderate the effect of minority stressors on later wellbeing. Our findings highlight the vulnerability of the TGD group in terms of wellbeing and minority stressors and are discussed with relevance for policy and future research.

Systematic review: Psychological/psychosocial interventions for the families of gender diverse youth under 18 years old

BACKGROUND

The aim of this paper is the systematic review of psychological/psychosocial interventions for gender diverse youth under 18 years of age and their families, based on the published protocol: PROSPERO 2020 CRD42020163995.

METHODS

A search strategy was developed using key terms. An electronic literature search was completed using the following data bases (OVID MEDLINE; EBSCO CINAHL; ProQuest MEDLINE; OVID PsycINFO). Only studies published in English between 2001-2021 were included. This review is based on PRISMA guidance. Studies meeting inclusion criteria were quality appraised using the Mixed Methods Assessment Tool (MMAT).

RESULTS

8405 studies were independently screened. Four studies met the inclusion criteria for the study. Parents of transgender youth attended between one and 11 psychological/psychosocial group interventions. Parents reported reduced isolation and increased knowledge, which enabled them to advocate for their young person`s needs. Psychological/psychosocial group interventions were creating challenges in terms of group processes, with some parents dominating interactions. Psychological/psychosocial group interventions were positive for parents, but no outcomes were collected for transgender young people.

CONCLUSION

More research is required to understand the role of group facilitators, the optimal group size and the number of psychological/psychosocial intervention sessions required.

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.

Social Support and Mental Health Among Transgender and Nonbinary Youth in Quebec

Purpose: Transgender and nonbinary (TNB) youth face elevated levels of discrimination, stigma, mental health disorders, and suicidality when compared with their cisgender counterparts. Family and school support may mitigate some of the effects of the stressors facing TNB youth. This study aimed to better understand the impact of each of these sources of support on TNB youths' mental health and wellbeing. Methods: We used data collected between 2018 and 2019 as part of the Canadian Trans Youth Health Survey, a bilingual online survey to measure social support, physical health, and mental health in a sample of 220 TNB youth aged 14-25 living in Québec, Canada. We examined the relationships among different sources of support, and mental health and wellbeing outcomes using logistic regression. Analyses were conducted on the full sample and according to linguistic groups (French and English). Results: Participants reported high levels of mental health symptoms, self-harm, and suicidality, and mental health symptoms were higher in the English-speaking group (p = 0.005). In models controlling for age, family connectedness was associated with good/excellent self-reported mental health (odds ratio [OR] = 2.62, p = 0.001) and lower odds of having considered suicide (OR = 0.49, p = 0.003) or attempted suicide (OR = 0.43, p = 0.002), whereas school connectedness was associated with higher odds of good/very good/excellent general (OR = 2.42, p = 0.013) and good/excellent mental (OR = 2.45, p = 0.045) health. Conclusion: Family and school support present consistent associations with TNB youths' health and may constitute key areas for intervention for those supporting them.