Mental Health Outcomes Among Transgender and Gender-Nonbinary Youth

Investigators sought to assess risk factors associated with poor mental health in Chinese transgender and gender-nonbinary adolescents.

Transgender and gender-nonbinary youth experience high rates of depressive symptoms, anxiety symptoms, and suicidal ideation, according to results of a survey conducted in China and published in JAMA Network Open.1

Investigators conducted a nationwide survey study between January and September of 2017 using self-selected samples. Questionnaires were completed anonymously. Participants were asked to report their assigned biologic sex at birth, as well as their self-identified gender. The Chinese-modified versions of the Center for Epidemiological Studies Depression 9-item and the 7-item General Anxiety Disorder scales were used to screen for depressive and anxious symptoms, respectively. Lifetime suicidal ideation was assessed using standardized yes or no questions. Participants also reported any school- or family-related abuse, neglect, and bullying owing to being transgender or gender-nonbinary. Univariate and multivariate logistic regression was performed to identify factors associated with suicidal ideation.    

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A total of 564 survey responses were received; 385 (68.2%) respondents were included in analyses. Participants were between 12 and 18 years of age (mean age, 16.7 years), and 323 participants (83.9%) were students. The analytic cohort comprised 109 (28.3%) transgender adolescent boys, 167 (43.4%) transgender adolescent girls, and 109 (28.3%) gender-nonbinary adolescents.

Among participants who reported that their family was aware of their gender identity, 296 (92.8%) reported experiencing parental abuse or neglect owing to being transgender or gender-nonbinary. Regarding school-related discrimination, 295 (76.6%) participants from the entire cohort reported bullying or abuse from classmates or teachers. Nearly half (44.9%) of all respondents had a Center for Epidemiological Studies Depression 9-item scale score indicating that they were at risk for major depressive disorder.

Additionally, 148 (38.4%) participants had a 7-item Generalized Anxiety Disorder scale score indicating they were at risk for an anxiety disorder. Suicidal ideation was reported by 196 (50.9%) participants, and 61 (15.8%) reported having attempted suicide at some point in their lifetime.

According to univariate analyses, suicidal ideation was more likely to be reported by participants who strongly disliked their assigned sex (odds ratio [OR], 4.98; 95% CI, 2.93-8.47) and participants who experienced depressed mood at the onset of puberty (OR, 7.44; 95% CI, 3.66-15.13; both P <.001). In univariate analysis, experiencing bullying from a classmate or teacher was significantly associated with suicidal ideation (OR, 1.68; 95% CI, 1.04-2.70; P =.03). However, after adjustments for level of education attained, aversion to assigned sex, and depressed mood at the onset of puberty, the association was no longer significant (OR, 1.63; 95% CI, 0.97-2.73).

These data reflect the significant challenges faced by transgender and gender-nonbinary youth, both in China and elsewhere. In a companion editorial published in JAMA Network Open, Cary L. Klemmer, MSW, emphasized the importance of structural-level interventions to improve mental health among transgender and gender-diverse adolescents.2 Existing guidelines from researchers and community organizations suggest the use of educational programs at schools to “promote acceptance of…gender diversity.”

Additionally, Klemmer endorsed the use of convenience sampling, respondent-driven sampling, and snowball sampling methods to reach representative samples of transgender individuals. Further research is necessary to explore the factors that influence mental health outcomes and to identify appropriate means of intervention to improve the lives of transgender individuals.


1. Peng K, Zhu X, Gillespie A, et al. Self-reported rates of abuse, neglect, and bullying experienced by transgender and gender-nonbinary adolescents in China. JAMA Netw Open. 2019;2(9):e1911058.

2. Klemmer CL. Transgender and gender-diverse adolescents’ experiences of violence, depression, anxiety, and suicidal ideation in the People’s Republic of China. JAMA Netw Open. 2019;2(9):e1911068.