Various health-related disparities such as higher rates of disability, multiple chronic diseases, mental illness, and substance use disorders affect transgender individuals disproportionately, compared to their effects on cisgender individuals.1,2 Despite the high prevalence of these issues, significant barriers that block transgender patients’ access to competent, compassionate health care include gender-based stigma and discrimination.1
Recent studies have shed light on mental health concerns in transgender youth specifically, with findings indicating a 2- to 3-fold increase in depression and suicidality in this population.3 Other results demonstrated that more than 75% of transgender and gender nonbinary youth experienced symptoms of generalized anxiety disorder.4
A study published in March 2021 in JAMA Network Open further revealed that while Black and Latinx transgender youth (BLTY) experienced similar rates of mental health symptoms compared to White transgender youth, BLTY experienced higher symptom rates compared to their Black and Latinx cisgender peers. As hypothesized, victimization and harassment based on gender, sexuality, or race were linked to an increased risk of symptoms in BLTY.5
However, although the study authors expected to find that school connectedness and caring adult relationships would be protective against mental health symptoms in these groups as shown in previous studies of transgender and other youth, this was not the case for the BLTY included in this study. “These findings suggest that it may be particularly salient for pediatric clinicians to screen BLTY for school-based bullying and partner with schools to mitigate such harassment,” they wrote.5
Another investigation published in the same journal in April 2021 reported that anxiety and depression levels of socially transitioned transgender youth were similar to or slightly elevated compared to their siblings and cisgender peers. “The current findings do not negate the experiences of the many transgender people who face high rates of mental health challenges, but do provide further evidence that being transgender is not synonymous with these challenges,” the study authors concluded.
They noted that the results could possibly be due to participants’ early social transition, race, higher socioeconomic status, or high levels of support for their identities, although additional research is needed to evaluate the impact of these factors.6
To learn more about the mental health challenges affecting transgender youth and how clinicians can better support these patients, we interviewed Jason V. Lambrese, MD, staff child and adolescent psychiatrist at Cleveland Clinic’s Lakewood Family Health Canter in Lakewood, Ohio, and Ralph Vetters, MD, MPH, pediatrician and site medical director at the Sidney Borum Jr. Health Center, a program of Fenway Health in Boston.
What does the available evidence suggest about mental health issues and treatment barriers among transgender youth?
Dr Lambrese: Unfortunately, mental illness is more common in transgender youth compared to their cisgender peers. Because of the stress and discrimination that trans youth face, they are at increased risk for depression, anxiety, and suicidality. Studies show that up to 50% of trans youth will contemplate suicide, with risk being higher if youth are rejected by their families.7
In addition, many trans youth lack access to safe, competent, and affirming mental health care, leaving these symptoms untreated. For many transgender people, addressing their gender dysphoria with gender-affirming medical (hormone therapy) or surgical interventions leads to a reduction in their overall levels of distress.8
Dr Vetters: We know that transgender-identified youth have a much greater risk for suicide, self-harm, depression, and anxiety than non-transgender peers. They are more likely to experience violence victimization, substance use, and increased sexual risk behaviors.9
Across the board, they present with greater acuity and fewer resources than non-trans peers. We also know that they tend to access and utilize health care less than non-trans peers.10 The combination of greater acuity and less health care utilization translates into worse outcomes into adulthood in terms of substance use, traumatic experiences, and behavioral health decompensation.
On the practice level, what are some key recommendations for clinicians in terms of addressing these issues and needs in treatment?
Dr Lambrese: Clinicians need to provide a safe space for transgender and gender questioning youth to explore their identity within the therapeutic realm. This includes speaking with youth without a parent present, reviewing confidentiality, and asking open-ended questions.
Clinicians should be asking all patients for their preferred name and pronouns, noting these in the medical record, and using these consistently — both in documentation and in conversation. Many clinicians find it helpful to start this conversation by sharing the clinician’s preferred name and pronouns, ie, “I’m Dr Smith. I am a psychiatrist and my pronouns are he/him. What name do you like to use? Can you share with me your preferred pronouns?”
Dr Vetters: Providing excellent care to transgender youth requires a broad buy-in from all aspects of a practice, from patient services to the ancillary staff. Trans youth report decreased interest in accessing care if a clinic uses the wrong pronouns or chosen name.
They do not want to “teach” their providers gender-affirming health care. They want access to appropriate treatment — gender-affirming hormones and pubertal blockers, for example — on the basis of standardized diagnoses and protocols without gatekeeping by hesitant and oppositional clinicians.11
Clinics need to have clear and obvious commitments to LGBTQIA adolescent health with posters on the walls and statements on their web pages affirming commitments to trans-sensitive care. Clinicians need to be skilled at taking gender histories, being aware of the various manifestations of gender dysphoria, capable of working with parents and families struggling to understand a child newly presenting as trans, and understanding the differences between gender identity, sexual orientation, and gender presentation.
Paperwork and administrative systems need to have flexibility in listing gender identities, not the typical “male” or “female” check boxes. Electronic medical records, paperwork, lab slips all need to have indications of gender identity, pronoun preferences, and preferred names. Building a trans-embracing clinical environment improves access and utilization — if you build it, they will come!
More broadly, what are ways in which clinicians can advocate for improvements in mental health and care for this population?
Dr Lambrese: Clinicians need to ensure that safe and affirming spaces are available for youth to share their questions and concerns. This includes not just the exam room, but also the intake forms, waiting room, and interactions with clerical and clinical staff. Clinicians ought to be aware of resources available to trans youth, including the Trevor Project.
Dr Vetters: We need to oppose the recent assault on transgender care in different states by reactionary politicians. The evidence shows that treatment of trans and gender-variant youth with hormones and puberty blockers decreases suicidality, self-harm, depression, anxiety, substance use, and gender dysphoria.8,12
Children will die because of these policies.
We can save lives and help children develop into productive adults by using evidence-based care in their treatment and support. Secondly, we need to advocate for greater coverage of transgender health care services by insurance providers in general, including easier access to puberty blockers, gender-affirming surgeries, and family counseling.
What are additional research and treatment needs in this population?
Dr Lambrese: Research into the needs of transgender youth, particularly children, is ongoing. Additional prospective studies on the experiences of youth who socially and/or medically transition are needed. There are a growing number of specialty clinics which address the mental health and medical needs of transgender youth, but these are often located in urban areas and may have long waitlists.
Therefore, all clinicians need to be educated on the health care needs of this vulnerable population.
- Downing JM, Przedworski JM. Health of transgender adults in the U.S., 2014-2016. Am J Prev Med. 2018;55(3):336-344. doi:10.1016/j.amepre.2018.04.045
- Hughto JMW, Quinn EK, Dunbar MS, Rose AJ, Shireman TI, Jasuja GK. Prevalence and co-occurrence of alcohol, nicotine, and other substance use disorder diagnoses among US transgender and cisgender adults. JAMA Netw Open. 2021;4(2):e2036512. doi:10.1001/jamanetworkopen.2020.36512
- Shumer D. Health disparities facing transgender and gender nonconforming youth are not inevitable. Pediatrics. 2018;141(3):e20174079. doi:10.1542/peds.2017-4079
- 2021 National Survey on LGBTQ Youth Mental Health. The Trevor Project. Accessed July 15, 2021. https://www.thetrevorproject.org/survey-2021/
- Vance SR Jr, Boyer CB, Glidden DV, Sevelius J. Mental health and psychosocial risk and protective factors among Black and Latinx transgender youth compared with peers. JAMA Netw Open. 2021;4(3):e213256. doi:10.1001/jamanetworkopen.2021.3256
- Gibson DJ, Glazier JJ, Olson KR. Evaluation of anxiety and depression in a community sample of transgender youth. JAMA Netw Open. 2021;4(4):e214739. doi:10.1001/jamanetworkopen.2021.4739
- Klein A, Golub SA. Family rejection as a predictor of suicide attempts and substance misuse among transgender and gender nonconforming adults. LGBT Health. 2016;3(3):193-9. doi:10.1089/lgbt.2015.0111
- Jarrett BA, Peitzmeier SM, Restar A, et al. Gender-affirming care, mental health, and economic stability in the time of COVID-19: a global cross-sectional study of transgender and non-binary people. medRxiv. 2020;2020.11.02.20224709. doi:10.1101/2020.11.02.20224709
- Johns MM, Lowry R, Andrzejewski J, et al. Transgender identity and experiences of violence victimization, substance use, suicide risk, and sexual risk behaviors among high school students — 19 states and large urban school districts, 2017. MMWR Morb Mortal Wkly Rep. 2019;68(3):67–71. doi:10.15585/mmwr.mm6803a3
- Rider GN, McMorris BJ, Gower AL, Coleman E, Eisenberg ME. Health and care utilization of transgender and gender nonconforming youth: a population-based study. Pediatrics. 2018;141(3):e20171683. doi:10.1542/peds.2017-1683
- Gridley SJ, Crouch JM, Evans Y, et al. Youth and caregiver perspectives on barriers to gender-affirming health care for transgender youth. J Adolesc Health. 2016;59(3):254-261. doi:10.1016/j.jadohealth.2016.03.017
- Turban JL, King D, Carswell JM, Keuroghlian AS. Pubertal suppression for transgender youth and risk of suicidal ideation. Pediatrics. 2020;145(2):e20191725. doi:10.1542/peds.2019-1725