Gender-Diverse Secondary Students in China Face Disproportionate Rates of Anxiety, Depression

transgender symbol on hand
transgender symbol on hand
Transgender or gender nonconforming adolescents face a wide range of physical and mental health concerns. In mainland China, a school-based study explores the prevalence and mental health status of these adolescents.

Study data published in JAMA Network Open suggest that gender diverse students in China shoulder a greater psychiatric burden than their cisgender peers. Compared to cisgender adolescents, transgender and nonbinary youth in China reported greater rates of depression, anxiety, self-harm, and suicide ideation or attempt.

Gender diverse youth also reported greater rates of in-school bullying than their peers. Results from this study underscore the need for school-based interventions to support the mental well-being of transgender or gender nonconforming (TGNC) adolescents.

This cross-sectional survey study enrolled students attending 18 public secondary schools in the city of Suzhou, China. Data were collected between June and July of 2019.

Student gender identity was determined using 2 metrics: assigned gender at birth and perceived gender. Those whose assigned gender was congruent with current gender were classified as cisgender. Those whose assigned gender was different from their current gender were classified as transgender.

Students who wrote that their perceived gender was “neither male nor female” were classified as non-binary. Students who indicated that they were “unsure” about their current gender were considered “questioning.”

A battery of validated physical and psychiatric health questionnaires was used to measure student health. Self-harm and suicidality were assessed by asking participants to describe self-harm thoughts and behavior, suicidal thoughts, suicide plan, and suicide attempts. Participants were also asked to report if they had experienced bullying during the prior academic year. Mixed-effects logistic regression was performed to assess the relationship between gender identity and student health. Results were expressed as odds ratios (ORs) with 95% confidence intervals (CIs).

A total of 12,108 adolescents participated in the survey. Mean age was 15.8 ± 1.0 years. Of participants who were assigned male at birth (AMAB), 5855 (89.8%) were classified as cisgender boys; 208 (3.2%) as transgender girls; 138 (2.1%) as non-binary; and 317 (4.9%) as questioning. Among participants who were assigned female at birth (AFAB), 4142 (74.1%) were classified as cisgender girls; 861 (15.4%) as transgender boys; 112 (2.0%) as non-binary; and 475 (8.5%) as questioning.

Compared to cisgender youth, TGNC youth reported significantly lower overall health, greater depression symptoms, greater anxiety symptoms, poorer sleep, and higher rates of suicide ideation (all P <.001). TGNC youth were also much more likely to report experiences of past-year bullying from peers (P <.001).  Specifically, TGNC who were AMAB were approximately twice as likely to experience bullying at school compared to cisgender boys (transgender girls: OR, 2.34 [95% CI, 1.64-3.33]; non-binary AMAB youth: 1.97 [1.23-3.16]; and questioning AMAB youth: 1.95 [1.43-2.67]).

Both cisgender girls and TGNC youth were at greater risk of reporting thoughts of self-harm and suicide compared to cisgender boys. Compared to cisgender boys, these same groups were also much more likely to report deliberate self-harm within the past month (cisgender girls: OR, 1.49 [95% CI, 1.33-1.68]; transgender girls: 2.74 [1.93-3.91]; transgender boys: 3.06 [2.57-3.66]; nonbinary AMAB youth: 2.56 [1.66-3.94]; nonbinary AFAB youth: 3.06 [1.95-4.81]; questioning AMAB youth: 2.14 [1.56-2.92]; and questioning AFAB youth: 2.53 [2.00-3.01]) and prior suicide attempt (transgender girls: 4.35 [2.88-6.56]; transgender boys: 2.92 [2.26-3.76]; nonbinary AMAB youth: 3.94 [2.36-6.55]; nonbinary AFAB youth: 3.06 [1.67-5.63]; questioning AMAB youth: 2.61 [1.73-3.94]; and questioning AFAB youth: OR, 1.93 [1.33-2.81]).

The primary study limitations were the cross-sectional design and the sampling of an urbanized region. Results may not be generalizable to youth in more rural areas of China. Additionally, participants’ interpretation of gender identity questions may have varied and led to an underreporting of gender minority status. Even so, results suggest significant gaps in mental and physical health between TGNC youth and their cisgender peers. Concerted efforts to support the well-being of gender minority students are essential, particularly in a school environment.

“[F]indings suggest a compelling need for researchers, practitioners, and policy makers to address…mental health problems [among] TGNC adolescents,” the investigators wrote.


Wang Y, Yu H, Yang Y, et al. Mental health status of cisgender and gender-diverse secondary school students in China. JAMA Netw Open. 2020 Oct 1;3(10):e2022796. doi: 10.1001/jamanetworkopen.2020.22796