Perceived Gender Transition Progress, Gender Congruence, and Mental Health Symptoms Among Transgender Adolescents

Abstract

Purpose:

Transgender adolescents (TGAs) have high risk for experiencing mental health problems, but little is known about how aspects of gender identity relate to their mental health symptoms. Evidence from child and adult samples of transgender individuals indicates making progress in gender transition milestones and higher levels of congruence between gender identity and gender expression are related to fewer mental health problems. We examined associations between perceived transition progress, gender congruence, and mental health symptoms in a diverse, nationwide sample of TGAs.

Methods:

TGAs (n = 1,943) participated in a cross-sectional online survey. Perceived gender transition progress, gender congruence, and depressive and anxiety symptoms were assessed. Path analysis was conducted to examine whether transition progress was related to mental health symptoms via higher levels of gender congruence.

Results:

Most TGAs had undertaken at least one social transition step (98%), but only 11% had taken medical transition steps. Higher gender congruence was associated with lower mental health symptoms. Greater transition progress was associated with higher gender congruence, and perceived transition progress evidenced negative indirect associations with mental health symptoms. TGAs identifying with binary identities (transmasculine and transfeminine youth) reported lower levels of transition progress and gender congruence compared to other subgroups of TGAs.

Discussion:

Higher levels of perceived transition progress and gender congruence are related to lower mental health symptoms among TGAs. Mental health interventions tailored to the unique developmental needs of TGAs are needed given high risk for mental health problems within this population, and interventions addressing transition progress and gender congruence should be examined.

Transgender adolescents (TGAs; adolescents whose gender identity is different than their sex assigned at birth) experience higher rates of mental health problems as compared to their cisgender peers (adolescents whose gender identity is aligned with their sex assigned at birth) [1–6]. TGAs have elevated risk for experiencing depressive symptoms during adolescence [1,3,5], and researchers have estimated that 83% of TGAs experience depressed mood [5]. Furthermore, over half of TGAs meet diagnostic criteria for a depressive disorder [1]. Similarly, TGAs are more likely than their peers to experience problematic levels of anxiety during adolescence [1,7], and 37%–48% of TGAs meet criteria for an anxiety disorder [1,8].

TGAs experience multiple stressors during childhood and adolescence which could increase their susceptibility to experiencing depressive and anxiety symptoms during adolescence. TGAs are more likely to experience peer victimization and low parental support than their cisgender peers, may have to endure school policies that exclude them from certain activities or gender-appropriate facilities at school, and often experience distress from incongruence between their gender expression and their gender identity, all of which could contribute to their risk for experiencing mental health problems during adolescence [3,8–11]. Importantly, many TGAs undergo gender transition during adolescence. Taking social transition steps is common among TGAs during adolescence, including disclosing gender identity to parents and peers, using pronouns and a name that align with their true gender identity, and changing their hairstyle or clothing [2]. A small proportion of TGAs also begin medical transition steps during adolescence, including beginning hormone replacement therapy and/or undergoing gender affirming surgeries (e.g., breast reduction) [12]. Making progress through gender transition milestones has the potential to reduce stress and subsequent mental health problems among TGAs. Transgender children 14 and younger who have already completed their social transition are not more likely to experience depression and anxiety than their cisgender peers [13–15].

Although there is compelling evidence from studies of transgender children age 14 and younger, studies of associations between gender transition and mental health are very limited among TGAs despite high risk for mental health problems during adolescence. One prior study found that TGAs who used a name that aligned with their gender identity across multiple social contexts experienced fewer depressive symptoms compared to TGAs who used their name in fewer contexts [16]. However, not all individuals seek to complete the same steps during their transition (e.g., some TGAs may not use a different name during their transition if their birth name is gender-neutral). Therefore, researchers have recommended measuring perceived transition progress to more precisely capture transgender individuals’ subjective sense of transition progress rather than examining specific transition milestones [17,18]. No extant research, however, has examined perceived transition progress among TGAs. Given that most transgender youth begin to identify as TGAs and share their gender identity with others during adolescence [19], it is critical to accrue more evidence of how perceived gender transition progress is related to mental health problems during adolescence.

Perceived transition progress during adolescence has the potential to increase TGAs’ gender congruence, a key factor related to mental health among transgender individuals. Gender congruence is the extent to which an individual’s gender expression is similar to or different from their gender identity [20]. Within adult samples, transgender individuals who have completed a higher proportion of their desired gender transition milestones report higher gender congruence [21,22]. Furthermore, higher gender congruence is related to experiencing fewer mental health symptoms among adult transgender individuals [23,24]. Gender congruence has been examined less frequently among TGAs, with one study finding that TGAs assigned female at birth (AFAB) presenting for care at a gender clinic who experienced greater gender congruence had lower levels of anxiety and depressive symptoms [25]. In another small clinical sample of TGAs (n = 109), TGAs who reported low levels of gender congruence were more likely to meet criteria for a depressive disorder [8]. While initial findings indicate gender congruence is related to mental health symptoms among TGAs in clinical samples, no prior studies with large nationwide samples have examined this association. Furthermore, prior studies have not examined how perceived transition progress is related to gender congruence among TGAs.

While most prior studies have operationalized gender identity such that all TGAs are combined into one group, important subgroup differences in psychosocial experiences and risk for mental health problems are increasingly documented. Researchers have noted that experiences of TGAs can vary based on both their sex assigned at birth [3] and their gender identity, documenting differing reports from binary youth (identifying as transmasculine or transfeminine) and nonbinary youth (youth whose gender identity falls outside the male–female binary; e.g., who identify as nonbinary, genderqueer, genderfluid) [6]. While subgroup differences in perceived transition progress and gender congruence have not been previously examined among TGAs, limited evidence within adult samples has been mixed thus far; one study found higher gender congruence among nonbinary individuals [26] but another reported higher congruence among binary participants [27]. Researchers have reported that nonbinary adults seek to undergo fewer gender transition steps as compared to binary transgender adults [26]. Among adolescents, more evidence is needed to understand how gender transition might vary across subgroups of TGAs.

The current study sought to examine three aims within a large, nationwide sample of TGAs. First, we examined TGA subgroup differences in perceived transition progress, gender congruence, and mental health symptoms. Second, we examined associations between perceived transition progress and gender congruence among TGAs, and we investigated whether transition progress was indirectly related to mental health symptoms via level of gender congruence. Third, we examined whether subgroup differences in perceived transition progress and gender congruence were indirectly related to mental health symptoms among TGAs.

Method

Procedure

Data derived from the Gender Minority Youth (GMY) Study, a large, nationwide cross-sectional online survey of mental and behavioral health among adolescents aged 14–18 in the United States collected in 2018 (n = 3,318 total) [28]. Participants were recruited through advertisements on Facebook and Instagram, social media platforms used by most adolescents at the time of recruitment. TGAs were oversampled by using interest labels including “Transgender,” “Gender-specific and gender-neutral pronouns,” “Genderqueer,” and “Passing (gender)” in some ads designed to specifically target TGAs. The current analysis included 1,943 TGAs who identified with a gender identity that differed from their sex assigned at birth or indicated they were currently questioning their gender identity.

Advertisements were served 377,469 times, and 8,747 clicks were recorded (2.48% click-through rate). A total of 5,642 participants assented, entered the survey, and began responding to questions. Adolescents were screened out of the survey if they were outside the targeted age range; in light of underrepresentation of TGAs assigned male at birth (AMAB) in the early period of data collection, additional screening was used toward the end of recruitment to allow only TGAs AMAB to participate. In total, 1,997 participants were screened out of the survey. All participants provided assent (with a waiver of parental permission) prior to completing the GMY Study. Participants could enter a drawing for a $50 gift card and were provided with resources related to mental health, child abuse, and sexual assault. The University of Pittsburgh’s Human Research Protection Office approved this study.

We took multiple steps to ensure the quality of the dataset. First, we used Internet Protocol addresses to identify potential duplicate cases, and cases with the same Internet Protocol address were hand-checked. Duplicates with the same demographic characteristics and height/weight were removed (n = 320). Second, outlier analysis indicated no cases had evidence of values outside the expected range on variables reported as counts. Third, free-response text was reviewed, and seven cases were removed which had inappropriate responses to survey questions. Additional details about the GMY Study methods and dataset are available elsewhere [28].

Measures

Gender identity.

Participants reported their sex assigned at birth as either male or female. Participants selected all gender identities they identify with: (1) male, (2) female, (3) transgender, (4) female to male transgender, (5) male to female transgender, (6) trans male/transmasculine, (7) trans female/transfeminine, (8) genderqueer, (9) gender expansive, (10) intersex, (11) androgynous, (12) nonbinary, (13) two-spirited, (14) third gender, (15) agender, (16) not sure, and (17) other. A five-category gender identity variable was created, including transmasculine youth (including participants who reported female sex assigned at birth and male, female to male transgender, and/or trans male/transmasculine identities), transfeminine youth (including participants who reported male sex assigned at birth and female, male to female transgender, and/or trans female/transfeminine identities), nonbinary AFAB, nonbinary AMAB, and questioning gender identity (including participants who selected “not sure” and no other gender identities). Adolescents were categorized as nonbinary if they reported a genderqueer, gender expansive, intersex, androgynous, nonbinary, two-spirited, third gender, or agender current gender identity and no binary gender identities. We found empirical support for this approach to categorization in prior analyses of this dataset [6]. As a team, we carefully weighed the risks and benefits of categorizing nonbinary youth with their sex assigned at birth (SAAB). Although we recognize the potentially invalidating nature of this categorization, we note that several studies have found significant group differences in important outcomes based on SAAB. Because our goal is to attend to heterogeneity to improve the treatment of transgender adolescents, we decided to utilize SAAB-based categorization. Questioning adolescents could not be divided by sex assigned at birth because of small cell sizes.

Perceived transition progress was assessed with the following item. “Thinking about your ideal gender expression, what percentage of transition milestones have you already met?” Response options included: 0%: “I have made no steps in my transition that I would like to make,” 25%, 50%, 75%, and 100%: “I have made all steps in my transition that I would like to make.” This item was adapted to be appropriate for adolescents from a measure of transition status developed through qualitative interviews with transgender adults that has demonstrated validity in studies of anxiety and depressive symptoms [17,18]. TGAs also reported whether they had engaged in specific social and medical transition steps, and percentages engaging in each transition milestone within TGA subgroups are presented in Table 2.

Table 2.

Descriptive statistics and gender transition milestone engagement within subgroups of transgender adolescents

	Full sample (n = 1,943)	Transmasculine (n = 990)	Transfeminine (n = 132)	Nonbinary AFAB (n = 640)	Nonbinary AMAB (n = 84)	Questioning (n = 97)
Mean transition progress	2.12	2.06	1.83	2.29	2.21	1.86
Mean congruence	2.27	2.14	1.77	2.45	2.5	2.75
Mean depressive symptoms	34.09	34.29	34.93	33.62	32.09	35.98
Mean anxiety symptoms	13.79	13.9	13.48	13.63	13.63	14.1
Engagement in gender transition steps:
Dressing in a different way	96%	100%	79%	95%	81%	86%
Doing hair in a different way	87%	96%	75%	80%	60%	62%
Going by a different name	78%	93%	80%	62%	49%	41%
Hormone replacement therapy	9%	16%	15%	2%	3%	1%
Gender affirmation surgery on chest	2%	3%	3%	0%	2%	0%
Gender affirmation surgery on genitalia	0%	0%	1%	0%	2%	0%

AFAB = assigned female at birth; AMAB = assigned male at birth.

Gender congruence

Gender congruence was assessed with the Appearance Congruence subscale of the Transgender Congruence Scale [20]. This 9-item scale assesses the extent to which an individual’s gender expression is congruent with their gender identity, including items such as “My outward appearance represents my gender identity.” Response options ranged from “strongly disagree” to “strong agree” on a 5-point Likert scale, and a composite mean score was calculated for each participant. This scale has demonstrated reliability and validity in adult samples [20,23] and demonstrated strong reliability within our adolescent sample (α = 0.88) [4].

Mental health symptoms.

Anxiety symptoms were assessed with the Generalized Anxiety Disorder seven-item (GAD-7) scale, a well-validated measure of anxiety symptoms [29] which has demonstrated reliability and validity within adolescent samples [30]. Depressive symptoms were assessed with the Centers for Epidemiological Studies Depression scale [31], an established 20-item measure of depressive symptoms that is valid within adolescent samples [32]. GAD-7 and Centers for Epidemiological Studies Depression total scores were calculated by summing all items in each scale, and each scale evidenced sufficient reliability in the present sample (α = 0.91 and α = 0.78, respectively).

Participants

Participants lived in all 50 states as well as Washington, DC. Participants included 990 transmasculine youth, 132 transfeminine youth, 640 nonbinary adolescents AFAB, 84 nonbinary adolescents AMAB, and 97 adolescents who were questioning their gender identity. Sixty-seven percent of participants identified as White, 7% as Black/African American, 9% as Latinx, 3% as Asian American or Pacific Islander, 2% as Native American or American Indian, 1% identified with another race/ethnicity, and 12% identified with more than one race/ethnicity.

Analytic plan

First, bivariate associations between all variables were examined. Path analysis was then conducted using Mplus Version 8 (Muthén & Muthén, Los Angeles, CA) [33], with anxiety and depressive symptoms included as two separate dependent variables within the same multivariate model. Paths from perceived transition progress to gender congruence to mental health symptoms were included (Figure 1). Direct paths from perceived transition progress to mental health symptoms were also included, and indirect effects between transition progress and mental health symptoms via gender congruence were examined. Gender identity subgroup (with transmasculine youth as the reference group given this was the largest subgroup [6]) was included in each path, and indirect effects between subgroup and mental health symptoms via perceived transition progress and gender congruence were also examined. Age and race/ethnicity were also controlled for within each path.

Figure 1.

Path analysis depicting direct effects between gender identity subgroup, transition progress, gender congruence, and depressive and anxiety symptoms. **p < .01; ***p < .001.

Paths were estimated using full information maximum likelihood procedures [34], so all 1,943 TGAs were included in analyses and their data contributed to the model regardless of missingness. The highest level of missing data was observed for the GAD-7, as this assessment was placed later in the GMY battery, and participants were more likely to complete the survey through the GAD-7 if they were older and identified as transfeminine. Age was included as a covariate to further control for potential biases related to missingness. To assess the significance of indirect effects, 95% confidence intervals were estimated using a bootstrapping procedure that was not bias-corrected. This approach has been recommended for assessing indirect effects in path analysis, as using bias-corrected bootstrapped estimates and corresponding confidence intervals can increase the likelihood of Type I error [35]. Bootstrapped 95% confidence intervals for indirect effects were estimated using 20,000 iterations, and confidence intervals excluding zero were interpreted as significant.

Results

The means, ranges, standard deviations, and subsample sizes for all continuous variables, as well as correlations between variables, for the full sample are reported in Table 1. Descriptive data for each TGA subgroup, including number of participants engaging in each gender transition milestone, are presented in Table 2. Most TGAs had engaged in at least one social transition step (98%) but had not yet begun any medical transition steps (only 11% reported any medical transition). Univariate associations between categorical (including gender identity subgroup and race/ethnicity) and continuous variables were examined using one-way ANOVA. Gender identity subgroups differed in reports of transition progress and gender congruence (F(4,1625) = 8.40; p < .001 and F(4,1628) = 28.12; p < .001 respectively). Tukey post hoc tests indicated nonbinary adolescents AFAB reported more transition progress than transmasculine youth, transfeminine youth, and questioning participants. Transmasculine youth reported less gender congruence than nonbinary and questioning youth, and transfeminine youth reported less congruence than all other subgroups. There were also significant differences in transition progress across racial/ethnic subgroups (F(6,1623) = 2.73; p = .012), with participants identifying as mixed race/ethnicity reporting more transition progress than Latinx youth. No univariate differences in depressive or anxiety symptoms were observed across subgroups.

Table 1.

Means, ranges, standard deviations, number of respondents, and correlations among continuous variables

Variable	1. Age	2. Transition progress	3. Gender congruence	4. CES-D	5. GAD-7
1. Age		0.099*	0.005	−0.051	−0.012
2. Transition progress			0.474*	−0.180*	−0.155*
3. Gender congruence				−0.279*	−0.187*
4. Depression (CES-D)					0.723*
5. Anxiety (GAD-7)
Mean (M)	15.92	2.12	2.27	34.09	13.79
Range	14–18	1–5	1 −5	1 −59	0–21
Standard deviation (SD)	1.22	0.96	0.84	12.36	5.65
Respondents (n)	1,943	1,630	1,633	1,363	1,034

CES-D = Centers for Epidemiological Studies Depression; GAD-7 = Generalized Anxiety Disorder seven-item.

^*p < .05.

All paths were estimated while controlling for age, race/ethnicity, and gender identity subgroup. Controlling for covariates, transition progress was positively associated with gender congruence. Gender congruence was negatively associated with both anxiety and depressive symptoms, and transition progress was associated with anxiety but not depressive symptoms within the same equations. In addition, transfeminine youth evidenced lower transition progress than transmasculine youth, and nonbinary adolescents AFAB evidenced higher transition progress when compared to transmasculine youth, when adjusting for other demographic variables. In the equation predicting gender congruence, transfeminine youth evidenced lower congruence as compared to transmasculine youth, and transmasculine youth evidenced lower congruence compared to nonbinary and questioning youth, while also accounting for transition progress. Direct effects are represented in Figure 1 for variables of interest, and estimated coefficients and significance levels of direct paths are included in Table 3. Full model results, including direct effects of covariates, are presented in Tables A1 and A2. Furthermore, sensitivity analyses were conducted to determine whether victimization experiences confounded associations between transition progress, gender congruence, and mental health symptoms. The overall pattern of results was unchanged when victimization was added to the model as a covariate, and full results of sensitivity analyses are presented in Supplementary Material.

Table 3.

Direct effects in path analysis examining associations between gender identity subgroup, transition progress, gender congruence, and depressive and anxiety symptoms

Dependent variable	Estimate	SE	p value
Transition progress
Gender identity (transmasculine reference)
Transfeminine	−0.25	0.11	.016
Nonbinary AFAB	0.23	0.05	< .001
Nonbinary AMAB	0.14	0.12	.269
Questioning	−0.15	0.12	.217
Gender congruence
Transition progress	0.41	0.02	< .001
Gender identity (transmasculine reference)
Transfeminine	−0.27	0.08	.001
Nonbinary AFAB	0.22	0.04	< .001
Nonbinary AMAB	0.29	0.09	.002
Questioning	0.67	0.09	< .001
Depressive symptoms
Gender congruence	−4.03	0.46	< .001
Transition progress	−0.63	0.40	.116
Gender identity (transmasculine reference)
Transfeminine	−1.05	1.42	.462
Nonbinary AFAB	0.50	0.72	.486
Nonbinary AMAB	−0.70	1.69	.676
Questioning	3.88	1.67	.020
Anxiety symptoms
Gender congruence	−1.15	0.23	< .001
Transition progress	−0.42	0.20	.038
Gender identity (transmasculine reference)
Transfeminine	−1.03	0.72	.150
Nonbinary AFAB	0.25	0.36	.496
Nonbinary AMAB	0.14	0.84	.871
Questioning	0.56	0.82	.495

AFAB = assigned female at birth; AMAB = assigned male at birth; SE = standard error.

Indirect effects were examined to determine whether perceived transition progress was related to anxiety and depressive symptoms via gender congruence. Transition progress was negatively associated with both anxiety and depressive symptoms via higher levels of gender congruence. In addition, indirect effects between gender identity subgroup and mental health symptoms via transition progress and gender congruence were examined. Transfeminine youth exhibited higher depressive and anxiety symptoms as compared to transmasculine youth via lower levels of transition progress and gender congruence. Nonbinary adolescents AFAB exhibited lower depressive and anxiety symptoms as compared to transmasculine youth via higher levels of transition progress and gender congruence. Estimated indirect effects and 95% bootstrapped confidence intervals are reported in Table 4.

Table 4.

Indirect effects between gender identity subgroup and transition progress and mental health symptoms via gender congruence within mediation model

	Estimate	95% Confidence interval
		Lower limit	Upper limit
Effects on depressive symptoms:
Transition progress - > gender congruence	−1.65a	−2.07	−1.26
Gender identity subgroup - > transition progress - > gender congruence
Transfeminine	0.42a	0.10	0.74
Nonbinary AFAB	−0.38a	−0.60	−0.19
Nonbinary AMAB	−0.23	−0.72	0.21
Questioning	0.24	−0.31	0.77
Effects on anxiety symptoms:
Transition progress - > gender congruence	−0.47a	−0.68	−0.27
Gender identity subgroup - > transition progress - > gender congruence
Transfeminine	0.12a	0.03	0.23
Nonbinary AFAB	−0.11a	−0.19	−0.05
Nonbinary AMAB	−0.07	−0.21	0.06
Questioning	0.07	−0.09	0.23

AFAB = assigned female at birth; AMAB = assigned male at birth.

^aIndicates 95% confidence interval that does not include zero.

Finally, to more precisely examine the association between perceived social transition progress and gender congruence, we conducted post hoc sensitivity analyses while selecting only participants who had not taken medical transition steps. Adjusted regression results indicated perceived transition progress remained positively related to gender congruence among TGAs who had only engaged in social transition steps (B = 0.34; p < .001).

Discussion

This is the first study to demonstrate that TGAs who perceive more progress in their gender transition and higher congruence between their gender expression and gender identity report lower levels of depressive and anxiety symptoms. Our findings extend those of studies examining transition progress, gender congruence, and mental health conducted among transgender children and adults to adolescents. Perceived transition progress evidenced a direct association with anxiety symptoms but was unassociated with depressive symptoms when accounting for gender congruence. Additionally, perceived transition progress evidenced indirect associations with mental health symptoms via gender congruence.

Our results also indicate that certain subgroups of TGAs may experience particular challenges to achieving transition milestones during adolescence. TGAs who identify with binary identities reported the lowest levels of transition progress and gender congruence, with transfeminine youth reporting the most limited transition progress and lowest gender congruence, and these subgroup differences had indirect effects on mental health symptoms in our path analysis. TGAs with binary identities may have the least perceived transition progress because they hope to achieve comparatively more transition milestones than TGAs with nonbinary identities. Within adult samples, there is evidence that binary transgender adults are more likely to receive surgery and use hormone replacement therapy than nonbinary adults, but also that binary and nonbinary adults are equally likely to change their appearance in other ways [26]. However, gender transition is an individual journey; many nonbinary TGAs may desire medical affirmation of their gender during their transition, and some nonbinary TGAs may want to achieve more transition milestones than some TGAs with binary identities.

While many transgender individuals’ gender transitions include both social and medical transition steps, most TGAs in our sample had not taken medical transition steps. Only 11% of our sample had engaged in medical interventions related to their gender transition at the time of the study. Many TGAs who desire medical gender transition care might not have access to it during adolescence because parental permission is required for medical interventions for youth under the age of 18, and since the time of our 2018 survey, legal restrictions have further limited youths’ access to gender-affirming care, as we discuss further below. To examine the potential influence of social transition progress in particular, we conducted post hoc analyses to examine the association between perceived transition progress and gender congruence while selecting only participants who reported they had not yet engaged in any medical transition steps. Results from this model indicated that TGAs who had made more progress in their social transition perceived higher levels of congruence between their gender expression and gender identity. Our results demonstrate that early perceived progress in gender transition is related to experiencing fewer mental health symptoms among TGAs during adolescence, and social transition progress alone was related to lower mental health symptoms.

TGAs have very high risk for experiencing mental health problems during adolescence [5,6], and our results identify perceived transition progress and gender congruence as two potential targets of behavioral health interventions designed to reduce risk for adverse mental health outcomes among TGAs. Numerous multidisciplinary gender-affirming care programs exist in communities throughout the United States [36,37], and these settings might be particularly well-suited to providing TGAs with integrated mental health and medical transition support to provide them the opportunity to navigate their desired gender transition milestones effectively and efficiently and increase their gender congruence. Family-based approaches, including gender-affirming family therapy and support groups for parents and caregivers that are tailored to the unique developmental needs of TGAs, also hold promise and could reduce barriers to continued transition progress throughout adolescence [38,39], as parents must provide permission for TGAs to begin medical transition steps prior to age 18. Other existing sources of community support, including gender-affirming youth groups such as gender–sexuality alliances, could serve as critical sources of support for TGAs throughout their gender transition [40]. At this time, no formal mental health interventions designed to support TGAs through their gender transition have been empirically tested within this population [39], and further clinical intervention research among TGAs is required. Overall, clinical interventions which incorporate collaborations between clinicians and TGAs to further transition progress and enhance gender congruence have potential to reduce internalizing symptoms among TGAs during adolescence.

The current study adds to a growing literature documenting more positive mental health among TGAs who have access to their desired social and medical gender transition milestones. Although our cross-sectional results cannot determine causality, they suggest the possibility that denial of gender-affirming care for TGAs could have a deleterious influence on their mental health symptoms. State legislatures across the United States have recently written and passed laws designed to deny gender-affirming care to TGAs by enacting criminal penalties against physicians and parents who provide and facilitate gender-affirming care for TGAs [41,42]. These efforts may exacerbate dire mental health disparities between TGAs and their peers [41], and it is imperative that legislators act swiftly to protect the rights of TGAs and their families to seek gender-affirming care.

The contributions of the current study must be understood within the context of methodological limitations. First, our study was cross-sectional, and caution must be taken when interpreting the directions of associations within the estimated path analysis. While the temporality of measures included in the analyses support the hypothesized directions (i.e., prior progress in gender transition predicting current gender congruence and mental health symptoms), cross-sectional analyses may be biased by reverse causation. For example, TGAs who are experiencing depressive and anxiety symptoms might have more difficulty making progress in their desired transition milestones (e.g., social anxiety could make disclosure to peers more difficult). Future prospective studies of TGAs’ experiences across adolescent development and into young adulthood are critical to understand how gender transition is related to well-being over time. Second, our sample of TGAs was large and diverse, but it consisted entirely of social media users. Although estimates have indicated the vast majority of adolescents in the United States use the social media platforms through which we recruited TGAs [43], future studies should assess whether findings differ in samples of TGAs recruited through other methods. Third, although we attend to heterogeneity in gender identity among TGAs, difficult choices had to be made to reduce the dimensionality of the data. For example, some participants selected both binary and nonbinary identities. These participants were categorized as binary for analytic purposes, and while this categorization approach was based on empirical evidence, it may not accurately categorize all youth and could invalidate individual participants’ experiences and identities. We suggest that future studies ask participants to both “select all that apply” and also “choose the best fit” when assessing gender identity to categorize TGAs as accurately as possible. Finally, our sample is disproportionately White as compared to the US adolescent population. Future studies of large samples of TGAs of color are required to examine whether associations between transition progress, gender congruence, and mental health symptoms vary across racial and ethnic identities.

TGAs experience alarmingly high risk for mental health problems during adolescence, and this population must be prioritized in future adolescent mental health research. Results from the current study indicate that perceived progress within TGAs’ gender transition and higher levels of gender congruence are related to lower levels of depressive and anxiety symptoms within this population. Future interventions designed to reduce depressive and anxiety symptoms among TGAs might be enhanced by specific foci on perceived transition progress and gender congruence.

IMPLICATIONS AND CONTRIBUTION.

Transgender adolescents have high risk for experiencing depressive and anxiety symptoms, and little is known about psychosocial factors contributing to their risk. Findings indicate higher perceived gender transition progress and higher congruence between gender identity and gender expression could be related to experiencing fewer mental health symptoms among transgender adolescents.