Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2024 Jul 1.
Published in final edited form as: Soc Sci Med. 2023 Jun 9;329:116013. doi: 10.1016/j.socscimed.2023.116013

Transgender/Nonbinary Young Adults’ Exposure to Cissexism-Related Social Stressors: Variation Across Gender Groups

Gabriel R Murchison a, Rodrigo A Aguayo-Romero b,c,d, Elle Lett e,f, Sabra L Katz-Wise g,h,i, Madina Agénor d,j,k, Allegra R Gordon g,i,l
PMCID: PMC10710666  NIHMSID: NIHMS1942703  PMID: 37315357

Abstract

Background:

Young adults who are transgender and/or nonbinary (TNB) experience discrimination, violence, and other social stressors as a result of cissexism, the system of power relations that marginalizes people whose genders diverge from sociocultural expectations for the sex they were assigned at birth. However, variation in TNB young adults’ exposure to social stressors across gender groups, particularly specific nonbinary gender groups (e.g., agender, genderqueer), has not been well characterized.

Methods:

We analyzed data from an online cross-sectional survey of U.S. TNB young adults (N=667; ages 18–30 years; 44% White, 24% multiracial, 14% Black, 10% Latinx, 7% Asian, 1% another race/ethnicity), assessing gender non-affirmation; cissexist discrimination, rejection, and victimization; general discrimination; sexual assault victimization; and psychological, physical, and sexual abuse in childhood/adolescence. We used generalized linear models to test for variation in stressors across six gender groups (transgender woman [n=259], transgender man [n=141], agender [n=36], gender fluid [n=30], genderqueer [n=51], nonbinary [n=150]) and compare each group to the full sample. We performed similar analyses among nonbinary gender groups.

Results:

Exposure to stressors was considerable in all groups. Several stressors (e.g., past-year cissexist discrimination) did not vary significantly by gender group. Compared to the full sample, transgender women reported greater lifetime cissexist rejection and lifetime and past-year cissexist victimization. Compared to the full sample, transgender men and women reported greater lifetime cissexist discrimination and lower past-year gender non-affirmation. No stressors varied significantly across nonbinary gender groups.

Conclusion:

Among TNB young adults, women, men, and nonbinary people experience distinct patterns of some (though not all) stigma-related stressors. Decisions about (dis)aggregating research participants by gender group, or providing gender-tailored services for TNB people, should account for patterning of pertinent stressors. Efforts to eliminate structural cissexism should address intersections with other systems of power relations, including sexism and binary normativity.

Keywords: gender identity, transgender, nonbinary, stigma, discrimination

INTRODUCTION

For decades, transgender and/or nonbinary (TNB) people have resisted efforts to erase their identities, marginalize them socially and economically, and deny them full participation in public life (Stryker, 2008). At present, TNB people in the United States and elsewhere face escalating threats from activists and politicians working to further institutionalize cissexism: the system of power relations that privileges people whose gender aligns with sociocultural expectations for the sex they were assigned at birth while marginalizing those who diverge from such norms (Barbee et al., 2022; Hughes et al., 2021). Besides imposing overwhelming structural barriers to TNB people’s health and wellbeing, these campaigns also inflame interpersonal prejudice, including discrimination and victimization (Barbee et al., 2022; Hendricks & Testa, 2012; Hughes et al., 2021). Young TNB people, who are particularly vulnerable to the mental health impacts of cissexist experiences (Puckett et al., 2021), have been the central targets of these campaigns (Barbee et al., 2022; Hughes et al., 2021).

Cissexism most directly impacts people who are transgender, nonbinary, or both. Transgender describes people whose genders diverge from sociocultural expectations for the sex they were assigned at birth (Matsuno et al., 2022). Nonbinary describes people who do not identify exclusively with either of the gender categories widely recognized by Western colonialist societies: girls/women and boys/men (Costello, 2020; Matsuno et al., 2022). Many nonbinary people identify as transgender, though some find the term does not reflect their experience (Darwin, 2020). Regardless of whether they identify as transgender, nonbinary people face many of the same interpersonal and structural manifestations of cissexism as transgender girls/women and boys/men (Matsuno et al., 2022; Testa et al., 2015).

Some nonbinary people use nonbinary as the primary descriptor of their gender identity, and some use other terms such as genderqueer, gender fluid, gender nonconforming, gender variant, or agender (Galupo et al., 2017; James et al., 2016). (In this paper, phrases such as “nonbinary people” refer to nonbinary in its broader sense, except when otherwise specified.) Some nonbinary gender terms connote a particular experience of gender—for instance, agender often describes having no gender, while gender fluid often describes shifts in gender across time or context (Galupo et al., 2017). Other terms, including nonbinary and genderqueer, reflect a broad range of experiences, such as having elements of multiple genders or a gender not closely related to either binary gender (Galupo et al., 2017). Whether nonbinary people’s experiences with cissexism vary across these specific gender groups remains largely unexplored.

Minority Stress Among TNB People

Building on minority stress theory (Brooks, 1981; Hendricks & Testa, 2012; Meyer, 2003), a robust literature links structural cissexism (e.g., laws, policies, media) and interpersonal cissexism (e.g., bullying, abuse) to health inequities between TNB and cisgender populations (Lefevor et al., 2019; Reisner et al., 2016; Valente et al., 2020). Minority stress theory posits that social oppression triggers cascading stress processes, including physiological, psychological, and behavioral stress and coping responses, which can adversely impact mental and physical health (Cohen et al., 2007). Hendricks and Testa (2012) identified four forms of interpersonal cissexism that contribute to minority stress: gender non-affirmation (i.e., lack of interpersonal recognition or respect of one’s gender identity), discrimination, rejection, and victimization. These experiences may be compounded by general social stressors, such as sexual violence and child abuse, for which TNB people are disproportionately targeted due to structural cissexism (Coulter et al., 2017; Schnarrs et al., 2019).

Intersectionality and Gender Group Variation in Cissexism-Related Social Stressors

Intersectionality, a framework developed by Black feminist scholars and activists (Bowleg, 2012; Collins, 1990; Crenshaw, 1991), offers a powerful perspective for understanding TNB people’s experiences of cissexism. Intersectionality highlights the interdependence of multiple systems of social power relations (e.g., racism, sexism), which jointly produce distinctive experiences of privilege and marginalization at the intersections of social positions (e.g., race and gender; Bowleg, 2012; Collins, 1990; Crenshaw, 1991). Accordingly, prior research has described how multiple systems of power relations contribute to TNB people’s experiences of marginalization; for instance, Black and Latina transgender women report experiencing sexual harassment and violence based on dehumanizing stereotypes inflected by racism, sexism, and cissexism (Gamarel et al., 2020). Even as intersectionality calls for attention to the experiences of multiply marginalized groups (e.g., Black transgender women), this framework emphasizes that multiple marginality is associated with different—not simply additional—experiences of marginalization (Bowleg, 2012).

Intersectionality suggests that TNB people’s experiences of cissexism-related social stressors are likely to vary across gender groups (Matsuno et al., 2022). Qualitative research suggests that the confluence of sexism and cissexism produces gender-specific manifestations of cissexism, such as stereotypes encouraging sexual violence against transgender women (Gamarel et al., 2020; Matsuzaka & Koch, 2019). Sexism’s impact on TNB people is by no means limited to women—for instance, transfeminine nonbinary people may also experience disproportionate sexual harassment (Matsuno et al., 2022)—but may nonetheless produce distinct experiences across gender groups. Similarly, in Western contexts, TNB people are marginalized not only through cissexism but also through binary normativity, which privileges those who are exclusively boys/men or girls/women at the expense of those with another (or no) gender (Matsuno et al., 2022). Like sexism, binary normativity impacts all TNB people; for instance, many TNB people experience harassment in gender-segregated public restrooms, a structural manifestation of binary normativity (James et al., 2016). However, nonbinary people also experience binary normativity in distinctive ways (Matsuno et al., 2022), which may produce unique patterns of social stressors among nonbinary people relative to transgender men and women.

Variation in Cissexism-Related Social Stressors Across Nonbinary Gender Groups

There are also reasons to expect variation in cissexism-related social stressors among specific nonbinary gender groups. The term one uses for one’s gender may be related to one’s strategies for dealing with cissexism, which may include rejecting (or internalizing) dominant cultural gender norms, treating gender as more (or less) central to one’s overall identity, choosing (not) to disclose one’s TNB identity, and/or affiliating with communities with more congruent gender norms (Ehrensaft, 2012; Kuper et al., 2018). These strategies may be informed by past experiences with social stressors, particularly those that are gender-related and/or occur during childhood and adolescence (key periods for gender identity development; Ehrensaft, 2012)—and, in turn, may influence future exposure to such stressors. These strategies may also influence one’s choice of gender term; for instance, in some sociohistorical contexts, TNB people responding to gender-related social stressors with critical consciousness and activism have used the term genderqueer to communicate these political commitments (Stryker, 2008). Accordingly, one might expect to find distinct patterns of exposure to social stressors—both lifetime and recent—among nonbinary people with these and other specific gender terms.

Prior Research on Gender Group Variation in Exposure to Cissexism-Related Social Stressors

Several studies have assessed potential differences in exposure to social stressors among transgender women, transgender men, and nonbinary people, with heterogeneous results. Reisner and Hughto (2019) found lower levels of lifetime intimate partner violence and childhood physical abuse in nonbinary adults compared with transgender men and women, but no such differences in childhood sexual abuse. Kidd and colleagues (2021) found lower levels of past-year cissexist discrimination among nonbinary adults compared with transgender men and women. In a sample of “transitioned” Swiss TNB adults, Jäggi and colleagues (2018) found higher levels of lifetime cissexist discrimination and current gender non-affirmation among nonbinary adults compared with transgender men and women, but no significant differences in lifetime cissexist rejection or victimization.

Findings in younger samples have also been mixed. Lefevor and colleagues (2019) found that nonbinary college students reported higher levels of harassment and sexual assault compared with transgender men and women. However, studies including adolescents have found few gender group differences in social stressors. Poquiz and colleagues (2021) found that nonbinary youth (ages 12–24 years) reported lower levels of cissexist discrimination than transgender girls/women and boys/men, but these groups did not differ significantly on current gender non-affirmation, lifetime cissexist rejection, or lifetime cissexist victimization. Moreover, Chavanduka and colleagues (2021) found no significant variation in current gender non-affirmation or lifetime cissexist discrimination, rejection, or victimization among transgender girls/women, transgender boys/men, and nonbinary youth (ages 15–24 years).

In sum, prior research indicates that TNB people experience distinctive patterns of social stressors across gender groups, particularly when comparing nonbinary people with transgender girls/women and boys/men. However, the direction of effects has been inconsistent across samples, stressors, and measurement periods. Further, these studies have typically analyzed nonbinary people as a single group rather than distinguishing among specific nonbinary gender groups.

The Present Study

While several studies suggest that TNB people’s exposure to cissexism-related social stressors varies across gender groups, the literature does not offer a clear or consistent picture of these patterns. In particular, little is known about variability in social stressors across specific nonbinary gender groups. There is a particular need to explore these patterns in young adults, who appear especially vulnerable to minority stress (Puckett et al., 2021). Addressing these questions is vital for advocates and public health practitioners who seek to develop programs and policy initiatives appropriate for the full spectrum of TNB young adults. Moreover, from a research perspective, this information can provide a basis for decisions to disaggregate or combine various gender groups for analysis.

A possible reason for the heterogeneity of prior findings lies in TNB gender development milestones: consequential events in the process of understanding and affirming one’s gender identity, such as first recognizing or disclosing one’s gender identity (Puckett et al., 2021). TNB people’s gender development experiences are diverse, and there is no singular set of milestones relevant to all TNB people (Puckett et al., 2021). Nonetheless, gender development milestones can mark important shifts in exposure to cissexism-related social stressors (Puckett et al., 2021); for instance, disclosing one’s gender identity might precipitate a decrease in gender non-affirmation (by creating opportunities for others to recognize one’s authentic gender) but an increase in cissexist rejection. The average ages at which TNB people report gender development milestones vary—sometimes markedly—by gender group (Puckett et al., 2021). Thus, there may be complex relationships among age, gender group, milestones, and stressors, potentially causing associations between genders group and stressors to differ depending on the measurement period for stressors (e.g., lifetime, past year).

With these issues in mind, we used online survey data from a national sample of 667 TNB young adults (ages 18–30 years), living in the U.S., to address the following research questions:

1. How does TNB young adults’ exposure to cissexism-related social stressors vary across gender groups? Based on prior research and an intersectional conceptualization of cissexism, we anticipated that exposure to cissexism-related social stressors would vary significantly among transgender women, transgender men, agender participants, gender fluid participants, genderqueer participants, and nonbinary [gender group] participants. Due to inconsistent prior findings (discussed above), we did not hypothesize specific directions of association for each stressor.

1a. How does TNB young adults’ exposure to cissexism-related social stressors vary across gender groups among participants primarily living in their affirmed gender? In an effort to distinguish the role of gender development milestones from other sources of gender group variation, we conducted a secondary analysis restricted to participants endorsing a potentially consequential milestone: primarily living in their affirmed gender. We focused on this milestone because it implies expressing one’s affirmed gender across multiple contexts (e.g., workplace, family) in which overt cissexism was assessed. Compared to the primary analyses, we anticipated that restriction would partially attenuate gender group variation in some stressors.

2. How does TNB young adults’ exposure to cissexism-related social stressors vary across four nonbinary gender groups (agender, gender fluid, genderqueer, and nonbinary)? These analyses were exploratory given the lack of prior research on this topic.

For each question, we considered lifetime and past-year exposure to four social stressors directly attributed to cissexism: gender non-affirmation and cissexist discrimination, rejection, and victimization. We also considered five general social stressors that may be influenced, directly or indirectly, by cissexism (Coulter et al., 2017; Schnarrs et al., 2019): general discrimination, past-year sexual assault victimization, and exposure to psychological, physical, and sexual abuse in childhood/adolescence.

METHODS

Sample and Data Collection

We used data from an online survey of 714 TNB U.S. young adults, ages 18 to 30 years, collected as part of a broader mixed-methods study called the Body Image, Sexual Health & Relationships Project (B*SHARP). In addition to age and U.S. residency, prospective participants were eligible if they reported a combination of gender and sex assigned at birth other than man/male or woman/female. Data were collected February-July 2019. Recruitment was based on (1) outreach via LGBTQ groups and organizations; (2) paid Facebook and Instagram advertisements targeting LGBTQ young adults; (3) posts to LGBTQ, transgender, and nonbinary groups on Facebook and Reddit; and (4) outreach to participants from the qualitative phase of the study. We monitored recruitment to ensure adequate representation across gender, race and ethnicity, and sex assigned at birth. During initial recruitment, participants were diverse in gender but were disproportionately White and disproportionately assigned female at birth (AFAB). We addressed these imbalances by capping enrollment of participants who were both White and AFAB while continuing to enroll participants of color and participants assigned male at birth (AMAB).

We used an online form to screen prospective participants for eligibility. Eligible young adults received a link to the survey via email. They could then provide informed consent, complete the survey anonymously on a computer or mobile device, and either receive a $10 gift card or direct a $10 donation to their choice of two LGBTQ advocacy organizations. The Institutional Review Board of Boston Children’s Hospital approved the study protocol prior to data collection.

To ensure adequate subsample sizes, the present analysis was limited to participants with the six most frequently reported gender terms: woman/transgender woman (n=259), man/transgender man (n=141), nonbinary (n=150), genderqueer (n=51), agender (n=36), and gender fluid (n=30), for a total sample size of N=667 (See Table 1). In this analytic sample, the mean age was 23.8 years (standard deviation=3.3 years) and participants resided in 48 U.S. states and the District of Columbia. Additional sample characteristics are provided in Table 1.

Table 1.

Demographic characteristics and means/prevalences for exposure to social stressors among B*SHARP online survey participants across six gender groups, n=667.

Nonbinary gender groups
Transgender woman (n=259) Transgender man (n=141) Agender (n=36) Gender fluid (n=30) Genderqueer (n=51) Nonbinary (n=150)
Race/ethnicity, n (%)
American Indian or Alaska Native 2 (0.8) 2 (1.4) 0 (0.0) 1 (3.3) 0 (0.0) 2 (1.3)
Asian or Asian American 8 (3.1) 12 (8.5) 5 (13.9) 2 (6.7) 8 (15.7) 11 (7.4)
Black or African American 32 (12.4) 17 (12.1) 7 (19.4) 3 (10.0) 8 (15.7) 24 (16.1)
Latinx or Hispanic 19 (7.3) 21 (14.9) 0 (0.0) 6 (20.0) 5 (9.8) 12 (8.1)
Middle Eastern or North African 1 (0.4) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 4 (2.7)
More than one race or ethnicity 32 (12.4) 35 (24.8) 13 (36.1) 10 (33.3) 17 (33.3) 46 (30.9)
Native Hawaiian or other Pacific Islander 1 (0.2) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
White 164 (63.3) 54 (38.3) 11 (30.6) 8 (26.7) 13 (25.5) 50 (33.6)
Nativity, n (%)
Born outside the U.S. 12 (4.6) 10 (7.1) 5 (13.9) 2 (6.7) 4 (8.0) 14 (9.4)
Born in the U.S. 247 (95.4) 131 (92.9) 31 (86.1) 28 (93.3) 46 (92.0) 135 (90.6)
Sex assigned at birth, n (%)
Assigned male at birth 259 (100.0) – 4 (11.1) 5 (16.7) 2 (3.9) 21 (14.0)
Assigned female at birth – 141 (100.0) 32 (88.9) 25 (83.3) 49 (96.1) 129 (86.0)
Primarily living in affirmed gender, n (%)
Live in affirmed gender all or most of the time 177 (68.3) 121 (85.8) 25 (69.4) 16 (53.3) 32 (62.7) 102 (68.0)
Region, n (%)
East North Central 32 (12.4) 15 (10.6) 6 (16.7) 4 (13.3) 8 (15.7) 11 (7.3)
East South Central 10 (3.9) 4 (2.8) 2 (5.6) 0 (0.0) 1 (2.0) 4 (2.7)
Middle Atlantic 38 (14.7) 19 (13.5) 4 (11.1) 5 (16.7) 4 (7.8) 28 (18.7)
Mountain 25 (9.7) 8 (5.7) 1 (2.8) 0 (0.0) 2 (3.9) 9 (6.0)
New England 31 (12.0) 27 (19.1) 9 (25.0) 8 (26.7) 20 (39.2) 39 (26.0)
Pacific 54 (20.8) 28 (19.9) 4 (11.1) 5 (16.7) 7 (13.7) 22 (14.7)
South Atlantic 41 (15.8) 26 (18.4) 8 (22.2) 7 (23.3) 5 (9.8) 26 (17.3)
West North Central 10 (3.9) 5 (3.5) 1 (2.8) 1 (3.3) 2 (3.9) 1 (0.7)
West South Central 18 (6.9) 9 (6.4) 1 (2.8) 0 (0.0) 2 (3.9) 10 (6.7)
Age, mean (SD)
In years 24.18 (3.26) 23.68 (3.31) 24.03 (3.57) 22.17 (2.83) 23.65 (3.50) 23.57 (3.09)
Overt cissexism (lifetime), mean (SD)
Gender non-affirmation (lifetime) 5.07 (1.50) 5.12 (1.41) 4.69 (1.21) 5.12 (1.45) 5.27 (1.20) 5.25 (1.07)
Cissexist discrimination (lifetime) 2.86 (1.67) 2.67 (1.50) 1.97 (1.65) 2.06 (1.46) 1.93 (1.41) 2.11 (1.50)
Cissexist rejection (lifetime) 3.62 (1.84) 3.45 (1.92) 3.22 (2.07) 3.14 (1.81) 2.90 (2.04) 3.15 (1.71)
Cissexist victimization (lifetime) 2.91 (2.19) 1.82 (1.78) 2.06 (2.08) 1.35 (1.49) 1.30 (1.26) 1.68 (1.62)
Overt cissexism (past year), mean (SD)
Gender non-affirmation (past year) 3.30 (2.08) 3.07 (2.38) 4.61 (1.18) 4.24 (2.07) 4.60 (1.79) 4.66 (1.67)
Cissexist discrimination (past year) 1.47 (1.35) 1.39 (1.29) 1.25 (1.30) 1.37 (1.36) 1.13 (0.90) 1.54 (1.34)
Cissexist rejection (past year) 1.69 (1.52) 1.76 (1.63) 1.64 (1.74) 1.71 (1.57) 1.47 (1.31) 1.63 (1.65)
Cissexist victimization (past year) 0.98 (1.34) 0.65 (1.17) 0.72 (1.09) 0.45 (0.97) 0.50 (0.86) 0.62 (0.97)
General discrimination, mean (SD)
Everyday Discrimination Scale 3.05 (1.11) 2.67 (1.11) 2.92 (1.12) 2.91 (1.03) 2.88 (1.11) 2.93 (0.95)
Sexual assault victimization, n (%)
Sexual assault victimization in past 12 months 80 (31.0) 31 (22.0) 11 (30.6) 15 (50.0) 17 (33.3) 51 (34.0)
Abuse in childhood/adolescence (before age 18), n (%)
Psychological abuse by adult in household 141 (54.7) 90 (64.3) 28 (77.8) 15 (50.0) 32 (62.7) 85 (56.7)
Physical abuse by adult in household 64 (24.8) 41 (29.1) 12 (34.3) 7 (23.3) 13 (26.0) 38 (25.3)
Sexual abuse by adult or person 5+ years older 46 (18.0) 26 (18.7) 8 (22.9) 8 (27.6) 13 (27.1) 40 (28.0)
Open in a new tab

Measures

Gender.

Participants were asked, “Which of the following best describes your current gender identity?” and could select one option from a list of 15 terms developed for the 2015 U.S. Transgender Survey (James et al., 2016), or write in another gender term. Most participants (93.4%) reported one of the gender terms analyzed here: transgender woman, transgender man, nonbinary, genderqueer, gender fluid, and agender. Terms with sample sizes too small for inclusion (n < 5) included androgynous, two spirit, non-cisgender, and not sure. As in prior studies (Kidd et al., 2021; Reisner & Hughto, 2019), we combined responses of “woman” and “trans woman” into a single “transgender women” group, and we combined responses of “man” and “trans man” into a “transgender men” group. (All participants in these groups were identified as transgender based on their self-reported gender term and sex assigned at birth, but not all chose a gender term including the word “trans.”)

Overt Cissexism.

Exposure to overt cissexism was assessed using the gender non-affirmation, discrimination, rejection, and victimization subscales of the Gender Minority Stress and Resilience Measure (GMSRM; Testa et al., 2015). The gender non-affirmation subscale comprises five items assessing interpersonal non-acknowledgment of one’s gender identity (sample: “People don’t respect my gender identity because of my appearance or body”; lifetime alpha=.77 and past-year alpha=.84). The discrimination subscale comprises five items assessing whether the participant experienced discrimination in a specific domain due to their gender identity or expression (sample: “I have had difficulty finding housing or staying in housing because of my gender identity or expression”; lifetime alpha=.71 and past-year alpha=.61). The rejection subscale comprises six items assessing whether the participant experienced rejection in a specific domain due to their gender identity or expression (sample: “I have been rejected or distanced from friends because of my gender identity or expression”; lifetime alpha=.69 and past-year alpha=.63). The victimization subscale comprises six items assessing whether the participant experienced various forms of victimization due to their gender identity or expression (sample: “I have been threatened with physical harm because of my gender identity or expression”; lifetime alpha=.83 and past-year alpha=.76). For all subscales, participants indicated whether they experienced each event before age 18, after age 18, and/or in the past year. For the gender non-affirmation subscale, this reflects a modification from the original response options (Testa et al., 2015). Lifetime and past-year subscale scores were calculated by adding one point for each event experienced during that measurement period. Lifetime and past-year scores were moderately correlated (r=.45 for gender non-affirmation; r=.61 for cissexist discrimination; r=.51 for cissexist rejection; r=.51 for cissexist victimization). Lifetime GMSRM subscales were moderately correlated with one another and with general discrimination (see below), supporting their construct validity as measures of related but distinct manifestations of cissexism. The strongest correlation was between cissexist discrimination and cissexist rejection (r=.62), and the weakest was between gender non-affirmation and cissexist victimization (r=.21).

General Discrimination.

Exposure to general discrimination (based on cissexism and/or other reasons) was assessed using the Everyday Discrimination Scale (Williams et al., 1997). Participants were given the prompt “In your day-to-day life, how often do any of the following things happen to you?” followed by nine items tapping potentially discriminatory mistreatment (sample: “People act as if they’re better than you are”; 0=Never, 5=Almost every day). Scores were the mean of all items, with alpha=.91.

Sexual Assault.

Past-year sexual assault victimization was assessed with six items from the American Association of Universities Campus Climate Survey on Sexual Assault and Sexual Misconduct (Cantor et al., 2015). These items assessed sexual contact without the participant’s consent, specifying and defining various types of sexual contact (insertive or receptive penetration, oral sex, kissing, touching) and tactics (force, incapacitation, verbal coercion, ignoring verbal/nonverbal cues). We created a binary indicator for any sexual assault victimization.

Abuse in Childhood/Adolescence.

We assessed exposure to abuse during childhood and adolescence (before age 18 years) with eight items from the Adverse Childhood Experiences Scale (Felitti et al., 1998). These items assessed psychological abuse by parents/household adults (sample: “Did a parent or other adult in the household often or very often swear at, insult, or put you down?”), physical abuse by parents/household adults (sample: “Did a parent or other adult in the household often or very often push, grab, shove, or slap you?”), and sexual abuse by adults or anyone at least five years older (sample: “Did an adult or person at least 5 years older touch or fondle you in a sexual way?”). Response options were “Yes” and “No.” We created separate binary indicators for any psychological, physical, and sexual abuse.

Primarily Living in Affirmed Gender.

Participants were asked, “Do you currently live in your affirmed gender all or almost all of the time? (Your affirmed gender is the one you see as accurate for yourself)” with the options “Yes, I live in my affirmed gender most or all of the time and “No, I don’t live in my affirmed gender most or all of the time” (Testa et al., 2015).

Demographic Characteristics.

Participants were asked to select their race/ethnicity from a list of eight options (see Table 1) or a write-in response. Participants endorsing multiple options were classified as “More than one race or ethnicity,” Participants also reported age in years, the sex on their original birth certificate (male or female), whether they were born in the United States, and state of residence.

Analysis

We identified and removed potentially fraudulent responses using criteria including (1) inconsistencies between the screening form and survey, (2) “attention check” items, and (3) duplicate or nonsensical responses to open text questions. Analysis was conducted in R 3.6.2 (R Core Team, 2019). Missingness was 2.5% or less for all study variables. Missing data were multiply imputed (m=15) with fully conditional specification using the mice package (Van Buuren & Groothuis-Oudshoorn, 2011), and imputed data were used for all analyses other than descriptive statistics.

We first calculated descriptive statistics for each gender group (means and standard deviations for continuous variables; counts and percentages for binary variables). We then fit multivariable generalized linear models for each stressor as a function of gender group and demographic covariates (age in years, race and ethnicity, nativity, region). Linear models were used for continuous outcomes; logistic models were used for binary outcomes. To test for overall gender group variation in each stressor, we performed likelihood ratio tests comparing the full models to reduced models without gender group terms (Meng & Rubin, 1992). Next, to determine which gender group differed significantly from the full sample, we calculated adjusted marginal means (continuous outcomes) and prevalences (binary outcomes) for each gender group, then tested the difference between these group means/prevalences and the full sample adjusted marginal means/prevalences (i.e., adjusted mean/prevalence differences). For continuous outcomes, we computed marginal means, confidence intervals, and significance tests using the emmeans package (Lenth et al., 2023). For binary outcomes, we calculated prevalence differences manually, then calculated confidence intervals and hypothesis tests based on the adjusted bootstrap percentile method (Davison & Hinkley, 1997). For tests of adjusted mean/prevalence differences, we applied the Holm correction for multiple comparisons (Holm, 1979), treating each outcome as a family of tests. We performed three versions of these analyses, corresponding to the research questions above: (1) in the full sample, (1a) restricted to participants primarily living in their affirmed gender, and (2) restricted to nonbinary participants.

RESULTS

Variation in Participant Characteristics Across Gender Groups

Table 1 reports participant characteristics and the unadjusted means/prevalences of stressors for each gender group. A majority of transgender women participants were White (63.3%), while other gender groups had no majority race/ethnicity. For all gender groups, a majority of participants reported primarily living in their affirmed gender, ranging from 53.3% (gender fluid) to 85.8% (transgender men). All gender groups had considerable exposure to overt cissexism; for instance, most gender groups had mean lifetime cissexist rejection scores greater than 3, indicating rejection in more than half of the six contexts assessed. Other stressors were also common; for example, the prevalence of past-year sexual assault victimization ranged from 22% (transgender men) to 50% (gender fluid), and at least 50% of each group reported experiencing psychological abuse in childhood/adolescence.

Gender Group Variation in TNB Young Adults’ Exposure to Cissexism-Related Social Stressors

In demographics-adjusted analyses, some cissexism-related social stressors exhibited little variation by gender group, while others were heightened within specific gender groups (Table 2). Among measures of overt cissexism, there was no significant gender group variation in lifetime gender non-affirmation (P=.450), past-year cissexist discrimination (P=.695), or past-year cissexist rejection (P=.826). Lifetime cissexist discrimination was significantly elevated in transgender women and men compared to the full sample, with an adjusted mean difference (AMD) of 0.72 (95% CI: 0.40, 1.05) for women and AMD=0.42 (95% CI: 0.06, 0.77) for men. Past-year gender non-affirmation showed the reverse pattern, with lower mean levels in women and men compared to the full sample (AMD=−0.93; 95% CI: −1.35, −0.51 for women; AMD=−1.03; 95% CI: −1.49, −0.57 for men). Furthermore, three outcomes were significantly elevated among transgender women (but not men) compared to the full sample: lifetime cissexist rejection (AMD=0.48; 95% CI: 0.10, 0.86), lifetime cissexist victimization (AMD=1.29; 95% CI: 0.91, 1.68), and past-year cissexist victimization (AMD=0.40; 95% CI: 0.15, 0.65).

Table 2.

Exposure to social stressors among transgender and/or nonbinary young adults in the B*SHARP survey, n=667, comparing adjusted mean/prevalence for each gender group to adjusted mean/prevalence in the full sample

Adjusted mean difference (95% CI) comparing each gender group to the full sample
 Variation among gender groups
Transgender woman (n=259) Transgender man (n=141) Agender (n=36) Gender fluid (n=30) Genderqueer (n=51) Nonbinary (n=150)
Overt cissexism (lifetime)
Gender non-affirmation (lifetime) −0.04 (−0.33, 0.25) 0.01 (−0.30, 0.32) −0.31 (−0.84, 0.22) 0.13 (−0.33, 0.59) 0.05 (−0.53, 0.62) 0.17 (−0.14, 0.48) P=.450
Cissexist discrimination (lifetime) 0.72 (0.40, 1.05) 0.42 (0.06, 0.77) −0.31 (−0.91, 0.29) −0.18 (−0.70, 0.34) −0.42 (−1.08, 0.23) −0.23 (−0.58, 0.12) P<.001
Cissexist rejection (lifetime) 0.48 (0.10, 0.86) 0.18 (−0.23, 0.59) −0.03 (−0.72, 0.66) −0.03 (−0.63, 0.57) −0.45 (−1.21, 0.30) −0.15 (−0.55, 0.26) P=.011
Cissexist victimization (lifetime) 1.29 (0.91, 1.68) −0.03 (−0.45, 0.39) 0.16 (−0.56, 0.87) −0.52 (−1.13, 0.10) −0.70 (−1.47, 0.08) −0.21 (−0.62, 0.21) P<.001
Overt cissexism (past year)
Gender non-affirmation (past year) −0.93 (−1.35, −0.51) −1.03 (−1.49, −0.57) 0.59 (−0.18, 1.36) 0.32 (−0.35, 0.99) 0.45 (−0.39, 1.29) 0.60 (0.15, 1.05) P<.001
Cissexist discrimination (past year) 0.09 (−0.18, 0.37) 0.03 (−0.27, 0.32) −0.08 (−0.59, 0.42) 0.10 (−0.34, 0.54) −0.26 (−0.81, 0.29) 0.13 (−0.17, 0.42) P=.695
Cissexist rejection (past year) 0.04 (−0.29, 0.37) 0.10 (−0.26, 0.46) −0.01 (−0.62, 0.60) 0.16 (−0.37, 0.69) −0.21 (−0.87, 0.45) −0.08 (−0.44, 0.27) P=.826
Cissexist victimization (past year) 0.40 (0.15, 0.65) 0.01 (−0.26, 0.27) 0.04 (−0.41, 0.49) −0.18 (−0.57, 0.21) −0.19 (−0.68, 0.30) −0.07 (−0.33, 0.19) P=.001
General discrimination
Everyday Discrimination Scale 0.18 (−0.05, 0.40) −0.24 (−0.48, 0.00) 0.04 (−0.37, 0.45) 0.07 (−0.29, 0.42) −0.04 (−0.49, 0.40) 0.00 (−0.24, 0.24) P=.015
Adjusted prevalence difference (95% CI) comparing each gender group to the full sample
Variation among gender groups
Transgender woman (n=259) Transgender man (n=141) Agender (n=36) Gender fluid (n=30) Genderqueer (n=51) Nonbinary (n=150)
Sexual violence exposure
Sexual assault victimization in past 12 months 2.7 (−2.4, 7.8) pp −10.0 (−15.8, −3.8) pp −1.2 (−14.8, 14.1) pp 15.4 (−2.4, 35.3) pp 1.0 (−11.0, 14.4) pp 2.0 (−4.9, 8.8) pp P=.031
Abuse in childhood/adolescence (before age 18)
Psychological abuse by adult in household −3.4 (−8.4, 1.5) pp 4.7 (−2.5, 11.8) pp 19.2 (5.1, 31.4) pp −11.2 (−29.9, 7.3) pp 5.0 (−8.6, 17.9) pp −2.6 (−9.4, 4.5) pp P=.051
Physical abuse by adult in household 0.1 (−4.5, 4.9) pp 2.1 (−4.3, 8.5) pp 8.3 (−7.5, 25.1) pp −4.5 (−18.3, 12.1) pp −0.4 (−11.3, 12.0) pp −3.0 (−8.9, 3.1) pp P=.748
Sexual abuse by adult or person 5+ years older −2.7 (−6.7, 1.9) pp −3.7 (−9.4, 2.2) pp 1.2 (−11.9, 16.6) pp 6.2 (−8.3, 22.4) pp 5.5 (−6.6, 19.0) pp 4.4 (−1.6, 11.1) pp P=.426
Open in a new tab

Note. pp = percentage points. Adjusted mean differences are based on estimated marginal means from multivariable linear models. Adjusted prevalence differences are based on predicted marginal prevalences from multivariable logistic models; confidence intervals are based on the adjusted bootstrap percentile method. Models are adjusted for age, race/ethnicity, nativity, and region. Bold indicates statistically significant differences between each group and the full sample mean/prevalence. Bold italics indicate statistically significant variation among gender groups based on likelihood ratio tests of multivariable models. Hypothesis testing for specific gender groups incorporated the Holm correction for multiple comparisons, treating each outcome as a family of tests. Due to the multiple comparisons correction, some hypothesis test results may be null despite confidence intervals that do not include the null.

For stressors other than overt cissexism, there was significant gender group variation for general discrimination (P=.015), but no group differed significantly from the overall mean when correcting for multiple comparisons. The prevalence of sexual assault victimization was significantly lower in transgender men than the full sample, with an adjusted prevalence difference (APD) of −10.0 percentage points (pp; 95% CI: −15.8, −3.8 pp). Psychological, physical, and sexual abuse in childhood/adolescence did not vary significantly by gender group.

As a secondary analysis, we examined gender group variation in exposure to social stressors among participants primarily living in their affirmed gender (Supplemental Table 1). Results were generally similar to those reported above. However, in the restricted analysis, transgender men no longer differed significantly from the full sample in lifetime cissexist discrimination (AMD=0.30; 95% CI: −0.09, 0.68) or past-year sexual assault victimization (APD=−5.6 pp; 95% CI: −12.0, 1.1 pp).

Variation in Exposure to Cissexism-Related Social Stressors Across Nonbinary Gender Groups

There was little evidence that cissexism-related social stressors varied among the nonbinary gender groups, i.e., agender, gender fluid, genderqueer, and nonbinary (Table 3). Joint significance tests were null for all outcomes, and no gender group mean/prevalence differed significantly from the sample mean/prevalence. We noted an elevated point estimate for childhood/adolescent psychological abuse among agender participants (APD=17.0 pp; 95% CI: 3.2, 29.5 pp), but this difference was not significant after correction for multiple comparisons.

Table 3.

Exposure to social stressors among nonbinary young adults in the B*SHARP survey, n=267, comparing adjusted mean/prevalence for each nonbinary gender group to adjusted mean/prevalence in the full nonbinary sample

Adjusted mean difference (95% CI) comparing each nonbinary gender group to the full nonbinary sample
 Variation among nonbinary gender groups
Agender (n=36) Gender fluid (n=30) Genderqueer (n=51) Nonbinary (n=150)
Overt cissexism (lifetime)
Gender non-affirmation (lifetime) −0.34 (−0.75, 0.08) 0.07 (−0.38, 0.53) 0.15 (−0.22, 0.52) 0.11 (−0.17, 0.40) P=.165
Cissexist discrimination (lifetime) −0.05 (−0.57, 0.47) −0.09 (−0.66, 0.48) 0.17 (−0.29, 0.63) −0.03 (−0.39, 0.33) P=.812
Cissexist rejection (lifetime) 0.09 (−0.52, 0.71) −0.23 (−0.90, 0.45) 0.16 (−0.39, 0.71) −0.03 (−0.45, 0.40) P=.775
Cissexist victimization (lifetime) 0.48 (−0.09, 1.04) −0.43 (−1.04, 0.19) −0.10 (−0.60, 0.40) 0.05 (−0.34, 0.44) P=.122
Overt cissexism (past year)
Gender non-affirmation (past year) 0.07 (−0.53, 0.66) −0.04 (−0.69, 0.61) −0.12 (−0.65, 0.41) 0.10 (−0.31, 0.51) P=.854
Cissexist discrimination (past year) −0.05 (−0.50, 0.39) −0.25 (−0.73, 0.23) 0.18 (−0.21, 0.58) 0.12 (−0.18, 0.43) P=.376
Cissexist rejection (past year) 0.00 (−0.56, 0.55) −0.13 (−0.74, 0.47) 0.22 (−0.27, 0.71) −0.08 (−0.46, 0.30) P=.651
Cissexist victimization (past year) 0.17 (−0.18, 0.51) −0.12 (−0.50, 0.25) −0.08 (−0.38, 0.23) 0.03 (−0.20, 0.27) P=.565
General discrimination
Everyday Discrimination Scale 0.05 (−0.29, 0.39) −0.09 (−0.46, 0.28) 0.10 (−0.21, 0.40) −0.05 (−0.29, 0.18) P=.733
Adjusted prevalence difference (95% CI) comparing each nonbinary gender group to the full nonbinary sample
Variation among nonbinary gender groups
Agender (n=36) Gender fluid (n=30) Genderqueer (n=51) Nonbinary (n=150)
Sexual violence exposure
Sexual assault victimization in past 12 months −3.9 (−18.1, 11.2) pp 7.5 (−8.7, 26.1) pp 1.6 (−10.2, 13.4) pp −1.2 (−6.3, 3.9) pp P=.763
Abuse in childhood/adolescence (before age 18)
Psychological abuse by adult in household 17.0 (3.2, 29.5) pp −11.0 (−28.8, 5.8) pp 3.1 (−9.5, 13.9) pp −2.9 (−7.8, 2.5) pp P=.063
Physical abuse by adult in household 10.3 (−5.4, 25.6) pp −5.4 (−19.9, 9.4) pp 0.6 (−9.9, 12.7) pp −1.5 (−6.1, 3.7) pp P=.477
Sexual abuse by adult or person 5+ years older −0.6 (−14.8, 14.0) pp −1.2 (−14.1, 15.6) pp 2.8 (−9.3, 15.5) pp −0.5 (−5.3, 4.6) pp P=.972
Open in a new tab

Note. pp = percentage points. Adjusted mean differences are based on estimated marginal means from multivariable linear models. Adjusted prevalence differences are based on predicted marginal prevalences from multivariable logistic models; confidence intervals are based on the adjusted bootstrap percentile method. Models are adjusted for age, race/ethnicity, nativity, and region. Hypothesis testing for specific gender groups incorporates the Holm correction for multiple comparisons, treating each outcome as a family of tests. Due to the multiple comparisons correction, some hypothesis test results may be null despite confidence intervals that do not include the null. No hypothesis tests for specific gender groups were statistically significant after the multiple comparisons correction.

DISCUSSION

This study offers new insight into how U.S. TNB young adults’ exposure to cissexism-related social stressors varies by gender group. In particular, this study is among the first to compare experiences of stigma, discrimination, and violence among subgroups of nonbinary people, including identities such as gender fluid and agender that are often obscured or omitted in health research. As anticipated, for overt cissexism, patterns varied across forms and measurement periods: Several outcomes showed little variation, one was elevated among men and women compared with the full sample, one was lower among men and women compared with the full sample, and three were elevated among women (but not men) compared with the full sample. These findings are consistent with an intersectional perspective in which the confluence of cissexism, sexism, and gender binarism produces distinct experiences for TNB people of various genders (or no gender). This perspective could also account for the finding that transgender men reported less past-year sexual assault victimization relative to the full sample, though sexual assault was troublingly prevalent in all groups. Notably, we found no significant variation in social stressors among the four nonbinary gender groups examined (agender, gender fluid, genderqueer, and nonbinary), suggesting that grouping these identities under a broader nonbinary category may be appropriate in some contexts, such as research studies, program planning, and program evaluation addressing TNB young adult health from a minority stress perspective.

In this study, transgender men and women reported significantly higher levels of lifetime cissexist discrimination compared with the full TNB sample. Not only is cissexist discrimination a psychological stressor (Testa et al., 2015), it shapes social determinants of health via under- or unemployment, housing insecurity, educational disruption, and criminal legal system involvement (James et al., 2016). The fact that we observed gender group variation for the lifetime measurement period, but not over the past year, suggests that transgender men and women, compared with other TNB young adults, may tend to experience heightened cissexist discrimination earlier in life (e.g., childhood, adolescence). Earlier exposure to discrimination may have distinctive consequences, such as educational disruption (Wilkinson et al., 2018), with potential long-term health impacts. Thus, future studies should characterize any gender group differences in the developmental timing of cissexism exposure—and examine the long-term health correlates of exposure during specific developmental periods.

Transgender men and women also differed from the full sample in reporting lower levels of past-year gender non-affirmation, while point estimates for agender, gender fluid, genderqueer, and nonbinary [gender group] participants were similar to one another. This pattern suggests that past-year gender non-affirmation is heightened for nonbinary young adults overall—consistent with prior evidence that nonbinary people face distinctive challenges in having their gender identities socially acknowledged (Jäggi et al., 2018; Matsuno et al., 2022). Notably, analyses of lifetime gender non-affirmation found no significant gender group variation. Thus, gender non-affirmation should be understood as pervasive for TNB people generally, despite apparent gender group variation in exposure during young adulthood. Future research should further explore the life course timing of gender non-affirmation across gender groups, including any implications for clinical mental health care. Of the forms of overt cissexism considered here, gender non-affirmation is most closely linked to depression and suicidality (Jäggi et al., 2018; Pellicane & Ciesla, 2022; Testa et al., 2015). Accordingly, there is a pressing public health need to address the factors contributing to widespread experiences of gender non-affirmation in TNB young adults, including the harmful beliefs that nonbinary genders are “made up” or otherwise unworthy of social recognition (Matsuno et al., 2022).

Three stressors—lifetime cissexist rejection, lifetime cissexist victimization, and past-year cissexist victimization—were significantly elevated in transgender women (but not men) compared with the full sample. These results align with qualitative research describing how transgender women face distinctive and often intensified forms of marginalization at the confluence of cissexism and sexism, often manifesting in verbal, physical, or sexual victimization (Gamarel et al., 2020; Matsuzaka & Koch, 2019). Accordingly, research and services addressing cissexist rejection and victimization must account for the confluence of cissexism and sexism—and for transgender women’s experiences at this intersection.

Another important research direction will be further exploring the role of gender development milestones (Puckett et al., 2021), which could contribute to apparent gender group variation in the life course timing of cissexist discrimination and non-affirmation. Our secondary analysis offered some support for this proposition, suggesting that living in one’s affirmed gender might account for certain differences between transgender men and the full sample. However, few studies have directly examined associations between gender development milestones and cissexism-related social stressors, raising the possibility that other milestones are equally or more relevant. Future studies should examine a broader set of milestones in relation to stressors while also assessing whether participants consider each milestone personally applicable, an important consideration not addressed here.

Our second major research question addressed gender group variation among nonbinary young adults. None of the stressors we considered varied significantly across the nonbinary gender groups. This finding suggests that, in research and services addressing cissexism-related social stressors and their sequelae, it may be appropriate to group agender, gender fluid, genderqueer, and nonbinary young adults under a broader nonbinary category for the purposes of data analysis, program planning, and program evaluation. However, we strongly recommend including a broad range of gender terms during data collection and reporting those specific terms when describing participant characteristics. This approach communicates respect for diverse nonbinary identities and permits disaggregation when distinctions emerge.

Limitations and Future Research Directions

Findings must be considered in light of several limitations. First, because this study draws on a non-probability sample, estimates may not be representative of U.S. TNB populations overall. Second, this study may have been underpowered to detect some associations, particularly for nonbinary gender groups. Third, the reliability of the GMSRM discrimination, rejection, victimization, and non-affirmation subscales remains unclear, as these measures do not reflect a classical measurement model and thus internal consistency is not an appropriate measure of reliability (DeVellis, 2017); future research assessing test-retest reliability is needed. Fourth, this study focused on young adults, and gender group patterns in stressor exposure may differ for other age groups, particularly children and adolescents.

Future research should consider three key issues not fully addressed by the present study. First, while results suggest the value of analytically distinguishing nonbinary people from transgender men and women in minority stress research, uncritical categorization of TNB people as “binary” or nonbinary has the potential to reinforce the gender binary (Beischel et al., 2022), and some TNB people report that their experience of gender defies classification as binary or nonbinary (Beischel et al., 2022). Here, we categorized participants based on a single self-reported gender term. This approach may have misclassified some participants, including those who identify with both nonbinary and binary terms, e.g., nonbinary woman (Beischel et al., 2022) or with multiple binary terms, e.g., both man and woman (Poquiz et al., 2021). Nonbinary identity may be better addressed using the “Gender/Sex 3×3” measure (Beischel et al., 2022), which directly asks whether participants consider their gender identity binary, nonbinary, or “neither binary nor nonbinary.” Second, qualitative research indicates that the intersections of cissexism with sexism and binary normativity are further shaped by racism (Gamarel et al., 2020; Matsuno et al., 2022). Accordingly, future studies should explore how gender group variation in cissexism-related social stressors may further vary across race and ethnicity. Third, this study was not able to examine either community-level resilience processes or what Edelman (2020) refers to as trans vitalities and coalitional activism. Research exploring these processes is an important next step given the crucial role that community resources play in helping TNB young adults survive and thrive in the face of intensifying social oppression.

CONCLUSION

This study provided further evidence that TNB young adults experience a considerable burden of cissexism-related social stressors regardless of their gender, while also identifying notable variation in certain stressors across gender groups. Results suggest that, compared with other TNB young adults, transgender men and women have experienced higher average levels of lifetime cissexist discrimination, nonbinary people report heightened past-year gender non-affirmation, and transgender women (but not men) have experienced higher average levels of lifetime cissexist rejection and victimization. These findings confirm the value of analytic distinctions among transgender women, transgender men, and nonbinary people in research and services addressing minority stress and its sequelae. The findings also point to the importance of studying TNB minority stress from a life course perspective, with certain stressors’ life course timing appearing to differ by gender group, potentially leading to distinct health and psychosocial outcomes (Wilkinson et al., 2018). We did not identify significant variation in stressors among specific nonbinary gender groups, suggesting that a broader nonbinary category, encompassing those with identities such as agender, gender fluid, genderqueer, and nonbinary, can be meaningful in health research and services based on a minority stress framework. Above all, our findings reinforce the public health imperative to eliminate cissexism, sexism, and binary normativity in all of their interpersonal and structural forms.

Supplementary Material

Supplemental Table 1

Acknowledgments

The authors would like to thank Rose Eiduson and Jordan Schultz for their contributions to the study design and all of the B*SHARP participants for making this research possible. This work was supported by the Aerosmith Endowment Fund for the Prevention and Treatment of HIV and Other Sexually Transmitted Infections (PI: Gordon). Additional funding was provided by The Harvard University Open Gate Foundation (PI: Murchison) and the Research Education Institute for Diverse Scholars (REIDS) pilot grant (PI: Agénor) from National Institute of Mental Health grant 1R25GM111837-01 awarded to the Center for Interdisciplinary Research on AIDS at Yale University. Allegra Gordon is supported by the National Institute on Drug Abuse (K01DA054357). Gabriel Murchison is supported by the National Institute on Mental Health (T32 MH020031). Sabra Katz-Wise is funded by the Maternal and Child Health Bureau, Health Resources and Services Administration (Leadership Education in Adolescent Health project 6T71-MC00009).

Footnotes

Declaration of Interests

Sabra Katz-Wise is a diversity consultant for Paramount Global. The other authors have no relevant financial or non-financial interests to disclose.

REFERENCES

  1. Barbee H, Deal C, & Gonzales G (2022). Anti-transgender legislation—A public health concern for transgender youth. JAMA Pediatrics, 176(2), 125–126. 10.1001/jamapediatrics.2021.4483 [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Beischel WJ, Schudson ZC, Hoskin RA, & van Anders SM (2022). The Gender/Sex 3×3: Measuring and Categorizing Gender/Sex Beyond Binaries. Psychology of Sexual Orientation and Gender Diversity. Advance online publication. 10.1037/sgd0000558 [DOI] [Google Scholar]
  3. Bowleg L (2012). The problem with the phrase women and minorities: Intersectionality-an important theoretical framework for public health. American Journal of Public Health, 102(7), 1267–1273. 10.2105/AJPH.2012.300750 [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Brooks VR (1981). Minority Stress and Lesbian Women. Lexington Books. [Google Scholar]
  5. Cantor D, Fisher B, Chibnall S, Townsend R, Lee H, Bruce C, & Thomas G (2015). Report on the AAU Campus Climate Survey on Sexual Assault and Sexual Misconduct (p. 288). Westat. https://www.aau.edu/sites/default/files/AAU-Files/Key-Issues/Campus-Safety/AAU-Campus-Climate-Survey-FINAL-10-20-17.pdf [Google Scholar]
  6. Chavanduka TMD, Gamarel KE, Todd KP, & Stephenson R (2021). Responses to the gender minority stress and resilience scales among transgender and nonbinary youth. Journal of LGBT Youth, 18(2), 135–154. 10.1080/19361653.2020.1719257 [DOI] [Google Scholar]
  7. Cohen S, Janicki-Deverts D, & Miller GE (2007). Psychological stress and disease. JAMA: The Journal of the American Medical Association, 298(14), 1685–1687. 10.1001/jama.298.14.1685 [DOI] [PubMed] [Google Scholar]
  8. Collins PH (1990). Black Feminist Thought: Knowledge, consciousness, and the politics of empowerment. Unwin Hyman. [Google Scholar]
  9. Costello CG (2020). Beyond Binary Sex and Gender Ideology. In Boero N & Mason K (Eds.), The Oxford Handbook of the Sociology of Body and Embodiment. 10.1093/oxfordhb/9780190842475.013.14 [DOI] [Google Scholar]
  10. Coulter RWS, Mair C, Miller E, Blosnich JR, Matthews DD, & McCauley HL (2017). Prevalence of Past-Year Sexual Assault Victimization Among Undergraduate Students: Exploring Differences by and Intersections of Gender Identity, Sexual Identity, and Race/Ethnicity. Prevention Science, 18(6), 726–736. 10.1007/s11121-017-0762-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Crenshaw K (1991). Mapping the Margins: Intersectionality, Identity Politics, and Violence against Women of Color. Stanford Law Review, 43(6), 1241–1299. 10.2307/1229039 [DOI] [Google Scholar]
  12. Darwin H (2020). Challenging the cisgender/transgender binary: Nonbinary people and the transgender label. Gender & Society, 34(3), 357–380. 10.1177/0891243220912256 [DOI] [Google Scholar]
  13. Davison A, & Hinkley D (1997). Bootstrap Methods and Their Application. Cambridge University Press. [Google Scholar]
  14. DeVellis RF (2017). Scale development: Theory and applications. SAGE Publications, Ltd. [Google Scholar]
  15. Edelman EA (2020). Beyond Resilience: Trans Coalitional Activism as Radical Self-Care. Social Text, 38(142), 109–130. 10.1215/01642472-7971127 [DOI] [Google Scholar]
  16. Ehrensaft D (2012). From gender identity disorder to gender identity creativity: True gender self child therapy. Journal of Homosexuality, 59(3), 337–356. 10.1080/00918369.2012.653303 [DOI] [PubMed] [Google Scholar]
  17. Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, & Marks JS (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245–258. 10.1016/s0749-3797(98)00017-8 [DOI] [PubMed] [Google Scholar]
  18. Galupo MP, Pulice-Farrow L, & Ramirez JL (2017). “Like a Constantly Flowing River”: Gender Identity Flexibility Among Nonbinary Transgender Individuals. In Sinnott JD (Ed.), Identity Flexibility During Adulthood: Perspectives in Adult Development (pp. 163–177). Springer International Publishing. 10.1007/978-3-319-55658-1_10 [DOI] [Google Scholar]
  19. Gamarel KE, Jadwin-Cakmak L, King WM, Lacombe-Duncan A, Trammell R, Reyes LA, Burks C, Rivera B, Arnold E, & Harper GW (2020). Stigma experienced by transgender women of color in their dating and romantic relationships: Implications for gender-based violence prevention programs. Journal of Interpersonal Violence, 37(9–10), NP8161–NP8189. 10.1177/0886260520976186 [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Hendricks ML, & Testa RJ (2012). A Conceptual Framework for Clinical Work With Transgender and Gender Nonconforming Clients: An Adaptation of the Minority Stress Model. Professional Psychology: Research and Practice, 43(5), 460–467. 10.1037/a0029597 [DOI] [Google Scholar]
  21. Holm S (1979). A Simple Sequentially Rejective Multiple Test Procedure. Scandanavian Journal of Statistics, 6(2), 65–70. [Google Scholar]
  22. Hughes LD, Kidd KM, Gamarel KE, Operario D, & Dowshen N (2021). “These Laws Will Be Devastating”: Provider Perspectives on Legislation Banning Gender-Affirming Care for Transgender Adolescents. Journal of Adolescent Health, 69(6), 976–982. 10.1016/j.jadohealth.2021.08.020 [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Jäggi T, Jellestad L, Corbisiero S, Schaefer DJ, Jenewein J, Schneeberger A, Kuhn A, & Garcia Nuñez D (2018). Gender Minority Stress and Depressive Symptoms in Transitioned Swiss Transpersons. BioMed Research International, 2018, Article 8639263. 10.1155/2018/8639263 [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. James S, Herman J, Rankin S, Keisling M, & Mottet L (2016). Report of the 2015 U.S. Transgender Survey. National Center for Transgender Equality. https://www.transequality.org/sites/default/files/docs/USTS-Full-Report-FINAL.PDF [Google Scholar]
  25. Kidd JD, Goetz TG, Shea EA, & Bockting WO (2021). Prevalence and minority-stress correlates of past 12-month prescription drug misuse in a national sample of transgender and gender nonbinary adults: Results from the U.S. Transgender Survey. Drug and Alcohol Dependence, 219, Article 108474. 10.1016/j.drugalcdep.2020.108474 [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Kuper LE, Wright L, & Mustanski B (2018). Gender identity development among transgender and gender nonconforming emerging adults: An intersectional approach. International Journal of Transgenderism, 19(4), 436–455. 10.1080/15532739.2018.1443869 [DOI] [Google Scholar]
  27. Lefevor GT, Boyd-Rogers CC, Sprague BM, & Janis RA (2019). Health disparities between genderqueer, transgender, and cisgender individuals: An extension of minority stress theory. Journal of Counseling Psychology, 66(4), 385–395. 10.1037/cou0000339 [DOI] [PubMed] [Google Scholar]
  28. Lenth RV, Bolker B, Buerkner P, Giné-Vásquez I, Herve M, Jung M, Love J, Miguez F, Riebl H, & Singmann H (2023). emmeans: Estimated Marginal Means, aka Least-Squares Means (1.8.5) [R package]. https://cran.r-project.org/web/packages/emmeans/index.html [Google Scholar]
  29. Matsuno E, Bricker NL, Savarese E, Mohr R, & Balsam KF (2022). “The default is just going to be getting misgendered”: Minority stress experiences among nonbinary adults. Psychology of Sexual Orientation and Gender Diversity. Advance online publication. 10.1037/sgd0000607 [DOI] [Google Scholar]
  30. Matsuzaka S, & Koch DE (2019). Trans Feminine Sexual Violence Experiences: The Intersection of Transphobia and Misogyny. Affilia, 34(1), 28–47. 10.1177/0886109918790929 [DOI] [Google Scholar]
  31. Meng X-L, & Rubin DB (1992). Performing Likelihood Ratio Tests with Multiply-Imputed Data Sets. Biometrika, 79(1), 103–111. 10.2307/2337151 [DOI] [Google Scholar]
  32. Meyer IH (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129(5), 674–697. 10.1037/0033-2909.129.5.674 [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Pellicane MJ, & Ciesla JA (2022). Associations between minority stress, depression, and suicidal ideation and attempts in transgender and gender diverse (TGD) individuals: Systematic review and meta-analysis. Clinical Psychology Review, 91, Article 102113. 10.1016/j.cpr.2021.102113 [DOI] [PubMed] [Google Scholar]
  34. Poquiz JL, Coyne CA, Garofalo R, & Chen D (2021). Comparison of Gender Minority Stress and Resilience Among Transmasculine, Transfeminine, and Nonbinary Adolescents and Young Adults. Journal of Adolescent Health, 68(3), 615–618. 10.1016/j.jadohealth.2020.06.014 [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Puckett JA, Tornello S, Mustanski B, & Newcomb ME (2021). Gender variations, generational effects, and mental health of transgender people in relation to timing and status of gender identity milestones. Psychology of Sexual Orientation and Gender Diversity, 9(2), 165–178. 10.1037/sgd0000391 [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. R Core Team. (2019). R: A Language and Environment for Statistical Computing (3.6.2). R Foundation for Statistical Computing. https://www.R-project.org/ [Google Scholar]
  37. Reisner SL, & Hughto JMW (2019). Comparing the health of non-binary and binary transgender adults in a statewide non-probability sample. PloS One, 14(8), Article e0221583. 10.1371/journal.pone.0221583 [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Reisner SL, Katz-Wise SL, Gordon AR, Corliss HL, & Austin SB (2016). Social Epidemiology of Depression and Anxiety by Gender Identity. Journal of Adolescent Health, 59(2), 203–208. 10.1016/j.jadohealth.2016.04.006 [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Schnarrs PW, Stone AL, Salcido R, Baldwin A, Georgiou C, & Nemeroff CB (2019). Differences in adverse childhood experiences (ACEs) and quality of physical and mental health between transgender and cisgender sexual minorities. Journal of Psychiatric Research, 119, 1–6. 10.1016/j.jpsychires.2019.09.001 [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. Stryker S (2008). Transgender history. Seal Press. [Google Scholar]
  41. Testa RJ, Habarth J, Peta J, Balsam K, & Bockting W (2015). Development of the Gender Minority Stress and Resilience Measure. Psychology of Sexual Orientation and Gender Diversity, 2(1), 65–77. 10.1037/sgd0000081 [DOI] [Google Scholar]
  42. Valente PK, Schrimshaw EW, Dolezal C, LeBlanc AJ, Singh AA, & Bockting WO (2020). Stigmatization, Resilience, and Mental Health Among a Diverse Community Sample of Transgender and Gender Nonbinary Individuals in the U.S. Archives of Sexual Behavior, 49(7), 2649–2660. 10.1007/s10508-020-01761-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Van Buuren S, & Groothuis-Oudshoorn K (2011). mice: Multivariate imputation by chained equations in R. Journal of Statistical Software, 45(1), 1–67. 10.18637/jss.v045.i03 [DOI] [Google Scholar]
  44. Wilkinson L, Pearson J, & Liu H (2018). Educational attainment of transgender adults: Does the timing of transgender identity milestones matter? Social Science Research, 74, 146–160. 10.1016/j.ssresearch.2018.04.006 [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Williams DR, Yu Y, Jackson JS, & Anderson NB (1997). Racial Differences in Physical and Mental Health: Socio-economic Status, Stress and Discrimination. Journal of Health Psychology, 2(3), 335–351. 10.1177/135910539700200305 [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplemental Table 1
NIHMS1942703-supplement-Supplemental_Table_1.docx (82.9KB, docx)

RESOURCES