Parental Support and Mental Health Among Transgender Adolescents

Abstract

Purpose

Family support is protective against health risks in sexual minority individuals. However, few studies have focused specifically on transgender youth, who often experience rejection, marginalization, and victimization that place them at risk for poor mental health. This study investigated the relationships among parental support, quality of life, and depression in transgender adolescents.

Methods

Sixty-six transgender youth presenting for care at Children’s Hospital Los Angeles completed a survey assessing parental support (defined as help, advice and confidante support), quality of life, and depression. Regression analyses assessed the associations between parental support and mental health outcomes.

Results

Parental support was significantly associated with higher life satisfaction, lower perceived burden of being transgender, and fewer depressive symptoms.

Conclusions

Parental support is associated with higher quality of life and is protective against depression in transgender adolescents. Interventions that promote parental support may significantly impact the mental health of transgender youth.

INTRODUCTION

“Transgender” is the state in which an individual’s “asserted gender,” or self-identification as male, female, both, or neither, does not match their “assigned gender” (identification by others as male or female based on natal sex).¹ Similar to their sexual minority peers, transgender adolescents in the United States face stigmatization, and many also experience physical abuse, incarceration, and economic and societal marginalization² that may place them at higher risk for depression and suicide. Although less robust than the literature exploring the mental health of sexual minority youth, research has demonstrated high rates of depression and life-threatening behaviors in transgender adolescents.^1,3 One study of transgender adult men found significantly diminished quality of life compared with the general population;⁴ however, similar research on transgender adolescents is lacking.

Parental support has been shown to protect against mental health problems in sexual minority adolescents⁵ and has been associated with more consistent condom use in a study of transgender female youth.⁶ It is reasonable to assume that family support would be similarly protective for mental health in transgender youth. Thus, the present study examined relationships among parental support, depression, and quality of life in transgender adolescents.

METHODS

Data were obtained as part of a larger prospective study examining the impact of a multidisciplinary treatment protocol for transgender youth naive to cross-sex hormones.

Subjects

Gender non-conforming youth presenting for care at the Center for Transyouth Health and Development at Children’s Hospital Los Angeles between February 2011 and April 2012 were consecutively screened for participation by their physicians. Eligibility criteria included age between 12 and 24 years old, self-identification of an internal gender identity different that the one assigned at birth, desire to initiate cross-sex hormone treatment to facilitate phenotypic transition to their desired sex, naivety to hormones or less than three months of previous hormone use, and ability to read and comprehend English. Those who could not speak English and those who were not ready for hormonal intervention were excluded from the study. This sample, reflecting participants approached over a one-year period for a study currently open for recruitment, included 66 youth. Nine additional youth were screened but ineligible due to prior hormone use, and one subject declined to participate.

Procedure

Prior to meeting with medical staff, participants underwent mental health assessment by a provider with knowledge of gender non-conformity in youth to identify major mental health concerns and provide a recommendation that hormone therapy would benefit the participant in their transition process. Participants over 18 years old provided consent for the study; parental consent along with minor assent was obtained for those under 18. No parents declined to consent to their child’s participation. Participants completed a computer-assisted survey assessing demographics, parental support, depression, suicidality, and quality of life prior to cross-sex hormone initiation and received a $20 gift card for their time. The study was approved by the Committee on Clinical Investigations at Children’s Hospital Los Angeles.

Measures

Parental support was assessed with the family subscale of the Multidimensional Scale of Perceived Social Support⁷ (4 items; α=0.93), substituting “parent(s)” for “family” (e.g., “I get the emotional help and support I need from my parent(s)”) and using a five-point Likert scale. The 21-item Beck Depression Inventory II⁸ assessed the existence and severity of depressive symptoms within the past few days (α=0.94). Quality of life was assessed with two subscales, life satisfaction and perceived burden associated with being transgender, adapted from a measure previously used with pediatric HIV patients.⁹ Satisfaction comprised 6 five-point Likert-type items (α=0.74) asking respondents “How satisfied are you with:” their knowledge about being transgender; social relationships; sex life; work, school, and household activities; body appearance; and in general. Burden was assessed with 11 five-point Likert-type items (α=0.82) assessing the extent to which being transgender interferes with other activities or causes distress (e.g., “How often are you embarrassed by having to deal with being transgender in public?”).

Analysis

Linear regression analyses investigated the effects of parental support on depression and quality of life. Covariates included participant’s age in years, nationality (1=US-born, 0=other), race/ethnicity (recoded Caucasian=1, other=0), and assigned sex (1=female, 0=male).

RESULTS

Descriptive statistics for the sample are presented in Table 1. Greater depressive symptoms were associated with greater perceived burden (r=0.64, p<0.001) and lower life satisfaction (r=−0.37, p<0.01). Life satisfaction and perceived burden were negatively correlated (r=−0.52, p<0.01). Controlling for demographic variables, parental support was significantly associated with higher life satisfaction, lower perceived burden, and fewer depressive symptoms; complete regression results are presented in Table 2. US-born participants reported lower perceived burden and fewer depressive symptoms, although other demographic characteristics were not associated with mental health outcomes.

Table 1.

Descriptive statistics (N=66).

Variable	Categories	N (%)
Assigned Sex	Assigned male (asserted female)	32 (48.5%)
	Assigned female (asserted male)	34 (51.5%)
Ethnicity/Race	Caucasian	34 (51.5%)
	Other race:	32 (48.5%)
	Latino(a)	19 (28.8%)
	African American/Black	7 (10.6%)
	Other	6 (9.1%)
Country of birth	US, not including Puerto Rico	59 (89.4%)
	Other	7 (10.6%)

Variable	Range	Mean (SD)
Age	12–24 years	19.06 (2.88)
Parental support	1–5	3.63 (1.20)
BDI total score	0–55 (theoretical range 0–63)	11.05 (11.96)
QoL - Satisfaction	1.67–4.83 (theoretical range 1–5)	3.35 (0.73)
QoL - Burden	0.36–3.45 (theoretical range 0–4)	1.68 (0.72)

Table 2.

Regression coefficients predicting mental health outcomes.

	Life Satisfaction		Perceived Burden		Depressive Symptoms
	β	p-value	β	p-value	β	p-value
Parental support	0.324	0.02	−0.441	<0.001	−0.263	0.05
Age (years)	−0.066	0.63	0.188	0.13	0.105	0.45
US-born	0.040	0.75	−0.308	0.01	−0.358	0.01
Caucasian race	0.093	0.47	0.104	0.36	0.175	0.17
Assigned female at birth	0.013	0.92	0.070	0.56	−0.037	0.78

DISCUSSION

Most research examines sexual minority and gender non-conforming youth together as one (LGBT) population, of which transgender youth typically comprise a small percentage. This study, focusing solely on the experiences of an ethnically diverse group of transgender adolescents, suggests that parental support is associated with greater life satisfaction and is protective against depressive symptoms and perceived burden of being transgender.

Study limitations include a sample of youth initiating hormone treatment at a medical center that is not representative of all transgender youth. Findings were based on self-report and may be open to self-presentational biases. The parental support measure did not delineate whether the subject was referring to one or more parents, differentiate between parents and other guardians or caregivers, or explore the impact of other sources of support on mental health. Also, it did not distinguish between general parental support versus support specifically for gender identity or assess particular parental qualities or actions constituting support.

While family support is generally understood to play a protective role in the lives of adolescents,¹⁰ parents of transgender youth may have a crucial opportunity to offset the mental health impact of societal harassment and discrimination their children receive. Clinicians and support organizations working with families of transgender youth (e.g., PFLAG) are uniquely positioned to advocate for the importance of parental support. Further research into distinct supportive behaviors or relationship qualities would be potentially valuable for familial intervention development.

IMPLICATIONS AND CONTRIBUTIONS.

This study is the first to document associations among parental support, mental health, and quality of life in a sample of transgender youth. Physicians, therapists, and family support groups can inform parents of the protective health benefits of supporting their transgender child and endorse parenting behaviors that convey supportive messages.