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. Author manuscript; available in PMC: 2016 May 26.
Published in final edited form as: JAMA Pediatr. 2016 May 1;170(5):481–486. doi: 10.1001/jamapediatrics.2016.0067

Psychiatric Diagnoses and Comorbidities in a Diverse, Multicity Cohort of Young Transgender Women

Baseline Findings From Project Life Skills

Sari L Reisner 1, Katie B Biello 1, Jaclyn M White Hughto 1, Lisa Kuhns 1, Kenneth H Mayer 1, Robert Garofalo 1, Matthew J Mimiaga 1
PMCID: PMC4882090  NIHMSID: NIHMS785880  PMID: 26999485

Abstract

IMPORTANCE

Transgender youth, including adolescent and young adult transgender women assigned a male sex at birth who identify as girls, women, transgender women, transfemale, male-to-female, or another diverse transfeminine gender identity, represent a vulnerable population at risk for negative mental health and substance use outcomes. Diagnostic clinical interviews to assess prevalence of mental health, substance dependence, and comorbid psychiatric disorders in young transgender women remain scarce.

OBJECTIVE

To report the prevalence of mental health, substance dependence, and comorbid psychiatric disorders assessed via clinical diagnostic interview in a high-risk community-recruited sample of young transgender women.

DESIGN, SETTING, AND PARTICIPANTS

Observational study reporting baseline finding from a diverse sample of 298 sexually active, young transgender women aged 16 through 29 years (mean age, 23.4 years; 49.0%black, 12.4%Latina, 25.5%white, and 13.1%other minority race/ethnicity) and enrolled in Project LifeSkills, an ongoing randomized controlled HIV prevention intervention efficacy trial in Chicago and Boston, between 2012 and 2015.

EXPOSURE

Transfeminine gender identity.

MAIN OUTCOMES AND MEASURES

Age- and site-adjusted prevalence and comorbidities of mental health and substance dependence disorders assessed via the Mini-International Neuropsychiatric Interview, including 1 or more diagnoses, 2 or more comorbid diagnoses, major depressive episode (current and lifetime), past 30-day suicidal risk (no/low risk vs moderate/high risk), past 6-month generalized anxiety disorder and posttraumatic stress disorder, and past 12-month alcohol dependence and nonalcohol psychoactive substance use dependence.

RESULTS

Of the 298 transgender women, 41.5%of participants had 1 or more mental health or substance dependence diagnoses; 1 in 5 (20.1%) had 2 or more comorbid psychiatric diagnoses. Prevalence of specific disorders was as follows: lifetime and current major depressive episode, 35.4%and 14.7%, respectively; suicidality, 20.2%; generalized anxiety disorder, 7.9%; posttraumatic stress disorder, 9.8%; alcohol dependence, 11.2%; and nonalcohol psychoactive substance use dependence, 15.2%.

CONCLUSIONS AND RELEVANCE

Prevalence of psychiatric diagnoses was high in this community-recruited sample of young transgender women. Improving access to routine primary care, diagnostic screening, psychotherapy, and pharmacologic treatments, and retention in care in clinical community-based, pediatric, and adolescent medicine settings are urgently needed to address mental health and substance dependence disorders in this population. Further research will be critical, particularly longitudinal studies across development, to understand risk factors and identify optimal timing and targets for psychosocial interventions.

Mental health disorders and substance dependence affect 3.8% to 26.2% of the US population and frequently manifest in adolescence and young adulthood, with younger age groups bearing disproportionate burden relative to older groups.1–3 Transgender youth—including adolescent and young adult transgender women assigned a male sex at birth who identify as girls, women, transgender women, transfemale, male-to-female, or another diverse gender identity on the transfeminine spectrum—represent a vulnerable population at risk for negative mental health4–7 and substance use8–11 outcomes in the United States.

Although community surveys of transgender persons in the United States have found a high prevalence of depression, anxiety, and substance use relative to that of the general adult US population,4,5,8–10,12–16 studies typically use screening instruments or subthreshold symptom questions and do not use diagnostic interviews, such as the Mini-International Neuropsychiatric Interview (MINI), to assess prevalence of mental health psychopathology and substance dependence, with one exception.17 Acommunity sample of 571 adult transgenderwomen17 recruited from the NewYork City metropolitan area (mean age 37 years) used the MINI and found that life-time prevalence of depressionwas54.3%, nearly 3 times higher than the corresponding National Comorbidity Survey estimate for the general population, 19.6%18; lifetime suicide ideation was 53.5% (more than 3 times higher than the corresponding National Comorbidity Survey estimate in the general population, 13.5%), and lifetime suicide plans and attempts (35.0%and 27.9%, respectively)were 7 to 10times higher than corresponding National Comorbidity Survey estimates (3.9% and 4.6%, respectively). Substance dependence was not assessed via the MINI in that study. Psychiatric screening instruments assist in appraising the possible presence of a particular problem and identifying individuals who may need amore thorough evaluation, whereas a structured psychiatric diagnostic interview allows definition of the specific nature of the problem, determination of a clinical diagnosis (eg, epidemiologic “cases”), and development of specific treatment recommendations for addressing the clinical problem.19–21 Diagnostic interview data focused on adolescent and young transgender women remain scarce and are important to establish guidelines for diagnosis and treatment for this youth group, given their complex life experiences.2,22

The aim of this study was to report the prevalence of mental health, substance dependence, and comorbid psychiatric disorders assessed via a diagnostic interview in an at-risk community-recruited sample of young transgender women.

Methods

Study Sample

Between 2012 and 2015, 300 young transgender women were enrolled in Project LifeSkills, an ongoing multisite trial in Chicago, Illinois (51%), and Boston, Massachusetts (49%), testing the efficacy of a culturally tailored, empowerment-based, and group-delivered HIV prevention intervention aimed at reducing youths’ risk forHIVacquisitionandtransmission.23 Participants were recruited with a variety of convenience sampling strategies, such as outreach to community-based organizations and events, as well as bars and clubs; study flyers on bulletin boards, websites, and list servs; socialmedia out-reach and advertisement (eg, Facebook, craigslist); word of mouth via peer recruiters and transgender community leaders; and tabling in the lobby of local health centers and social service organizations serving young transgender women. Grounded in community-based participatory research principles,24 recruitment was conducted with input from local transgender communities in each city, as well as from study staff who were members of the study population (ie, young transgender women). Eligible participants were aged 16–29 years; were assigned a male sex at birth and now self-identify as a woman, female, transgender woman, transfemale, male-to-female, or other identity on the transfeminine spectrum; were English speaking; and self-reported participating in risky sexual activity. Current gender dysphoria was not an inclusion criterion for this study.

Key Points.

Question

What is the prevalence of psychiatric diagnoses and comorbidities assessed via diagnostic interview in a high-risk community sample of sexually active adolescent and young adult transgender women aged 16 to 29 years?

Findings

In this observational study of 298 young transgender women, 41.5%had 1 or more mental health or substance dependence diagnoses; 20%had 2 or more comorbid psychiatric diagnoses.

Meaning

Interventions are urgently needed to address adverse mental health and substance use outcomes for young transgender women, including those delivered by health care professionals and via multidisciplinary teams in clinical community-based, pediatric, adolescent, and young adult medicine settings.

At baseline, the mean age of participants was 23.4 years (SD = 3.5 years; range, 16–29 years), and the sample was racially and ethnically diverse (49.0%black, 12.4%Latina, 25.5% white, and 13.1%other minority race/ethnicity). Differences by age and race or ethnicity were examined to identify subgroups of young transgender women at highest risk. The goal was to inform clinical care and future psychosocial interventions for young transgender women, including those delivered in pediatric, adolescent, and young adult medical care settings. Nearly three-quarters (74%) of the sample was unemployed, and nearly half (46%) reported an annual income of less than $10000. More than one-quarter (28%) reported having no health insurance and 58% reported having public insurance. Although the majority reported ever using cross-sex hormones (72%), less than one-quarter (21%) of the sample reported undergoing gender-reassignment surgery or laser therapy.

Participants completed a 2-hour baseline study visit composed of standardized quantitative assessment via a combination of computer-assisted self-interviewing for sexual risk outcomes and other sensitive topics, and biologic testing for HIV and other sexually transmitted infections (urethral gonorrhea and chlamydia). All participants completed written informed consent for study participation. The institutional review boards at both participating study sites approved the study.

Measures

The MINI version 6 is a brief structured diagnostic interview that examines mental health disorders and substance dependence according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision25 and International Classification of Diseases, 10th Revision26 diagnostic criteria.27 The MINI is fully structured to allow administration by nonspecialized lay interviewers. It was not administered as part of the main aims of the LifeSkills intervention, but was included in the baseline study assessment visit with the explicit goal of estimating the prevalence and distribution of psychiatric diagnoses in this unique community-based sample of at-risk young transgender women. Interviewers were trained to complete the MINI by social and psychiatric epidemiologists with experience in the assessment of psychopathology in high-risk urban populations. To keep the assessment short, the MINI was designed to primarily focus on the indication of current disorders. For each disorder, 1 or 2 screening questions rule out the diagnosis when answered negatively. For the purpose of this study, participants were asked all diagnostic questions relating to the following disorders: major depressive episode (current and lifetime), past 30-day suicidality risk (no/ low risk vs moderate/high risk), past 6-month generalized anxiety disorder and posttraumatic stress disorder, and past 12-month alcohol dependence and nonalcohol psychoactive substance use dependence. Diagnostic interview data were collected only on these 7 psychiatric diagnoses and did not include others (eg, panic disorder, obsessive-compulsive disorder, eating disorders) to minimize participant burden and fatigue in the current study. Each MINI module has been separately validated; thus, we would not expect that limiting to 7 diagnoses would affect reliability or validity of the diagnostic interview. Additionally, a count score was calculated according to the total number of current psychiatric disorders indicated.

Statistical Analysis

SAS version 9.4 was used for statistical analyses. Prevalence estimates of psychiatric disorders were calculated for the total sample. Age-adjusted and age- and study site–adjusted prevalences were estimated by weighting the crude prevalence by the age and age or site distributions of the sample. Specifically, this was done by multiplying the prevalence in each age stratum by the proportion of individuals in each one and summing these stratum-specific rates.28 Prevalence estimates by age (groupings: aged 16–19, 20–24, and 25–29 years) and race (ie, primary race/ethnicity identification; groupings: white, black, Latina, and other minority race/ethnicity) are also presented. χ2 Tests were calculated to assess differences in psychiatric disorders across age and race strata (adjusting for study site). Complete-case analyses were conducted, with less than 4% missing data across all analyses. The final data analytic sample was n = 298.

Results

Almost half the participants (41.5%) had 1 or more mental health or substance dependence diagnoses; 21.4%had 1 diagnosis; 20.1% had 2 or more (Table 1). Age- and site-adjusted prevalences were as follows: lifetime and current major depressive episode were 35.4%and 14.7%, respectively; past 30-day suicidality was 20.2%; past 6-month generalized anxiety disorder and posttraumatic stress disorder were 7.9%and9.8%, respectively; and past 12-month alcohol dependence and nonalcohol psychoactive substance use were 11.2% and 15.2%, respectively (Table 1).

Table 1.

Prevalence of Mental Health and Substance Dependence Diagnoses, Overall and by Age (N = 298)

No. %
No. (%)
Test Statistica P Value
Crude Age Adjusted Age and Site Adjusted Age 16–19 y (n = 55) Age 20–24 y (n = 146) Age 25–29 y (n = 97)
Major depressive episode
 Lifetime 103 35.3 35.6 35.4 7 (13.0) 51 (35.9) 45 (46.9) 13.0 .002
 Current 42 14.1 14.8 14.7 3 (5.5) 124 (6.4) 15 (15.5) 3.74 .15
Suicidality (moderate/high), past 30 d 55 18.8 19.6 20.2 4 (7.4) 28 (19.7) 23 (23.7) 5.02 .08
Generalized anxiety disorder, past 6 mo 25 8.3 8.4 7.9 1 (1.8) 16 (11.0) 8 (8.2) 3.32 .19
Posttraumatic stress disorder, past 6 mo 25 8.5 9.0 9.8 2 (3.6) 15 (9.7) 9 (9.5) 1.92 .38
Alcohol dependence, past 12 mo 33 11.0 11.0 11.2 2 (3.6) 15 (10.3) 16 (16.5) 4.23 .12
Nonalcohol psychoactive substance use dependence, past 12 mo 43 14.4 14.7 15.2 6 (10.9) 21 (14.5) 16 (16.5) 0.96 .62
No. of diagnosesb
 0 173 60.1 58.6 58.5 43 (79.6) 79 (56.4) 51 (54.3) 10.7 .005
 1 58 20.1 21.5 21.4 6 (11.1) 32 (22.9) 20 (21.3) 3.10 .21
 2 26 9.0 9.1 8.9 3 (5.6) 13 (9.3) 10 (10.6) 0.76 .68
 3 20 6.9 6.7 6.5 2 (3.7) 10 (7.1) 8 (8.5) 1.15 .56
 4 7 2.4 2.6 2.8 0 4 (2.9) 3 (3.2) 1.00 .95
 5 4 1.4 1.6 1.9 0 2 (1.4) 2 (2.1) 0.01 .99
 6 0
No. of diagnoses, mean (SD)b 0.76 (1.16) 0.78 (1.20) 0.80 (1.25) 0.33 (0.75) 0.81 (1.18) 0.91 (1.28) 3.16 .03
Open in a new tab
a

Test statistics for binary data (eg, lifetime major depressive episode) and categorical data (eg, age) are χ2 with 5 df (2 × 3 contingency table). Test statistics for continuous data (eg, mean number of diagnoses) are t test. All reported test statistics are adjusted for study site (Boston vs Chicago).

b

Includes current major depressive episode, suicidality (high/moderate), generalized anxiety disorder, posttraumatic stress disorder, alcohol dependence, and nonalcohol psychoactive substance use dependence.

Statistically significant age group differences were found for lifetime major depressive episode (χ2 = 13.0; P = .002), with highest prevalence in the age group 25–29 years (46.9%). Comparisons by age approached statistical significance for suicidality (χ2 = 5.02; P = .08), with highest prevalence in the age group 25–29 years (23.7%). In addition, the absence of diagnoses was significantly different by age, with the youngest women having the highest prevalence (79.6%) and the oldest group the lowest (54.3%; χ2 = 10.7; P = .005). Similarly, the mean number of diagnoses differed by age, with the same pattern of increasing comorbidity by age. Prevalence of mental health diagnoses by race was statistically significant for life-time and current major depressive episode (all P < .05), with highest prevalence in Latina young transgender women(48.6% and 27.0%, respectively) (Table 2). Comparisons by race approached statistical significance for suicidality and posttraumatic stress disorder.

Table 2.

Distribution of Mental Health and Substance Dependence Diagnoses by Race and Ethnicity

No. (%) Test Statistica P Value
White (n = 76) Black (n = 146) Latina (n = 37) Other Race/Ethnicity (n = 39)
Major depressive episode
 Lifetime 35 (46.1) 35 (24.5) 17 (48.6) 16 (42.1) 9.17 .03
 Current 12 (15.8) 13 (8.9) 10 (27.0) 7 (17.9) 7.89 .048
Suicidality (moderate/high), past 30 d 23 (30.3) 19 (13.5) 7 (18.9) 6 (15.4) 7.71 .05
Generalized anxiety disorder, past 6 mo 7 (9.2) 11 (7.5) 3 (8.1) 4 (10.3) 1.90 .59
Posttraumatic stress disorder, past 6 mo 8 (10.5) 7 (4.8) 5 (13.9) 5 (13.2) 7.32 .10
Alcohol dependence, past 12 mo 11 (14.5) 12 (8.2) 3 (8.1) 7 (17.9) 2.85 .42
Nonalcohol psychoactive substance use dependence, past 12 mo 8 (10.7) 24 (16.6) 3 (8.1) 8 (20.5) 4.21 .24
No. of diagnosesb
 0 40 (53.3) 90 (64.7) 22 (61.1) 21 (55.3) 2.47 .48
 1 16 (21.3) 30 (21.6) 5 (13.9) 7 (18.4) 1.11 .78
 2 10 (13.3) 9 (6.5) 4 (11.1) 3 (7.9) 2.26 .52
 3 6 (8.0) 7 (5.0) 3 (8.3) 4 (10.5) 2.08 .56
 4 1 (1.3) 2 (1.4) 1 (2.8) 3 (7.9) 4.84 .18
 5 2 (2.7) 1 (0.7) 1 (2.8) 0 0.63 .89
 6 0 0 0 0
No. of diagnoses, mean (SD)b 0.91 (1.24) 0.59 (1.00) 0.86 (1.33) 0.97 (1.35) 1.48 .21
Open in a new tab
a

Test statistics for binary data (eg, lifetime major depressive episode) and categorical data (eg, age) are χ2 with 5 df (2 × 3 contingency table). Test statistics for continuous data (eg, mean number of diagnoses) are t test. All reported test statistics are adjusted for age and study site (Boston vs Chicago).

b

Includes current major depressive episode, suicidality (high/moderate), generalized anxiety disorder, posttraumatic stress disorder, alcohol dependence, and nonalcohol psychoactive substance use dependence.

Discussion

Prevalence of mental health, substance dependence, and comorbid psychiatric disorders was high in this at-risk community sample of young transgender women. The estimates found here are 1.7 to 3.6 times that of the general US population.3,29,30 Differences in mental health disorders were also found by race, with Latina transgender women having the highest and black women the lowest prevalence of major depressive episode. A lower proportion of our sample had lifetime major depressive episode (35.4%) compared with that in a study of adult transgender women (54.3%), suggesting an important opportunity for early prevention efforts.17 Indeed, in age-stratified estimates we found significant differences by age, with increasing depression prevalence with age. Similarly, current suicidality followed this same pattern, showing an increasing trend by age. Also, comorbidities were least prevalent in the youngest group and highest in the oldest one. These data are consistent with the general adolescent and young adult development literature,31 which suggest that stressors, such as adverse role transitions or identity development processes, are associated with both onset and persistence of psychiatric disorders.32–34 For young transgender women, gender transition and gender affirmation represent unique stressors, both positive and negative, that may affect psychiatric health and well-being across adolescence and young adulthood.35 Improving access to culturally competent primary care, diagnostic screening, psychotherapy, and pharmacologic treatments, and retention in care in clinical community-based, pediatric, and adolescent and young adult medicine settings are urgently needed to address the adverse mental health and substance dependence disorders in this population, with attention to differences by race or ethnicity.36–38 Further research is needed, particularly longitudinal studies that examine the antecedents and health sequelae of mental health, substance dependence, and psychiatric comorbidities across adolescent and young adult development to identify optimal timing and targets for psychosocial interventions in relation to gender affirmation and gender role transitions.39,40

Transgender people who have a sex assigned at birth that differs from their current gender identity represent approximately 0.5% of the US population41 and experience documented disparities in mental health and substance use outcomes,4,5,8–10,12–17 as supported by the high prevalence estimates in the current study using a brief structured diagnostic interview with young transgender women. The high prevalence of mental health and substance use outcomes among young transgender women is a serious public health problem and necessitates clinical consideration in primary care settings and gender-related treatment. Pediatric, adolescent, or young adult primary care providers may be a first resource for families needing education and support and play a critical role in supporting transgender youth, including screening for psychosocial problems and health risks, referring for gender-specific mental health and medical care, and providing advocacy and support.36,42 Research suggests that medical intervention such as hormone therapy may reduce mental health distress in transgender youth.43 The majority (72%) of our sample reported cross-sex hormones; however, a high prevalence of psychiatric diagnoses and comorbidities was still observed. Clinicians should familiarize themselves with current international guidelines for the provision of clinical care to transgender young people37,44,45 to best meet both medical and mental health needs of this at-risk population.

Findings necessitate consideration alongside several limitations. First, this is an urban, community-recruited convenience sample that enrolled participants with sexually risky behavior in an HIV prevention efficacy trial; thus, results are not generalizable to the US general population of young transgender women. Because national survey approaches to quantify behavioral risks among adolescents and young adults in the United States, such as the Youth Risk Behavior Survey,46 do not include indicators of transgender status, population-based routine mental health and substance use surveillance data are lacking for this population. Given the high prevalence of psychiatric diagnoses in this sample, inclusion of these indicators is warranted in routine health surveillance. Second, individuals from the target study population (ie, young transgender women) served as interviewers of the young transgender women sampled. Thus, social desirability bias may be pertinent; however, such bias would likely underestimate the prevalence estimates reported herein.

Limitations notwithstanding, the present study highlights the high prevalence of psychiatric disorders, including substance use dependence, in this community sample of at risk sexually active young transgender women. Although US mental health services are slowly becoming more transgender inclusive, substance use treatment programs tailored to meet the needs of transgender individuals, particularly young transgender women, remain scarce.47 Culturally tailored interventions that work to decrease mental health distress and substance use among young transgender women are needed, as are longitudinal cohort studies that examine the course of mental and physical health of young transgender women over time across adolescence and young adulthood to inform interventions for this at-risk group of youth.48 Such studies will increase understanding of the prevalence, course, and trajectory of psychiatric comorbidities across development and gather information that is currently unknown, such as characterizing patterns of homotypic (continuity of the same disorder) or heterotypic (continuity from one diagnosis to another)49 diagnoses among young transgender women.

Acknowledgments

Funding/Support: Research reported in this publication was supported by the National Institute of Mental Health (NIMH) of the National Institutes of Health under award R01MH094323 (Drs Garofalo and Mimiaga). Ms White Hughto is supported by awards T32MH020031 and P30MH062294 from NIMH.

Footnotes

Conflict of Interest Disclosures: None reported.

Role of the Funder/Sponsor: The funders acknowledged herein had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Additional Contributions: We thank the Project LifeSkills Teams in Chicago and Boston and our participants for sharing their experiences.

Author Contributions: Drs Reisner and Biello had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Reisner, White Hughto, Kuhns, Garofalo, Mimiaga.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Reisner, Biello, White Hughto.

Critical revision of the manuscript for important intellectual content: All authors.

Administrative, technical, or material support: All authors.

References

  • 1.Substance Abuse and Mental Health Services Administration (SAMHSA) Results From the 2012 National Survey on Drug Use and Health: Summary of National Findings. Rockville, MD: SAMHSA; 2013. HHS Publication (SMA) 13–4795. [Google Scholar]
  • 2.Olson J, Forbes C, Belzer M. Management of the transgender adolescent. Arch Pediatr Adolesc Med. 2011;165(2):171–176. doi: 10.1001/archpediatrics.2010.275. [DOI] [PubMed] [Google Scholar]
  • 3.Merikangas KR, He JP, Burstein M, et al. Lifetime prevalence of mental disorders in US adolescents: results from the National Comorbidity Survey Replication–Adolescent Supplement (NCS-A) J Am Acad Child Adolesc Psychiatry. 2010;49(10):980–989. doi: 10.1016/j.jaac.2010.05.017. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Reisner SL, Vetters R, Leclerc M, et al. Mental health of transgender youth in care at an adolescent urban community health center. J Adolesc Health. 2015;56(3):274–279. doi: 10.1016/j.jadohealth.2014.10.264. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Olson J, Schrager SM, Belzer M, et al. Baseline physiologic and psychosocial characteristics of transgender youth seeking care for gender dysphoria. J Adolesc Health. 2015;57(4):374–380. doi: 10.1016/j.jadohealth.2015.04.027. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Garofalo R, Deleon J, Osmer E, Doll M, Harper GW. Overlooked, misunderstood and at-risk: exploring the lives and HIV risk of ethnic minority male-to-female transgender youth. J Adolesc Health. 2006;38(3):230–236. doi: 10.1016/j.jadohealth.2005.03.023. [DOI] [PubMed] [Google Scholar]
  • 7.Edwards-Leeper L, Spack NP. Psychological evaluation and medical treatment of transgender youth in an interdisciplinary “gender management service” (GeMS) in a major pediatric center. J Homosex. 2012;59(3):321–336. doi: 10.1080/00918369.2012.653302. [DOI] [PubMed] [Google Scholar]
  • 8.Coulter RW, Blosnich JR, Bukowski LA, et al. Differences in alcohol use and alcohol-related problems between transgender- and nontransgender-identified young adults. Drug Alcohol Depend. 2015;154:251–259. doi: 10.1016/j.drugalcdep.2015.07.006. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Reisner SL, Greytak EA, Parsons JT, Ybarra ML. Gender minority social stress in adolescence: disparities in adolescent bullying and substance use by gender identity. J Sex Res. 2015;52(3):243–256. doi: 10.1080/00224499.2014.886321. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Rowe C, Santos G-M, McFarland W, Wilson EC. Prevalence and correlates of substance use among trans female youth ages 16–24 years in the San Francisco Bay Area. Drug Alcohol Depend. 2015;147:160–166. doi: 10.1016/j.drugalcdep.2014.11.023. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.Hotton AL, Garofalo R, Kuhns LM, Johnson AK. Substance use as a mediator of the relationship between life stress and sexual risk among young transgender women. AIDS Educ Prev. 2013;25(1):62–71. doi: 10.1521/aeap.2013.25.1.62. [DOI] [PubMed] [Google Scholar]
  • 12.Clements-Nolle K, Marx R, Guzman R, Katz M. HIV prevalence, risk behaviors, health care use, and mental health status of transgender persons. Am J Public Health. 2001;91(6):915–921. doi: 10.2105/ajph.91.6.915. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Clements-Nolle K, Marx R, Katz M. Attempted suicide among transgender persons: the influence of gender-based discrimination and victimization. J Homosex. 2006;51(3):53–69. doi: 10.1300/J082v51n03_04. [DOI] [PubMed] [Google Scholar]
  • 14.Keuroghlian AS, Reisner SL, White JM, Weiss RD. Substance use and treatment of substance use disorders in a community sample of transgender adults. Drug Alcohol Depend. 2015;152:139–146. doi: 10.1016/j.drugalcdep.2015.04.008. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Reisner SL, White JM, Bradford JB, Mimiaga MJ. Transgender health disparities: comparing full cohort and nested matched-pair study designs in a community health center. LGBT Health. 2014;1(3):177–184. doi: 10.1089/lgbt.2014.0009. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Benotsch EG, Zimmerman R, Cathers L, et al. Non-medical use of prescription drugs, polysubstance use, and mental health in transgender adults. Drug Alcohol Depend. 2013;132(1–2):391–394. doi: 10.1016/j.drugalcdep.2013.02.027. [DOI] [PubMed] [Google Scholar]
  • 17.Nuttbrock L, Hwahng S, Bockting W, et al. Psychiatric impact of gender-related abuse across the life course of male-to-female transgender persons. J Sex Res. 2010;47(1):12–23. doi: 10.1080/00224490903062258. [DOI] [PubMed] [Google Scholar]
  • 18.Eaton WW, Anthony JC, Gallo J, et al. Natural history of diagnostic interview schedule/DSM-IV major depression: the Baltimore Epidemiologic Catchment Area follow-up. Arch Gen Psychiatry. 1997;54(11):993–999. doi: 10.1001/archpsyc.1997.01830230023003. [DOI] [PubMed] [Google Scholar]
  • 19.Susser E, Schwartz S, Morabia A. Psychiatric Epidemiology: Searching for the Causes of Mental Disorders. New York, NY: Oxford University Press; 2006. [Google Scholar]
  • 20.Center for Substance Abuse Treatment. Substance Abuse Treatment: Addressing the Specific Needs of Women (Treatment Improvement Protocol [TIP] Series, No. 51.) Rockville, MD: Center for Substance Abuse Treatment; 2009. Chapter 4: screening and assessment. [Google Scholar]
  • 21.Center for Substance Abuse Treatment. Trauma-Informed Care in Behavioral Health Services (Treatment Improvement Protocol [TIP] Series, No. 57.) Rockville, MD: Center for Substance Abuse Treatment; 2014. Chapter 4: screening and assessment. [Google Scholar]
  • 22.Stieglitz KA. Development, risk, and resilience of transgender youth. J Assoc Nurses AIDS Care. 2010;21(3):192–206. doi: 10.1016/j.jana.2009.08.004. [DOI] [PubMed] [Google Scholar]
  • 23.Garofalo R, Johnson AK, Kuhns LM, et al. Life skills: evaluation of a theory-driven behavioral HIV prevention intervention for young transgender women. J Urban Health. 2012;89(3):419–431. doi: 10.1007/s11524-011-9638-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24.Leung MW, Yen IH, Minkler M. Community based participatory research: a promising approach for increasing epidemiology’s relevance in the 21st century. Int J Epidemiol. 2004;33(3):499–506. doi: 10.1093/ije/dyh010. [DOI] [PubMed] [Google Scholar]
  • 25.Diagnostic and Statistical Manual of Mental Disorders. 4. Washington, DC: American Psychiatric Association; 2000. pp. 553–557. text rev ed. [Google Scholar]
  • 26.International Classification of Diseases. 10. Geneva, Switzerland: World Health Organization; 2009. [Google Scholar]
  • 27.Sheehan DV, Lecrubier Y, Sheehan KH, et al. The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry. 1998;59(suppl 20):22–33. [PubMed] [Google Scholar]
  • 28.Gail MH, Benichou J. Encyclopedia of Epidemiologic Methods. Chichester, UK: Wiley; 2000. [Google Scholar]
  • 29.Nock MK, Green JG, Hwang I, et al. Prevalence, correlates, and treatment of lifetime suicidal behavior among adolescents: results from the National Comorbidity Survey Replication Adolescent Supplement. JAMA Psychiatry. 2013;70(3):300–310. doi: 10.1001/2013.jamapsychiatry.55. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 30.McLaughlin KA, Koenen KC, Hill ED, et al. Trauma exposure and posttraumatic stress disorder in a national sample of adolescents. J Am Acad Child Adolesc Psychiatry. 2013;52(8):815–830. e14. doi: 10.1016/j.jaac.2013.05.011. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31.Arnett JJ. Emerging adulthood: a theory of development from the late teens through the twenties. Am Psychol. 2000;55(5):469–480. [PubMed] [Google Scholar]
  • 32.Kessler RC, Avenevoli S, Ries Merikangas K. Mood disorders in children and adolescents. Biol Psychiatry. 2001;49(12):1002–1014. doi: 10.1016/s0006-3223(01)01129-5. [DOI] [PubMed] [Google Scholar]
  • 33.Costello EJ, Pine DS, Hammen C, et al. Development and natural history of mood disorders. Biol Psychiatry. 2002;52(6):529–542. doi: 10.1016/s0006-3223(02)01372-0. [DOI] [PubMed] [Google Scholar]
  • 34.Arnett JJ. The developmental context of substance use in emerging adulthood. J Drug Issues. 2005;35(2):235–254. [Google Scholar]
  • 35.Sevelius JM. Gender affirmation: a framework for conceptualizing risk behavior among transgender women of color. Sex Roles. 2013;68(11–12):675–689. doi: 10.1007/s11199-012-0216-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 36.Vance SR, Jr, Ehrensaft D, Rosenthal SM. Psychological and medical care of gender nonconforming youth. Pediatrics. 2014;134(6):1184–1192. doi: 10.1542/peds.2014-0772. [DOI] [PubMed] [Google Scholar]
  • 37.Coleman E, Bockting W, Botzer M, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Int J Transgenderism. 2012;13(4):165–232. [Google Scholar]
  • 38.Reisner SL, Bradford J, Hopwood R, et al. Comprehensive transgender healthcare: the gender affirming clinical and public health model of Fenway Health. J Urban Health. 2015;92(3):584–592. doi: 10.1007/s11524-015-9947-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 39.Hoertel N, McMahon K, Olfson M, et al. A dimensional liability model of age differences in mental disorder prevalence. J Psychiatr Res. 2015;64:107–113. doi: 10.1016/j.jpsychires.2015.03.017. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 40.Tegethoff M, Belardi A, Stalujanis E, Meinlschmidt G. Association between mental disorders and physical diseases in adolescents from a nationally representative cohort. Psychosom Med. 2015;77(3):319–332. doi: 10.1097/PSY.0000000000000151. [DOI] [PubMed] [Google Scholar]
  • 41.Gates GJ. Demographics and LGBT health. J Health Soc Behav. 2013;54(1):72–74. doi: 10.1177/0022146512474429. [DOI] [PubMed] [Google Scholar]
  • 42.Guss C, Shumer D, Katz-Wise SL. Transgender and gender nonconforming adolescent care: psychosocial and medical considerations. Curr Opin Pediatr. 2015;27(4):421–426. doi: 10.1097/MOP.0000000000000240. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 43.de Vries AL, McGuire JK, Steensma TD, et al. Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics. 2014;134(4):696–704. doi: 10.1542/peds.2013-2958. [DOI] [PubMed] [Google Scholar]
  • 44.Steever J. Cross-gender hormone therapy in adolescents. Pediatr Ann. 2014;43(6):e138–e144. doi: 10.3928/00904481-20140522-09. [DOI] [PubMed] [Google Scholar]
  • 45.Simons LK, Leibowitz SF, Hidalgo MA. Understanding gender variance in children and adolescents. Pediatr Ann. 2014;43(6):e126–e131. doi: 10.3928/00904481-20140522-07. [DOI] [PubMed] [Google Scholar]
  • 46.Conron KJ, Landers SJ, Reisner SL, Sell RL. Sex and gender in the US health surveillance system. Am J Public Health. 2014;104(6):970–976. doi: 10.2105/AJPH.2013.301831. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 47.Cochran BN, Peavy KM, Robohm JS. Do specialized services exist for LGBT individuals seeking treatment for substance misuse? Subst Use Misuse. 2007;42(1):161–176. doi: 10.1080/10826080601094207. [DOI] [PubMed] [Google Scholar]
  • 48.Rosenthal SM. Approach to the patient: transgender youth: endocrine considerations. J Clin Endocrinol Metab. 2014;99(12):4379–4389. doi: 10.1210/jc.2014-1919. [DOI] [PubMed] [Google Scholar]
  • 49.Costello EJ, Mustillo S, Erkanli A, et al. Prevalence and development of psychiatric disorders in childhood and adolescence. Arch Gen Psychiatry. 2003;60(8):837–844. doi: 10.1001/archpsyc.60.8.837. [DOI] [PubMed] [Google Scholar]
  • 50.Kessler RC, Chiu WT, Demler O, et al. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):617–627. doi: 10.1001/archpsyc.62.6.617. [DOI] [PMC free article] [PubMed] [Google Scholar]

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