Abstract
Purpose
To examine the relation between chosen name use, as a proxy for youths’ gender affirmation in various contexts, and mental health among transgender youth.
Methods
Data come from a community cohort sample of 129 transgender and gender nonconforming youth from three U.S. cities. We assessed chosen name use across multiple contexts and examined its association with depression and suicidal ideation and suicidal behavior.
Results
After adjusting for personal characteristics and social support, chosen name use in more contexts was associated with lower depression, suicidal ideation, and suicidal behavior Depression, suicidal ideation, and suicidal behavior were lowest when chosen names could be used in all four contexts.
Conclusion
For transgender youth who choose a name different than the one given at birth, use of their chosen name in multiple contexts affirms their gender identity and reduces mental health risks known to be high in this group.
Keywords: transgender, youth, depression, suicidality
Transgender people (people whose gender identity does not align with their sex assigned at birth) are at higher risk for poor mental health compared to non-transgender people.1–2 A recent study on transgender youth from three U.S. cities documented extremely high levels of suicidal ideation and behavior,3 and another new study was the first to document elevated risk for transgender youth for suicdal ideation based on a statewide, representative sample.4
Because first names are often gender-specific, chosen name use is part of the social transition process to align one’s gender presentation with one’s gender identity. This gender social transition process, including changing first names, pronouns, hair, and clothing, is associated with better mental health among transgender youth.5 However, many transgender and gender nonconforming youth are unable to use their chosen name for interpersonal or institutional reasons. For example, families or peers may resist or reject youths’ chosen name, and medical institutions or schools may require a legal name change before youth can use a chosen name.6
Transgender youth whose gender expression and names do not appear to match may be vulnerable to unintended disclosure or “outing”, and to discrimination or victimization, factors which could lead to mental health problems.1 The purpose of the current study was to examine the relation between chosen name use, as a proxy for youths’ gender affirmation in various contexts, and mental health among transgender youth.
Methods
Data come from a community cohort sample of lesbian, gay, bisexual, transgender, and queer (LGBTQ) youth, and youth with same-sex attractions, recruited in three U.S. cities (one each in the Northeast, the Southwest, and the West Coast) between November 2011 and October 2012. The sample included 129 transgender and gender nonconforming youth (ages 15–21), 74 of whom reported a chosen name different from their name given at birth (participant characteristics provided in Table 1).
Table 1.
Associations Between Chosen Name Use and Depressive Symptoms, Suicidal Ideation, and Suicidal Behavior among Transgender Youth (n=74), Controlling for Covariates
| M (SD) or Count (%) | Coefficient (95% CI) | Incident Rate Ratio (95% CI) | ||
|---|---|---|---|---|
| Depressive Symptoms | Suicidal Ideation | Suicidal Behavior | ||
| Gender identity | ||||
| MTF | 28 (38) | 0 (Reference) | 1 (Reference) | 1 (Reference) |
| FTM | 28 (38) | −1.61 (−6.67, 3.46) | 1.28 (0.67, 2.47) | 0.25 (0.07, 0.91) |
| MTDG | 5 (7) | 3.97 (−2.18, 10.11) | 1.45 (0.54, 3.89) | 0.37 (0.09, 1.49) |
| FTDG | 13 (17) | −1.43 (−9.44, 6.57) | 1.39 (0.64, 3.02) | 1.58 (0.49, 5.11) |
| Race/ethnicity | ||||
| White | 18 (24) | 0 (Reference) | 1 (Reference) | 1 (Reference) |
| Asian | 6 (8) | −8.45 (−17.39, 0.49) | 0.00 (0.00, 0.00) | 0.00 (0.00, 0.00) |
| Black | 24 (33) | −1.40 (−9.13, 6.33) | 0.89 (0.48, 1.64) | 0.53 (0.16, 1.76) |
| Multiracial | 21 (28) | 1.53 (−5.50, 8.55) | 0.83 (0.49, 1.40) | 1.10 (0.46, 2.61) |
| Not reported | 5 (7) | −3.54 (−13.35, 6.27) | 0.85 (0.35, 2.06) | 2.17 (0.47, 10.08) |
| Sexual identity | ||||
| Lesbian/gay | 17 (23) | 0 (Reference) | 1 (Reference) | 1 (Reference) |
| Bisexual | 22 (30) | 4.01 (−4.67, 12.68) | 1.92 (0.82, 4.50) | 0.99 (0.23, 4.20) |
| Questioning | 9 (12) | 4.14 (−4.06, 12.35) | 1.75 (0.71, 4.29) | 0.70 (0.17, 2.86) |
| Heterosexual | 17 (23) | −0.87 (−9.02, 7.29) | 0.50 (0.12, 2.03) | 0.40 (0.06, 2.84) |
| Different | 9 (12) | 7.90 (−0.67, 16.47) | 1.47 (0.53, 4.06) | 1.03 (0.31, 3.43) |
| Age | 19.46 (1.76) | −0.56 (−1.95, 0.84) | 1.03 (0.85, 1.24) | 1.20 (0.91, 1.58) |
| Access to free luncha | ||||
| no | 39 (53) | 0 (Reference) | 1 (Reference) | 1 (Reference) |
| yes | 32 (43) | −1.53 (−8.74, 5.68) | 0.79 (0.34, 1.85) | 0.46 (0.16, 1.36) |
| Study site | ||||
| Northeast | 36 (49) | 0 (Reference) | 1 (Reference) | 1 (Reference) |
| Southwest | 10 (13) | 0.28 (−6.98, 7.54) | 0.80 (0.29, 2.21) | 0.23 (0.04, 1.30) |
| West Coast | 28 (38) | 3.04 (−3.38, 9.47) | 1.14 (0.51, 2.53) | 0.82 (0.19, 3.48) |
| Total social support | 41.64 (11.60) | −0.46 (−0.65, −0.26) | 0.99 (0.97, 1.01) | 0.95 (0.91, 0.99) |
| Chosen name use | 3.14 (1.27) | −5.37 (−8.20, −2.55) | 0.71 (0.52, 0.95) | 0.44 (0.25, 0.78) |
Abbreviations: MTF, male-to-female (transgender woman); FTM, female-to-male (transgender man); MTDG, male to different gender; FTDG, female to different gender.
Depressive symptoms
We used the 20-item Beck Depression Inventory for Youth scale to measure depressive symptoms (α = .94).7 Sample items included “I hate myself” and “I think my life will be bad.” Higher scores represent higher levels of depressive symptoms.
Suicidal ideation and behavior
We measured suicidal ideation (α = .83) and behavior (α = .96) using the Self-Harm Behavior Questionnaire,8 a measure of multiple dimensions of suicide (ideation, threat, attempt) and self-harm. Free response items following dichotomous yes/no occurence items assessed severity of ideation (method, whether other events precipitated ideation, suicide plan, reactions of others, preparation) and behavior (method, frequency, risk, medical treatment necessity, whether other events precipitated behavior, intent to die) on an ordinal scale from 0-22.
Chosen name use
We asked transgender youth whether they had a preferred name different from the name they were given at birth, and, if yes, asked, “are you able to go by your preferred name” at home (n = 54), at school (n = 57), at work (n = 50), or with friends (n = 69).
Social support
We controlled for total social support with the Child and Adolescent Social Support Scale (CASSS).9 The CASSS consists of five scales of twelve items each that assess supportiveness from parents (α = .96), close friends (α = .97), classmates (α = .96), teachers (α = .97), and their school (α = .97). We computed total scores as the sum of the means on each scale (α = .96).
Analysis Plan
We predicted depressive symptoms with ordinary least squares regression and suicidal ideation and behavior with poisson regression with robust standard error estimation and multiple imputation for missing data in Mplus 7.4.10 The Institutional Review Boards at New York University and the University of Arizona approved the study.
Results
There were no differences on depressive symptoms or suicidal beavior by personal characteristics including gender identity, race/ethnicity, sexual identity, age, access to free lunch, or study site. After adjusting for personal characteristics and total social support, chosen name use in more contexts predicted fewer depressive symptoms and less suicidal ideation and suicidal behavior (see Table 1). An increase by one context in which a chosen name could be used predicted a 5.37-unit decrease in depressive symptoms, a 29% decrease in suicidal ideation, and a 56% decrease in suicidal behavior. We observed similar results when we individually tested specific contexts for chosen name use (except that chosen name use with friends did not significantly predict mental health after adjusting for demographics and close friend support). Depressive symptoms, suicidal ideation, and suicidal behavior were at the lowest levels when chosen names could be used in all four contexts.
Discussion
Transgender youth who were able to use their chosen name in multiple contexts reported fewer depressive symptoms and less suicidal ideation and behavior. For transgender youth who choose a name different than that given at birth, use of their chosen name in multiple contexts appears to affirm their gender identity and lower mental health risks known to be high in this group. Despite the small number of youth in this study, it is one of the largest samples of transgender youth to date. New population-based samples that include much larger numbers of transgender youth show high mental health risk for transgender youth,4 but those studies do not include measures specific to transgender youth and their health, such as ability to use a chosen name.
Results have important implications for a range of social policies. Legal name changes may be onerous or unfeasible for many transgender youth. Yet multiple institutions – schools, community organizations, workplaces, healthcare providers, financial institutions – could adjust regulations and information systems to include youths’ chosen name in records, rosters, and means of identification (i.e., ID cards). Policies that promote the social transition process of gender affirmation among transgender youth, such as chosen name use or access to restrooms consistent with gender identity or presentation, will likely enhance safety and reduce physical and mental health disparities for transgender populations. Results indicate that peers, parents, teachers, health care providers, and education and medical institutions can support transgender youth and their mental health by referring to them by their chosen names.
Acknowledgments
This research uses data from the Risk and Protective Factors for Suicide Among Sexual Minority Youth Study, designed by Arnold H. Grossman and Stephen T. Russell, and supported by Award R01MH091212 from the National Institute of Mental Health. Administrative support for this research was also provided by Grant R24HD042849, Population Research Center, awarded to the Population Research Center at The University of Texas at Austin by the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Mental Health. Russell acknowledges the Priscilla Pond Flawn Endowment at the University of Texas. The authors acknowledge the site coordinators, staff of the community organizations, and leaders of college groups who cooperated in recruiting participants. We also express our gratitude to study’s participants for sharing their experiences with us.
Footnotes
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Implications and Contribution
It is critical to public health and policy to understand chosen name use among transgender youth, and whether use of a chosen name influences mental health. This study found mental health benefits associated with chosen name use among transgender youth who choose a name different than the one given at birth.
Contributor Information
Stephen T. Russell, University of Texas at Austin
Amanda M. Pollitt, University of Texas at Austin
Gu Li, University of British Columbia
Arnold H. Grossman, New York University
References
- 1.Institute of Medicine. The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. Washington, DC: National Academies Press; 2011. [PubMed] [Google Scholar]
- 2.Veale JF, Watson RJ, Peter T, Saewyc EM. Mental health disparities among Canadian transgender youth. J Adol Health. 2017;60:44–49. doi: 10.1016/j.jadohealth.2016.09.014. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Grossman AH, Park JP, Russell ST. Transgender youth and suicidal behaviors: Applying the Interpersonal Psychological Theory of Suicide. J Gay Lesbian Ment Health. 2016 doi: 10.1080/19359705.2016.1207581. [DOI] [PMC free article] [PubMed]
- 4.Perez-Brumer A, Day JK, Russell ST, Hatzenbuehler ML. Prevalence and correlates of suicidal ideation among transgender youth in California: Findings from a representative, population-based sample of high school students. J Am Acad Child Adolesc Psychiatry. 2017;56(9):739–746. doi: 10.1016/j.jaac.2017.06.010. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Steensma TD, McGuire JK, Kreukels BP, Beekman AJ, Cohen-Kettenis PT. Factors associated with desistence and persistence of childhood gender dysphoria: a quantitative follow-up study. J Am Acad Child Adolesc Psychiatry. 2013 Jun 30;52(6):582–90. doi: 10.1016/j.jaac.2013.03.016. [DOI] [PubMed] [Google Scholar]
- 6.Thaler C, Bermudez F, Sommer S. Legal advocacy on behalf of transgender and gender nonconforming youth. Social work practice with transgender and gender variant youth. 2009 Feb;27:139–62. [Google Scholar]
- 7.Beck JS, Beck AT, Jolly JB. Beck Youth Inventories. San Antonio, TX: Psychological Corporation Harcourt Brace; 2001. [Google Scholar]
- 8.Gutierrez PM, Osman A. Adolescent Suicide: An Integrated Approach to the Assessment of Risk and Protective Factors. DeKalb, IL: Northern Illinois University Press; 2008. [Google Scholar]
- 9.Kerres Malecki C, Kilpatrick Demary M. Measuring perceived social support: Development of the Child and Adolescent Social Support Scale (CASSS) Psychol Schs. 2001;39(1):1–18. doi: 10.1002/pits.10004. [DOI] [Google Scholar]
- 10.Muthén LK, Muthén BO. Mplus User’s Guide. Los Angeles, CA: Muthen & Muthen; 1999–2016. [Google Scholar]