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The International Journal of Transgenderism logoLink to The International Journal of Transgenderism
. 2019 May 16;20(4):447–458. doi: 10.1080/15532739.2019.1614130

Self-harm prevalence and ideation in a community sample of cis, trans and other youth

Catherine Butler a,✉, Richard Joiner a, Richard Bradley b, Mark Bowles c, Aaron Bowes c, Claire Russell, Veronica Roberts a
PMCID: PMC6913646  PMID: 32999629

Abstract

Background: Trans youth have been reported to have high rates of self-harm, depression and bullying, and find it difficult to seek support. However, much of this research comes from gender identity clinics; non-clinical samples and those who reject gender binaries remain under-researched.

Aims: This study investigated the experiences of a community school-based sample of Trans, identifying youth, Other, and cis-gendered adolescents in relation to their experiences of low mood, bullying, associated support, self-harm ideation and peer-related self-harm.

Methods: An online survey was completed by 8440 13–17 year olds (3625 male, 4361 female, 227 Other, and 55 Trans).

Results: Trans and Other students had significantly higher rates of self-harm ideation and peer self-harm, in comparison to cis-gendered students. These Trans and Other students reported significantly higher rates of bullying and self-reported depression and significantly less support from teachers and staff at school, in fact these students did not know where to go to access help.

Discussion: This community sample confirms findings of high rates of self-harm ideation, self-reported depression and bullying for Trans youth as previously reported in clinic-based samples. However, by accessing a community sample, the salience of the category “Other” was established for young people today. While Other and Trans identified students both struggled to find support, those who identified as Trans were more likely to have been bullied, and have experienced self-reported depression and thoughts of self-harm. Thus, those who identify as transgender represent a high-risk group that needs targeted support within schools and by statutory and nonstatutory community services. Unpacking the category of Other would be beneficial for future research, as well as exploring resilience within this group and intersecting identities such as sexuality, Autism, or experiences such as earlier abuse.

Keywords: gender nonbinary, transgender, self-harm, bullying, school, support, depression

Introduction

Transgender is an umbrella term referring to a range of gender identities and expressions different to those assigned at birth. This can include those who conform to the notion of a gender binary and wish to transition from one gender to another, or those who reject this idea (e.g., genderqueer, nonbinary, etc.). Some transgender people can experience discomfort or distress relating to the discrepancy between their gender identity and that which they were assigned at birth (Marshall et al., 2016), this is referred to as gender dysphoria.

Self-harm refers to behaviors that are purposefully done to injure the self, this might be motivated by a desire to die, or it might be without suicidal intent but to serve a different function such as emotional regulation or self-punishment (Claes & Vandereycken, 2007). Both self-harm and suicidal ideation tend to have their first onset during adolescence (Nock, 2009; Skegg, 2005) and adolescents in general have higher rates of self-harm, with 3–10% reported to have self-harmed in the previous 12 months and 9–14% over their lifetime (Kokkevi, Rotsika, Arapaki, & Richardson, 2012; Madge et al., 2011; Moran et al., 2012). It has been suggested that self-harm amongst adolescents has increased in the last 10 years (Jacobson & Gould, 2007; Whitlock, Eells, Cummings, & Purington, 2009), with estimates as high as 13–45% over a lifetime found within one community sample (Nock, 2010). It has been established that knowing someone who self-injuries significantly increases the likelihood of self-injury (Claes, Houben, Vandereycken, Bijttebier, & Muehlenkamp, 2010; Deliberto & Nock, 2008; Muehlenkamp, Hoff, Licht, Azue, & Hasenzahl, 2008; Prinstein, Guerry, Browne, & Rancourt, 2009).

Of concern is that young people have been found to be reluctant to seek help for mental health problems (Gulliver, Griffiths, & Christensen, 2010), and young people that self-harm are less likely to seek help (Evans, Hawton, & Rodham, 2005; Michelore & Hindley, 2012). Belonging to a sexual and/or gender minority makes youth even less likely to seek help from mainstream health and school services (McDermott et al., 2013), preferring instead to seek out specialist LGBT support services (McDermott, Roen, & Scourfield, 2008).

For transgender youth who attend specialist gender identity clinics, rates of self-harm and suicide ideation are found to be higher than those reported for adolescents in the general population (28.8–41.0% for self-harm, 17.5–42.2% for suicide ideation, and 11.9–15.8% for suicide attempts; Aitken, VanderLaan, Wasserman, Stojanovski, & Zucker, 2016). This pattern of higher rates is also reflected in community settings. Clark et al. (2014) surveyed transgender youth in a school and found significantly higher rates of self-harm (46%) compared to cisgendered students (4.1%). This is echoed by Reisner et al. (2015), who surveyed youth attending a generic health center rather than a specialist gender identity clinic, where transgender youth reported higher rates than cisgendered youth of self-harm (30% vs. 8%), suicidal ideation (56% vs. 20%) and suicide attempts (31% vs. 11%).

Several authors also report differences in self-harm rates within transgender clinical populations, with transgender men/boys having higher rates of self-harm than transgender women (in line with rates for natally assigned gender) (Claes et al., 2015; Davey, Arcelus, Meyer, & Bouman, 2016; Holt, Skagerberg, & Dunsford, 2016; Rimes, Goodship, Ussher, Baker, & West, 2017; Veale, Watson, Peter, and Saewyc, 2017). Age also has an impact, with higher rates of self-harm in transgender adolescents compared to transgender children below 12 or adults (Holt et al., 2016), consistent with age differences in self-harm in the general population (Moran, Coffey & Romaniuk, 2012). Cutting is the most common form of self-harm (Claes & Vandereycken, 2007; Skagerberg, Parkinson, & Carmichael, 2013), again reflecting patterns found in the general population (e.g., Truth Hurts, 2006), except that transgender young people report thoughts of cutting their genitals whereas arms and legs are most common in the general population (Skagerberg et al., 2013).

A variety of reasons have been proposed for the elevated rates of self-harm and suicidality in transgender adolescents. Social discrimination and bullying has a negative impact on all youth, but being attacked in the form of verbal, physical, and sexual abuse is more frequently reported in transgender youth than cisgendered youth (Grossman, D’Augelli, & Frank, 2011). McGuire, Anderson, Toomey, and Russell, (2010) found that 80% of their school sample of transgender youth report verbal abuse, which resulted in fear and distress and transgender-based discrimination was found to be a predictor of suicide attempts (Clements-Nolle, Marx, & Katz, 2006). Transgender adolescents often report feelings of loneliness, hopelessness (Sadowski & Gaffney, 1998), with associated emotional problems including depression, which is notably higher than for cisgendered peers (Connolly, Zervos, Barone, Johnson, & Joseph, 2016). In the general population depression is strongly correlated to self-harming behavior (Skegg, 2005).

According to the theory of minority stress (Meyer, 2003), external experiences of rejection and discrimination can result in internalized stress so that the person begins to expect such experiences. The theory highlights that social support (particularly with peers who are similar to allow for positive self-comparison), acceptance and integration can ameliorate minority stress, but transgender youth have been found to lack social support (Davey et al., 2014; Di Ceglie, Freedman, McPherson, & Richardson, 2002; Zucker, Lawrence & Kreukels, 2016). Poor peer-relations have been found to be the strongest predictor of behavioral and emotional problems for adolescents attending gender identity clinics (Cohen-Kettenis, Owen, Kaijser, Bradley, & Zucker, 2003; de Vries, Steensma, Cohen-Kettenis, VanderLaan, & Zucker, 2016).

In addition to the psychological challenges that can be associated with gender non-conformity during adolescence, there are also physical challenges as secondary-sex characteristics start to develop. For those attending clinics, this may be associated with distress linked to gender dysphoria, which might take the form of “shame, self-hatred, and body-distress” (McDermott, Roen, & Piela, 2015, p. 883), which can in itself trigger self-harm (Malpas, 2011; Skagerberg, Parkinson, & Carmichael, 2013; Spack et al., 2012).

No studies have compared self-harm between transgender youth who access these clinics and those that do not. That the majority of research is clinic-based excludes those who do not wish for the support of specialist clinics, those who do not have the support around them to attend, or those who cannot afford to access these services in countries where health care is not covered (Connolly et al., 2016). These findings therefore cannot be generalized to transgender people who have never attended a specialist clinic (Marshall et al., 2016). Previous research is also limited as it often does not include those who do not identify male, female or transgender, e.g. those who reject the gender binary and prefer other identity categories such as a gender or gender non-binary. There are increasing numbers of people who construct their identity this way (Kuper, Nussbaum, & Mustanski, 2012). A few recent studies report nonbinary youth have high levels of stress and hopelessness, and higher rates of self-harm, than those who identify as transgender females (Veale, Watson, Peter, & Saewyc, 2017), and higher rates of substance misuse than those with binary transgender identity (Keuroghlian, Reisner, White, & Weiss, 2015). In addition, the experiences of LGBT youth are frequently grouped together (e.g., Liu & Mustanski, 2012), however, in so doing, some unique issues for those who are transgender might be missed. Bockting, Huang, Ding, Robinson, and Rosser (2005) found higher rates of depression and lower rates of family and peer support for transgender youth than for their LGB counterparts.

It is hard to draw conclusions from some of the literature in this area because a distinction is generally not made between nonsuicidal self-harm and suicide attempts (e.g., Aitken et al., 2016). Marshall et al. (2016) call for more research accessing nonclinic participants to capture the variations in of the transgender population. This study therefore focused on a nonclinical sample of self-identified trans and cis-gendered adolescents, with the aim of investigating their experiences of low mood, bullying, associated support, peer-related self-harm and self-harm ideation.

Method

Online methods are becoming an established method of investigating youth self-harm. These have been flagged as particularly beneficial in accessing marginalized youth, including LGBT youth (Hillier & Rosenthal, 2001), and those that may belong to a geographically dispersed minority population (Rosser, Oakes, Bockting, Babes, & Miner, 2007). This method is thought to be useful in generating data directly from participants, without the filter of the participant/researcher interaction, responses are instead considered “initiated, motivated, and therefore determined by the young person themselves” (McDermott, Roen, & Piela, 2015, p. 876).

Participants

8440 students (Cornwall: 914; Kent: 6039; Lancashire: 1487) completed the screening survey. The young people were in UK academic year groups 9–13 (US equivalent second-year junior high to high school senior) and aged between 13 and 17 years. There were 3625 who identified as male; 4361 who identified as female, 55 who identified as Trans and 227 who identified as Other (i.e., who did not identify as Trans, Male, or Female).

Procedure

UK Secondary schools (US equivalent Junior High and High School) in the three areas where contacted by email inviting them to participate in the research. Once schools had opted-in to participate, an introductory assembly was delivered by a member of the research team about risk and self-harm and explaining the research project. Students from key year groups were invited to participate on a voluntary basis that day using school computers. Informed consent was obtained from all individual participants included in the study.

Survey

A bespoke online screening survey was developed by The Training Effect1 to aid the identification of adolescents at risk of engaging in self-harm. The students were asked the following four questions on self-harm.

  1. How common is self-harm amongst young people your age?

  2. Do any of your close friends self-harm?

  3. Have any of your close friends self-harmed in the past but don't now?

  4. Do you ever think about hurting yourself?

They were also asked if they had been bullied in the last two months, how many days they felt depressed in the last month; whether they knew what help was available to them for support and whether they felt teachers and other staff provide the support they need within school and whether they would feel comfortable seeking help with any problems or concerns they were facing. These questions were developed through reviewing current literature and through drawing on the extensive clinical experience of The Training Effect.

Data analysis

All analyses were conducted using computer statistical software SPSS Version 22 (SPSS Statistics, 2018). Chi-Squared analysis was conducted when the data was categorical and Kruskal-Wallis or Mann–Whitney was used where the data were ordinal. When multiple comparisons were made between the four groups (i.e., a total of six comparisons), we used Bonferroni corrections with a corrected p-value of 0.00833 (0.05/6). Effect sizes were measured using Cramer’s V.

Results

The perceived rate of self-harm differed between the four gender groups (χ2[9] = 720.2, p < .0005, Cramer’s V = 0.17). 21.8% of Trans youth and 11% of those who identified as Other answered that most young people self-harm, compared to only 2% of males and under 4% of females (Table 1). Post hoc analysis revealed that there was no difference between Trans and Other, but there were significant differences between all the other groups.

Table 1.

Self-harm amongst young people you know.

  Male1
 Female2
 Other3
 Trans3
  N % N % N % N %
How common is self-harm amongst young people your age? (χ2 [9] = 720.2, p < .0005, Cramer’s V = 0.17)
 Most Don’t 1207 33.3% 627 14.4% 45 19.8% 14 25.5%
 A few 1732 47.8% 1970 45.2% 94 41.4% 18 32.7%
 Many Do 611 16.9% 1606 36.8% 63 27.8% 11 20.0%
 Most Do 75 2.1% 158 3.6% 25 11.0% 12 21.8%
Do any of your close friends self-harm? (χ2 [6] = 413.7, p < .0005, Cramer’s V = 0.16)
 No 2695 74.3% 2366 54.3% 94 41.4% 20 36.4%
 Yes 408 11.3% 908 20.8% 62 27.3% 23 41.8%
 Prefer not to say 522 14.4% 1087 24.9% 71 31.3% 12 21.8%
Have any of your close friends self-harmed in the past but don't now? (χ2 [6] = 642.7, p < 0.0005, Cramer’s V = 0.20)
 No 2316 63.9% 1576 36.1% 87 38.3% 22 40.0%
 Yes 855 23.6% 1913 43.9% 74 32.6% 24 43.6%
 Prefer not to say 454 12.5% 872 20.0% 66 29.1% 9 16.4%
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Note: Column headings with post scripts that are different are significantly different (p < 0.0083 with Bonferroni correction).

There was also a significant difference between the four groups in terms of whether any of their close friends self-harm (χ2 [6] = 413.7, p < .0005, Cramer’s V = 0.16). Table 2 shows that 11% of males, 21% of females, 27% of Other, and 42% of Trans reported that a close friend self-harms. There was no significant difference between Trans and Other, but there were significant differences between all the other groups (see Table 1). There was a similar significant difference for students’ response to the question “Have any of your close friends self-harmed in the past but don't now? (χ2 [6] = 642.7, p < .0005, Cramer’s V = 0.20). Table 1 shows that under 13% of males, “20% of females, 33% of Other and 44% of Trans reported that a close friend self-harmed in the past but they do not any more. Post hoc analysis revealed that there was no significant difference between Trans and Other or between Trans and Female, but there were significant differences between all the other group comparisons.

Table 2.

Self-harm, bullying and depression.

Do you ever think about hurting yourself? (χ2 [12] = 805.73, p < .0005, Cramer’s V = 0.20)
  Male1
 Female2
 Other3
 Trans4
1 N % N % N % N %
None of the time 2800 77.2% 2524 57.9% 116 51.1% 17 30.9%
Rarely 511 14.1% 881 20.2% 30 13.2% 7 12.7%
Some of the time 213 5.9% 592 13.6% 28 12.4% 4 7.3%
Often 75 2.1% 264 6.1% 30 13.3% 8 14.5%
All of the time 26 0.7% 100 2.3% 23 10.1% 19 34.5%
Have you been bullied in school in the past 2 months?( χ2 [6] = 81.26, p < .0005, Cramer’s V = 0.18)
 
 Male1
 Female1
 Other2
 Trans3
No 2915 80.4% 3464 79.4% 146 64.3% 27 49.1%
Yes 378 10.4% 482 11.1% 43 18.9% 22 40.0%
Don’t Know 332 9.2% 415 9.5% 38 16.7% 6 16.4%
No 2915 80.4% 3464 79.4% 146 64.3% 27 49.1%
Over the past month on how many days have you felt down, depressed or hopeless? (χ2 [6] = 202.5, p < .0005, Cramer’s V = 0.09)
 
 Male1
 Female2
 Other3
 Trans4
No Days 1914 52.8% 1032 23.7% 75 33% 12 21.8%
1-5 Days 1077 29.7% 1627 37.3% 51 22.5% 9 16.4%
6-11 Days 301 8.3% 700 16.1% 27 11.9% 4 7.3%
12-17 Days 153 4.2% 513 11.8% 22 9.7% 1 1.8%
18-24 Days 83 2.3% 292 6.7% 15 6.6% 5 9.1%
25 plus Days 97 2.7% 197 4.5% 37 16.3% 24 43.6%
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Note: Column headings with post scripts that are different are significantly different (p < 0.0083 with Bonferroni correction).

Table 2 shows a significant difference between the four groups in terms of their responses to the question concerning whether students ever think about self-harm (χ2 [12] = 805.73, p < .0005, Cramer’s V = 0.20). 10% of Other and 34.5% of Trans reported that they think about self-harm all of the time, compared with 0.7% of males and 2.3% of females. Post hoc analysis revealed that there were significant differences between all pairwise comparisons of the groups.

Consistent with previous research, there was a significant difference between the four groups concerning whether any of the respondents had been bullied in the last 2 months (χ2 [6] = 81.26, p < .0005, Cramer’s V = 0.18). 10% of males and 11% of females had been bullied in the last two months compared with 17% of Other and 40% of Trans students. Post hoc analysis revealed that there was no significant difference between the males and females but there were significant differences between all the other comparisons (see Table 2). Similarly, self-reported depression was significantly higher, with 16.3% of Other and 43.6% of Trans youth reporting they felt depressed for 25 days in the past month, compared to 2.7% of male students and 4.5% of female students. There is a significant difference between the four groups in the number of days they feel depressed (χ2 [15] = 1126.18, p < .0005, Cramer’s V = 0.21). Post hoc analysis revealed that there were significant differences between all pairwise comparisons of the groups (see Table 2). There is also a significant positive relationship between how many days they feel depressed and whether they think about hurting themselves (rs= 0.57).

Furthermore, Table 3 shows there was a significant difference between the four groups to the question “Do you feel teachers and other staff provide the support you need within school?” (χ2 [6] = 247.5, p < .0005, Cramer’s V = 0.10). 40.1% of Other and 47.3% of Trans students disagreed with this statement, compared to 18% of males and 24% of females. Related to these findings, the students are asked if they needed support with any problems or concerns they were facing would they be happy to seek help? (Table 3). Post hoc analysis revealed that there was no significant difference between the Trans and the other groups, but there was between all other groups.

Table 3.

Support.

  Male1
 Female2
 Other3
 Trans3
  N % N % N % N %
Do you feel teachers and other staff provide the support you need within school? (χ2 [6] = 247.5, p < .0005, Cramer’s V = 0.10)
 Strongly Disagree 164 4.5% 231 5.3% 36 15.9% 16 29.1%
 Disagree 482 13.3% 810 18.6% 55 24.2% 10 18.2%
 Neither agree nor disagree 1118 30.8% 1526 35.0% 77 33.9% 12 21.8%
 Agree 1575 43.4% 1600 36.7% 50 22.0% 15 27.3%
 Strongly Agree 286 7.9% 194 4.4% 9 4.0% 2 3.6%
If you needed support with any problems or concerns you were facing would you be happy to seek help? (χ2 [6] = 202.5, p < .0005, Cramer’s V = 0.09)
 Definitely 473 13.0% 398 9.1% 18 7.9% 6 10.9%
 Probably 1252 34.5% 1185 27.2% 39 17.2% 12 21.8%
 Possibly 1397 38.5% 2000 45.9% 89 39.2% 14 25.5%
 Don’t think there is help 278 7.7% 469 10.8% 48 21.1% 13 23.6%
 Don’t know what help there is 225 6.2% 309 7.1% 33 14.5% 10 18.2%
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Note: Column headings with post scripts that are different are significantly different (p < 0.0083 with Bonferroni correction).

Table 3 shows the four groups significantly differed concerning knowing where to go to access help or knowing what help there is (χ2 [6] = 202.5, p < .0005, Cramer’s V = 0.09). Other and Trans youth were significantly more likely to say they do not know where to go to access help or that they do not know what help there is. Post hoc analysis revealed that there was no significant difference between the Trans and the other groups, but there was between all other groups.

Discussion

This study is important for two reasons—it uses a community sample that confirms many of the findings previously reported with transgender youth who attend clinics; but also, significantly more participants in our sample identified as “Other” (n = 227) rather than “Trans” (n = 55). We will discuss these points in term, relating the findings for both those who identify as “Other” and those as “Trans” to previous research.

These findings clearly confirm previous research that self-harm ideation and perceived peer self-harm is significantly higher in transgender youth populations. Nock (2010) found high rates of self-harm for adolescents in his community sample (13–45%), but did not collect demographics on the gender identity of those who participated so it is impossible to tell if some groups within this sample had higher rates than others. Like Nock, we do not know the gender identity of the close friends who were self-harming. Grard et al.’s (2018) research of 11,000 adolescents indicates that for both girls and boys the majority of their friendships are same-sex, although girls are more likely to have same-sex friendship (86.8%) than boys (78.8%). We therefore suggest that our data are in line with other research that reports higher rates of self-harm in females (e.g., McManus, Beddington, Jenkins, & Brugha, 2016), with 14.2% of females compared to 6.4% of males having a close friend who self-harmed. Our sample found 21.3% of all adolescents who responded had a close friend their own age who self-harmed—without participants who identified as Trans or Other, this rate remains high at 20.6%.

Rates of self-harm for adolescents attending a gender identity clinic (28.8–41.0%; Aitken et al., 2016) were similar to those within the community sample in this study, with 34.5% of those who identified as transgender reporting that they thought about harming themselves all the time. Similarly, of those who did not identify as Male, Female, or Trans, but as “Other,” 35.7% also reported frequently thinking about harming themselves (some of the time 12.4%; often 13.3%; all of the time 10.1%). These results echo those of Clark et al. (2014), where 46% of transgender school students in their sample reported self-harming, compared to only 4.1% of cis-gendered students.

Skegg (2005) found a strong correlation between self-harm and depression, and our research confirms previous clinic-based research (e.g., Connolly et al., 2006) that there are higher rates of depression for transgender youth than for cisgendered peers, with 43.6% of Trans youth and 16.3% of Other youth self-reporting depression for more than 25 days previously, compared to 2.7% of males and 4.5% of females. Similarly, Grossman et al. (2011) report higher rates of verbal, physical, and sexual abuse for transgender youth when compared to cisgendered youth, and our study echoed this with 40.0% of Trans youth and 16.7% of Other youth reporting bullying, compared to 10.4% of males and 11.1% of females. These poor peer-relationships might be a strong factor in the high rates of self-harm reported in this study, similar to previous findings (Cohen-Kettenis, Owen, Kaijser, Bradley, & Zucker, 2003; de Vries, Steensma, Cohen-Kettenis, VanderLaan, & Zucker, 2016).

When it comes to seeking support for these issues, previous research (e.g. Zucker, Lawrence & Kreukels, 2016) found that transgender youth lacked social support. Our research confirms this, with 40.1% of Other and 47.3% of Trans students reporting that school staff do not currently provide the support they need (compared to 18% of males and 24% of females), but of concern is that these students also did not know where to go to access support (18.2% Trans and 14.5% Other, compared to 6.2% males and 7.1% females), with 23.6% of Trans students and 21.1% of Other students not believing that any help actually exists (compared to 7.7% of males and 10.8% of females). McDermott et al. (2013) report sexual and gender minority youth prefer to access support from specialist organizations, but Connolly et al. (2016) highlighted the financial costs of travel associated of accessing specialist clinics. It is of note that in all the areas where our data was collected, transgender youth and their families would have had to travel if accessing specialist gender clinics was important to them.

What is particularly interesting in our sample, is the high number of participants who did not identify as “Trans” (n = 55), with 227 identifying as “Other.”By identifying as “Other” rather than “Trans,” these students may not fit the population profile of youth that access gender identity clinics, upon which the majority of transgender-related research is based. Accessing a community sample thus allowed us to discover how much more significant the category of Other is to young people today. Students who identified as Other rather than Trans still had significantly higher rates of bullying, self-reported depression and perceived self-harm in peers compared to their cis-gendered peers, but these rates were lower than for students who identified as Trans. However, both groups equally struggled to find support for these issues.

Limitations and future research

While this research has highlighted important information from a community sample, there are a number of areas where further investigation is needed to provide greater understanding. Given how many more students identified as Other than as Trans, it would have been useful to have a free-text box to enter their gender identity in order to understand the make-up of this category. Given the self-report nature of online data collection, it could be argued that there are validity concerns, i.e., does everyone who said they were Trans or Other actually identify as Trans or Other in all aspects of everyday life, or does it serve more as an internally held identity? In addition, transgender youth could have chosen the Trans, Male, or Female option depending on their preferred identity label. It would have been better to ask for gender assigned at birth and current gender identity. It would also have been interesting to break the Trans category down into Trans male and Trans female in order to compare any differences between these groups.

Whether students actually self-harmed was not asked, neither were the types of self-harm. This was deliberate because in asking the question as to whether they were self-harming, the research team would have felt ethically obligated to have followed up with participant’s wider support networks, which might have impacted on the candor with which participants answered questions. As it is established that knowing someone who self-harms is a risk factor (Claes, Houben, Vandereycken, Bijttebier, & Muehlenkamp, 2010; Deliberto & Nock, 2008; Muehlenkamp, Hoff, Licht, Azue, & Hasenzahl, 2009; Prinstein et al., 2009), if participants scored above a threshold on the questionnaire, they were offered access to a program called “Mind and Body” run by The Training Effect. This program is a targeted prevention and early intervention program for young people who engage in risk-taking behaviors that are associated with self-harm. In addition, in working closely with participating schools, the research results were shared to promote the need for established local support for these young people. For future research, if direct self-harm is asked about, Skagerberg, Parkinson, and Carmichael (2013) suggest that standardized measures of self-harm should be used to explore different types.

The triggers to self-harm were also not asked about, and so we are unable to explore if findings from clinic-based populations could be generalized to ours. The psychological and physical triggers resulting from discrimination, prejudice and gender dysphoria in clinical populations are discussed in the introduction. However, in these populations, many young people have intersecting difficulties that could in themselves result in higher rates of self-harm. Many would meet the criteria for an Autism Spectrum Condition (ASC) (Glidden, Bouman, Jones, & Arcelus, 2016), with rates as high as 48% recently reported for those whose parents completed the Social Responsiveness Scale (Clarke & Spiliadis, 2019). Young people with an ASC have been found to have higher than average rates of self-harm (Minshawi, Hurwitz, Fodstad, Biebl, Morriss, & McDougle, 2014). In addition, a high proportion of young people who attend clinics with signs of gender dysphoria later identify as lesbian, gay, or bisexual (LGB) in adulthood and no longer seek any medical interventions (Ristori & Steensma, 2016). Again, self-harm is more common in youth who identify as LGB (Batejan, Jarvi, & Swenson, 2015). Finally, higher rates of physical and sexual abuse have also been reported in transgender populations (e.g., Kussin-Shoptaw, Fletcher, & Reback, 2017), and self-harm is more frequent in those who have experienced prior abuse (Yates, 2004). These intersecting identities have yet to be explored in nonclinical transgender populations. Finally, while this study asked about self-reported depression, other forms of distress reported by previous studies were not asked about (e.g., anxiety—Bockting, Miner, Swinburne Romine, Hamilton, and Coleman et al. (2013); substance abuse—Olson et al., 2015; etc.), and use of an established measure of mood would be of benefit.

Implications

This study confirms high levels of bullying, self-reported depression and self-harm ideation for transgender youth, with a lack of social support to help them cope. Within the current sample of transgender youth, there were significantly higher numbers of those who identified as Other than as Trans. It is therefore essential that all professionals working with young people (whether based in clinical settings or community settings such as school) remain open and curious about a wide range of gender identities and presentations. Students that identified either as Trans or Other had difficulty accessing social support and we recommend professionals to make active approaches to offering this, and ensure that the support they can offer is what is needed. Given the high rates of self-harm reported in transgender populations, all professionals should be alert to this and clinicians should thoroughly assess for self-harming behavior, especially as children enter puberty, and any relevant child protection measures should be put in place. Transgender youth may need help building support networks and developing alternative coping strategies.

In addition to individual work, work on an institutional and societal level that combats discrimination and prejudice is called for. This requires a co-ordinated multi-agency approach (e.g., with schools, general practitioners, Child and Adolescent Mental Health Services and specialist gender identity services). In addition, national policies are needed that identify transgender youth as at high risk of self-harm and strategies should be developed to promote acceptance in wider society and a positive mental health for transgender youth.

Conclusions

This is an important study in accessing the views of students in a community sample. The high proportion of students who identify as Other rather than Male, Female, or Trans is significant, as well as the high rates of bullying, self-reported depression and self-harm ideation in Other and Trans youth. Of concern is that these young people feel that help is not available and do not know where to access it. There is therefore work to be done for future researchers to further understand the complexities of transgender youths’ lives and for those who work with them in community and clinical settings in providing accessible help that meets their needs.

Note

1

Training Effect provide a range of services to the public, private and third sector, including training, facilitation, research, consultancy, and business development. They have specific expertise in the areas of substance misuse, risk-taking behaviours, families with complex needs, mental and emotional health, poverty, CSE and child and youth services.

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