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Published in final edited form as: Youth Soc. 2019 Jun 16;2019:10.1177/0044118X19855898. doi: 10.1177/0044118X19855898

Predictors and Mental Health Benefits of Chosen Name Use among Transgender Youth

Amanda M Pollitt 1, Salvatore Ioverno 2, Stephen T Russell 2, Gu Li 3, Arnold H Grossman 4
PMCID: PMC7678041  NIHMSID: NIHMS1044373  PMID: 33223575

Abstract

Chosen name use among transgender youth (youth whose gender identities are different than their sex assigned at birth) can be part of the complex process of aligning gender presentation with gender identity and can promote mental health. However, little is known about the factors that predict whether or not transgender youth have a chosen name and outcomes of chosen name use, especially in specific social contexts. We examined, among a sample of 129 transgender youth from three cities in the United States, differences in sociodemographic characteristics and mental health outcomes between transgender youth with and without a chosen name and, among those with a chosen name, predictors and mental health benefits of being able to use a chosen name at home, school, and work. There were few differences between transgender youth with and without a chosen name. Among transgender youth with a chosen name, disclosure of gender identity to supportive family and teachers predicted chosen name use at home and school, respectively. Chosen name use was associated with large reductions in negative health outcomes and relatively smaller improvements in positive mental health outcomes. Our results show that chosen name use is part of the gender affirmation process for some, but not all, transgender youth and is associated with better mental health among transgender youth who adopt a chosen name.

Keywords: Transgender, Mental Health, Protective Factors, Social Environment, Youth, Chosen Name

One of the main developmental challenges for transgender people, people who are gender nonconforming, or who experience gender dysphoria, is reconciling their gender identity with the cultural and social expectations associated with sex assigned at birth (Grossman & D’Augelli, 2006; Grossman, D’Augelli, & Frank, 2011). For transgender youth, or youth whose gender identity is different from their sex assigned at birth, this process can often include navigating how they wish to present their physical appearance (clothing, hair, etc.) and whether to use a name different from their birth name (Reisner et al., 2016). Like many aspects of social appearance, names are often gendered as male or female, so choosing a new name can reinforce and/or communicate a specific gender identity. Thus, chosen name use is often one of the basic steps for transgender youth to express and construct their gender identity at the individual and social levels and it is part of a complex process of aligning gender identity, expression, and presentation (Sevelius, 2013). Generally, scholars, activists, and community members agree that the most sensitive and supportive way to interact with transgender youth is to respect their gender identity by using their affirming names and pronouns (Coolhart & MacKnight, 2015; Grossman & D’Augelli, 2006; Hill et al., 2017; Sausa, 2005).

Affirmation of one’s gender identity by others has implications for positive mental health outcomes and prevents transgender youth from being misgendered, i.e., a misclassification or incorrect assumption of their gender identity (McLemore, 2015). Misgendering occurs when others refer to transgender youth with incorrect gender pronouns or their birth names, or when transgender youth are denied access to gendered spaces that align with their gender identity, such as bathrooms or locker rooms. Misgendering is often routine and reoccurring for many transgender people (Nordmarken, 2014); experienced across different social contexts (such as with family, friends, in workplaces; James et al., 2016); and when seeking medical assistance (Law, Martinez, Ruggs, Hebl, & Akers, 2011; von Vogelsang, Milton, Ericsson, & Strömberg, 2016); and it may be particularly harmful to youths’ wellbeing (Grossman & D’Augelli, 2007; McLemore, 2015). These findings suggest that experiencing gender affirmation can be challenging for transgender people and they often face humiliation, discrimination, and violence from others (Galupo, Krum, Hagen, Gonzalez, & Bauerband, 2014; James et al., 2016; Kuper, Adams, & Mustanki, 2018; Maguen, Shipherd, Harris, & Welch, 2007). Further, transgender youth often face misgendering in settings at which youth are already particularly vulnerable, such as when receiving medical care (Gridley et al., 2016), in foster care (Mountz, Capous-Desyllas, & Pourciau, 2018), court settings (e.g., when parents of transgender youth are fighting for custody; Kuvalanka, Bellis, Goldberg, & McGuire, 2019), and programs supporting homeless youth (Robinson, 2018; Shelton, 2015). Overall, the discrepancy between the need for gender affirming environments and low access to them because of social marginalization may result in anxiety and depression (Reisner et al., 2016; Sausa, Keatley, & Operario, 2007; Testa et al., 2017).

Although it might be expected that name changes among transgender youth are a necessary aspect of gender identity construction, expression, and affirmation, this might not be true for all transgender youth. For example, transgender youth who are genderqueer or gender nonconforming (i.e., do not identify with a binary gender identity such as man or woman) may not choose a different name if their birth name is gender neutral or reflects some or all of their gender identity. A recent report found that only 39% of nonbinary adults changed their name on their driver’s license, compared to 61% of binary-identified transgender women and men (James et al., 2016); of transgender adults who did not change their legal names, 28% reported that it was because their name did not conflict with their gender identity or construction. Further, younger youth in the early stages of developing their gender expression or youth in less supportive social contexts may not choose a different name until later in adulthood. Thus, it is unclear whether there are demographic, social, or personal differences between transgender youth who do or do not choose to use a name different from their birth name and whether these youth also differ on mental health outcomes.

Though research shows that transgender people with chosen names express the need to be called by their chosen names (Coolhart & MacKnight, 2015; Grossman & D’Augelli, 2006; Sausa, 2005) and a number of investigators have speculated about the role of gender affirmation on transgender people’s wellbeing (Kuvalanka et al., 2019; Nordmarken, 2014; Nuttbrock et al., 2009; Sevelius, 2013), few studies have specifically investigated the mental health benefits of chosen name use for transgender youth in different social contexts. Instead, much of the research has focused on harmful reactions from non-transgender people: transgender people whose legal identification does not match their gender presentation face verbal and physical violence and denial of services (Hill et al., 2017; James et al., 2016). However, one previous study found that youth who could use their chosen name in a greater number of contexts reported fewer depressive symptoms and lower risk for suicidal ideation and attempts (Russell, Pollitt, Li, & Grossman, 2018). Thus, although legal name change is often not available to these youth due to age or other constraints, the capacity for transgender youth with a chosen name different from their birth name to use this name has important implications for mental health.

We focus on three key contexts in which transgender youth negotiate their identities: family, at school, and in the workplace. Research shows that transgender people are not always able to express or disclose their gender identity in these social contexts: Findings from a study on a national U.S. sample of transgender and gender nonconforming people showed that only 53% of participants reported that all of their immediate family members knew that they were transgender or gender nonconforming; only 12% of participants reported that they were out as transgender between kindergarten and grade 12; and only 46% could disclose in college, technical school or graduate school; and 51-58% of the sample were not out to bosses or coworkers (James et al., 2016). These three social contexts are important to consider when it comes to understanding gender affirmation processes, such as having the capacity to use a chosen name, because these are areas in which transgender youth can access important social, financial, and educational resources for wellbeing.

Family rejection is a common experience among transgender people (Grant et al., 2011; Grossman & D’Augelli, 2006; James et al., 2016). Often, parents fail to acknowledge their children’s gender identity by using their birth pronouns and names, by limiting their gender expression, by questioning their gender identity, and by threatening and harassing them (Grossman, D’Augelli, & Salter, 2006), which are associated with depressive symptoms and suicidal behaviors (Grossman & D’Augelli, 2007; Moody & Smith, 2013). However, though most research on family interactions among transgender people has focused on family rejection, several other studies focused on positive family experiences and found important benefits associated with family support in terms of gender identity development and mental health (James et al., 2016; Olson, Durwood, DeMeules, & McLaughlin, 2016). For example, among transgender people who are out to their immediate family, the majority report that their family uses their chosen name and some report that their family members help them change their name or gender on their identification (James et al., 2016). Overall, transgender people who reported more supportive family members were less likely to report homelessness, suicidality, and other negative health outcomes (James et al., 2016). Thus, we expect that transgender youth with chosen names whose parents who are supportive, accepting, and affirming of their gender identity might be more likely to use their chosen name at home, and this use will be associated with better mental health.

Another social context that is essential for transgender youth’s wellbeing is school. The majority of transgender youth consider their schools as challenging places in which to affirm their identity (Sausa, 2005), and these youth report harassment, discrimination, and misgendering, including being prevented from dressing according to their gender identity or using their chosen name or pronouns at school (James et al., 2016; McGuire et al., 2010). Despite alarming rates of fears of safety at school among transgender youth, few schools have guidelines regarding support or accommodation for transgender and gender nonconforming students (Greytak, Kosciw, & Diaz, 2009), and few studies have examined the impact of supportive policies on transgender students (Greytak, Kosciw, & Boesen, 2013; McGuire, Anderson, Toomey, & Russell, 2010). The available evidence shows that inclusive policies and supportive school personnel have an important role in reducing institutional gender-related discrimination and improving transgender students’ perceived school climate (Greytak et al., 2013; McGuire et al., 2010). However, whether these resources are associated with transgender youths’ capacity to use their chosen names at school, and whether this name use is associated with wellbeing is, to our knowledge, unknown.

For transgender youth who are eligible to work, jobs can provide necessary or supplemental income and health insurance, particularly if youth cannot attain such resources through their families. Although there are no known studies of workplace experiences for transgender youth, some evidence is available on the experiences of transgender adults in the workplace. National data showed that 23% of transgender people reported experiencing harassment or mistreatment on the job, 12% lost their job because of their gender identity, and 77% reported hiding or delaying their gender transition to avoid being mistreated (James et al., 2016). Other studies find that transgender people reported being outed by others, deliberate nonuse of their chosen names, and being limited in their gender expression in the workplace (Budge, Tebbe, & Howard, 2010; Dispenza, Watson, Chung, & Brack, 2012; Schilt & Connell, 2007). This lack of safe and inclusive climates in workplaces likely results in few transgender employees with the opportunity to be acknowledged with proper pronouns and chosen names. However, other studies showed that, contrary to what often happens in other social contexts like family and school, transgender people sometimes use gender identity management strategies (such as covering or concealment) in the workplace in response to experiences of discrimination and gender oppression (Brewster, Velez, DeBlaere, & Moradi, 2012; Law et al., 2011). Thus, though previous research suggests that it is unlikely that transgender youth with a chosen name are able to use their name at work, the mental health implications of this use are less clear.

In the current study, we present findings on individual characteristics associated with chosen name use in a sample of transgender youth and mental health outcomes of chosen name use. Specifically, we examined the characteristics associated with whether transgender youth have chosen a name different than their birth name, and among transgender youth with a chosen name, predictors of the use of a chosen name in family, school, and workplace contexts. Moreover, we investigated whether the capacity for transgender youth to use their chosen name in these specific contexts is associated with better mental health outcomes.

Method

Participants

Data come from the first of four panels in a longitudinal panel study of the risk and protective factors of suicide among 1061 lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth and participants with same-sex attraction in three urban cities in the Northeast, Southwest, and West Coast of the United States. Data were collected in 2012. This research was approved by the Institutional Review Board at [UNIVERSITY 1] and the [UNIVERSITY 2]. The majority of the youth were recruited from community-based agencies or college groups for LGBTQ youth, and other participants were referred by earlier participants. Only participants who self-identified as transgender or genderqueer were included in the current study. We report personal characteristics and descriptive statistics of study variables of those with and without a chosen name in Table 1. Of the included transgender participants (N = 129, ages 15-21 at time of recruitment, M = 18.7, SD = 1.7), more than half (N = 74; 57%) had a chosen name different from their name given at birth.

Table 1.

Descriptive Statistics of Study Variables

Variable (Range) With chosen name (n =74) Without chosen name (N = 55) Total sample
Mean(SD)/N(%) Mean(SD)/N(%) Mean(SD)/N(%)
Depressive symptoms (0–53) 19.50 (13.14) 19.35 (12.73) 19.44 (12.92)
Negative suicidal ideation (1-5) 1.65 (0.91) 1.77 (0.93) 1.70 (0.91)
Positive suicidal ideation (1-5) 3.46 (1.06) 3.09* (0.99) 3.30 (1.04)
Self-esteem (1-4) 2.98 (0.64) 2.90 (0.50) 2.95 (0.58)
Age (15-21) 19.05 (1.66) 18.22* (1.75) 18.70 (1.74)
Site location
 Northeast U.S. 36 (48.6) 22 (40.0) 58 (45.0)
 Southwest U.S. 10 (13.5) 10 (18.2) 20 (15.5)
 West Coast U.S. 28 (37.8) 23 (41.8) 51 (39.5)
Race
 Asian/Pacific Islander 6 (8.2) 7 (12.8) 13 (10.1)
 Black 24 (32.4) 8 (14.5) 32 (24.8)
 White 18 (24.3) 17 (30.9) 35 (27.1)
 Multiracial 21 (28.4) 13 (23.6) 34 (26.4)
 No Race Reported 5 (6.8) 10 (18.2) 15 (11.6)
Sexual identity
 Gay/lesbian 17 (23.0) 24 (43.6) 41 (31.8)
 Bisexual 22 (29.7) 15 (27.3) 37 (28.7)
 Questioning 9 (12.2) 5 (9.1) 14 (10.9)
 Heterosexual 17 (23.0) 7 (12.7) 24 (18.6)
 Different sexual identity 9 (12.2) 4 (7.3) 13 (10.1)
Gender
 Trans woman 28 (37.8) 16 (29.1) 44 (34.1)
 Trans man 28 (37.8) 12 (21.8) 40 (31.0)
 Different gender–assigned sex male 5 (6.8) 9* (16.4) 14 (10.9)
 Different gender–assigned sex female 13 (17.6) 18 (32.7) 31 (24.0)
Binary gender expression (0-4) 2.53 (1.43) 1.78* (1.31) 2.21 (1.42)
Out to family (1-4) 2.82 (1.27) 2.62 (1.29) 2.74 (1.28)
Family acceptance of gender (1-4) 2.05 (1.24) 2.25 (1.27) 2.13 (1.25)
Parental support (1-6) 2.82 (1.23) 3.59* (1.42) 3.14 (1.39)
School support (1-6) 2.81 (1.38) 3.16 (1.29) 2.95 (1.35)
Out to teachers (yes/no) 52 (70.27) 31 (56.36) 83 (64.34)
Out to classmates (yes/no) 49 (66.22) 36 (65.45) 85 (65.89)
School is unsafe for LGBTQ (1-4) 2.19 (0.11) 2.13 (0.79) 2.17 (0.85)
School absences unsafe LGBTQ (1-5) 1.50 (0.94) 1.35 (0.68) 1.43 (0.84)
Harassed at school for gender (1-5) 1.91 (1.31) 1.51 (0.92) 1.74 (1.17)
School anti-bullying policy (yes/no) 33 (47.14) 20 (38.46) 53 (43.44)
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Note.

*

p < .05.

Measures

Gender identity and expression.

Participants were asked, “What is your birth sex?” (male, female, intersex) and “What is your gender identity?” (man, woman, transgender man, transgender woman, queer, or write-in). Participants who (1) did not identify as man or woman, or (2) did not report a matched pair of gender identity and sex assigned at birth (e.g., a youth with a male birth sex and identity as a woman) were included. These youth were subsequently categorized into four separate transgender categories: male birth sex to female gender identity (MTF), female birth sex to male gender identity (FTM), male birth sex to a different gender identity (i.e., a gender identity not on the male/female binary; MTDG), and female birth sex to a different gender identity (FTDG). We also included a measure of gender expression to examine whether nonbinary gender expression would influence chosen name use. Participants were asked, “On the following scale, how would you describe yourself at this time in your life?” on a 1-9 scale from extremely feminine (1) to extremely masculine (9), with equally feminine/masculine in the middle of the scale at 5. To create a scale of nonbinary to binary gender expression, we centered the scale at equally feminine/masculine with higher scores indicating greater binary gender expression, whether feminine or masculine.

Depressive symptoms.

We measured frequency of experiencing depressive symptoms in the past two weeks with the Beck Depression Inventory for Youth (α = .95; Beck, 1996), a 20-item measure that asked questions such as, “I think that my life is bad” and “I wish I were dead.” Items were self-rated on a scale ranging from 0 (never) to 3 (always) and summed, with higher scores indicating higher depressive symptomology.

Suicidal ideation.

The Positive and Negative Suicide Ideation (PANSI) Inventory measures both positive protective (6 items; α = .83) and negative risk factors (8 items; α = .94) for suicidal behavior (Osman, Gutierrez, Kopper, Barrios, & Chiros, 1998). Example items from the positive suicide ideation subscale included, “Felt that life was worth living” and “Felt confident about your plans for the future;” items from the negative suicide ideation subscale included, “Thought about killing yourself because you could not find a solution to a personal problem” and “Felt hopeless about the future and you wondered if you should kill yourself.” These measures were on a scale from 1 (none of the time) to 5 (most of the time). The two-factor model of positive and negative suicide ideation has been validated in diverse samples (Muehlenkamp, Gutierrez, Osman, & Barrios, 2005); thus, we include both subscales as separate outcomes. Higher scores indicated higher positive or higher negative suicide ideation.

Self-esteem.

To measure self-esteem, we calculated participants’ means on the Rosenberg Self-Esteem Scale (Rosenberg, 1989), a 10 item (α = .88) measure of self-esteem with statements such as, “On the whole, I am satisfied with myself,” and “I wish I could have more respect for myself” (reverse coded) on a scale from 1 (strongly disagree) to 4 (strongly agree).

Social support.

We measured social support using the Child and Adolescent Social Support Scale (Malecki, Demaray, Elliott, & Nolten, 1999). This measure consists of five subscales that assess perceived social support from parents, a close friend, classmates, teachers, and people at their school. Each subscale contains 12 items, which were rated on a scale ranging from 1 (never) to 6 (always). Sample items included, “My parents show they are proud of me” (parental support) and “People in my school spend time with me when I need help” (school support). For the current study, we calculated mean scores of parental support (α = .96) and school support (α = .97), to correspond to the contexts we assessed for chosen name use (see below).

Chosen name use.

We asked transgender participants to respond yes or no to the question, “Is your preferred name different from the name you were given at birth?” If yes, we then asked if they could go by their chosen name at home (73.0%), in school (79.7%), at work (68.9%), and with friends (93.2%). The high percentage of youth who could use their chosen name with friends resulted in little variability for predicting chosen name use in this context; thus, we did not include it in our models.

Predictors of chosen name use.

We included a number of theoretical broad and context-specific predictors of chosen name use. These predictors included race/ethnicity (Latino/non-Latino; Asian/Pacific Islander, Black or African American, White or European American, Multiracial, and no race reported); sexual identity (gay/lesbian, bisexual, questioning, heterosexual, different sexual identity) and gender identity (MTF, FTM, MTDG, FTDG); community-based organization attendance (0 = no; 1 = yes); housing status; family acceptance of gender identity (1 = 0 to 25% to 4 = 75 to 100%); site location (northeast, southwest, and west coast); age (15-21); whether youth were out to family members (1 = 0 to 25% to 4 = 75 to 100%), teachers (0 = no; 1 = yes), and classmates (0 = no; 1 = yes); number of school absences due to feeling unsafe at school (1 = none to 5 = more than 30 days); number of times harassed at school because of sex or gender (1 = never to 5 = more than once/day); whether their school had an anti-bullying policy (0 = no; 1 = yes); and whether they felt their school is unsafe for LGBTQ students (0 = no; 1 = yes).

Analysis Plan

We conducted path models in Mplus 8 (Muthén & Muthén, 2012) to examine three analyses: (1) differences between transgender youth with and without a chosen name; (2) context-specific predictors of chosen name use in each respective context; and (3) the association between chosen name use in specific contexts and mental health outcomes, controlling for predictors of chosen name use. We first examined bivariate differences in study variables between transgender youth with and without a chosen name. Then, to understand what predicts the capacity for transgender youth with a chosen name to use their name in particular contexts, we examined how variables specific to each context (e.g., feeling unsafe at school) predicted chosen name use within that context (e.g., school) and systematically trimmed nonsignificant variables to create a parsimonious model given the relatively small size of the sample (Little, 2013, p. 195). We dropped variables with the largest p-values one-by-one until the only predictors left were significant at p < .20 (Little, 2013). Because the study did not include work-related variables that could be used to predict chosen name use at work, we only included age, site location, and binary gender expression as predictors of chosen name use at work. Finally, we examined how chosen name use at home, school, and work predicted mental health outcomes controlling for significant predictors of chosen name use identified in the previous models in separate models and in a single model. We used full information maximum likelihood with robust standard errors and multiple imputations with 10 datasets to handle missingness on study variables.

Results

We present personal characteristics and descriptive statistics of study variables in Table 1. Univariate comparisons between transgender youth with and without a chosen name on personal characteristics and study variables showed that transgender youth with a chosen name were about ten months older than youth without a chosen name, t(127) = 2.76, p = .007, reported higher binary gender expression, t(126) = −3.03, p = .002, reported less perceived parental support, t(125) = −3.19, p = .002, more positive suicide ideation than youth without a chosen name, t(127) = 2.03, p = .05, and were more likely to be male assigned at birth, χ2 (2, n = 129) = 5.98, p = .05. Youth with or without a chosen name did not differ on race, site location, sexual identity, total social support, teacher support, close friend support, school support, family acceptance, self-esteem, negative suicidal ideation, or depressive symptoms.

We then examined predictors of chosen name use in specific contexts (home, school, and work). Trimmed models (Table 2–4: Model 2) showed that greater parental support and outness to family was associated with higher odds of chosen name use at home. Youth who were out to teachers had higher odds of using their chosen name in school than youth who were not out to teachers. In addition, youth who felt that their school was or is unsafe for LGBTQ youth reported lower odds of chosen name use in school. Finally, youth in the West Coast site, compared to the Northeast site, reported lower odds of chosen name use for each context, including at work.

Table 2.

Predictors of Chosen Name Use at Home

DV: Chosen name use at home
Model 1 Model 2
AOR 95% CI p AOR 95% CI p
Age 1.29 [0.84, 1.99] .24 - - -
Southwest sitea 0.05 [0.003, 1.09] .06 0.12 [0.02, 0.67] .01
West coast sitea 0.72 [0.12, 4.40] .72 0.64 [0.12, 3.43] .60
Binary gender expression 0.81 [0.51, 1.29] .39 - - -
Parental support 2.80 [1.37, 5.71] .01 2.61 [1.33, 5.10] .002
Out to family 3.31 [1.53, 7.15] .002 3.92 [2.00, 7.68] <.001
Family acceptance of gender 2.31 [0.43, 12.29] .33 - - -
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Note. Model 1 includes all relevant predictors of chosen name use in each context; e.g., parental support predicting chosen name use at home. In Model 2, nonsignificant predictors (p > .20) from Model 1 were trimmed to reduce small sample size issues. Statistically significant predictors (p < .05) are shown in bold. DV = dependent variable; AOR = adjusted odds ratio; CI = confidence interval.

a

Reference category: Northeast site.

Table 4.

Predictors of Chosen Name Use at Work

DV: Chosen name use at work
Model 1 Model 2
AOR 95% CI p AOR 95% CI p
Age 1.56 [1.12, 2.16] .002 1.57 [1.12, 2.21] .003
Southwest sitea 0.51 [0.09, 2.80] .43 0.44 [0.08, 2.27] .31
West Coast sitea 0.26 [0.08, 0.88] .02 0.23 [0.07, 0.79] .01
Binary gender expression 1.15 [0.79, 1.67] .46 - - -
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Note. Model 1 includes all relevant predictors of chosen name use in each context; e.g., parental support predicting chosen name use at home. In Model 2, nonsignificant predictors (p > .20) from Model 1 were trimmed to reduce small sample size issues. Statistically significant predictors (p < .05) are shown in bold. DV = dependent variable; AOR = adjusted odds ratio; CI = confidence interval.

a

Reference category: Northeast site.

Finally, we examined whether contexts of chosen name use predicted mental health controlling for predictors of chosen name use. We examined each context in separate models then included all contexts in a single model to determine both the independent and unique contribution of each context. Chosen name use at home predicted fewer depressive symptoms, b = −0.52, SE = 0.18, p = .004, less negative suicidal ideation, b = −0.90, SE = 0.28, p < .001, and greater self-esteem, b = 0.45, SE = 0.17, p = .01, but did not predict positive suicidal ideation. Chosen name use at school predicted fewer depressive symptoms, b = −0.47, SE = 0.18, p < .001, and greater self-esteem, b = 0.35, SE = 0.16, p = .03, but not negative or positive suicidal ideation. Chosen name use at work was also associated with fewer depressive symptoms, b = −0.61, SE = 16, p < .001, lower negative suicidal ideation, b = −0.94, SE = 0.26, p < .001, and greater self-esteem, b = 0.37, SE = 0.16, p = .02, but not positive suicidal ideation. Standardized betas for chosen name use in each context independently predicting mental health are shown in Figure 1. Finally, with all predictors in the model, including controls and chosen name at home, school, and work, chosen name use at work emerged as a unique predictor of depressive symptoms, b = −0.51, SE = 0.19, B = −.37, p = .01, and negative suicidal ideation, b = −0.74, SE = 0.33, B = −.38, p = .02, but not positive suicidal ideation or self-esteem. Chosen name use at home and at school did not predict any negative health outcomes in this model.

Figure 1.

Figure 1.

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Standardized betas of chosen name use at home, school, and work independently predicting depressive symptoms, negative suicidal ideation, positive suicidal ideation, and self-esteem. *p < .05; **p < .01; ***p < .001.

Discussion

We examined predictors of chosen name use and associations with wellbeing among transgender youth. We found few demographic, personal characteristic, or mental health differences between transgender youth with or without a chosen name. This finding suggests that choosing a name different from the one assigned at birth may be an important aspect of for some but not all transgender youths’ transition and validation of their gender identity (Mullen & Moane, 2013; Sevelius, 2013). There are many reasons why some transgender youth might not choose a different name unrelated to stigma or societal constraints (for example, their name may already be gender neutral, or they may have strong attachment to their birth name); these youths’ identities and expression should be equally supported (Galupo et al., 2014; Mckee, 2007). Indeed, our finding that transgender youth with a chosen name reported greater binary gender expression than youth without a chosen name is consistent with research that shows that nonbinary transgender adults are less likely to change their names on their identification because their name does not conflict with their gender presentation (James et al., 2016). At the same time, transgender youth without a chosen name were younger than youth with a chosen name; perhaps these youth have not yet chosen or disclosed a chosen name to others, potentially avoiding exposure to minority stressors that could influence wellbeing (Meyer, 2003). Nondisclosure might also explain why transgender youth without a chosen name reported higher parental support than youth with a chosen name: Transgender people report significant losses of relationships with parents and family after disclosure (Mullen & Moane, 2013; Sevelius, 2013). Future studies should further examine gender affirmation processes among transgender youth, particularly from a longitudinal perspective, to better understand how chosen name use fits in this process.

For transgender youth with a chosen name, disclosure to and support from others were associated with the capacity to use their chosen name in a greater number of contexts. Our measure of support focused on both emotional and agentic support from parents, which research shows is critical for transgender youth to develop healthy identities and promote mental wellbeing (McGuire et al., 2016; Rahilly, 2015). Additionally, we found that being out to parents and teachers was associated with chosen name use, which offers additional evidence that chosen name use could be part of the disclosure process for transgender youth (Galupo et al., 2014; Maguen et al., 2007). Other studies show that having supportive teachers is associated with less victimization and absenteeism, and greater feelings of school connectedness among transgender youth (Diaz, Kosciw, & Greytak, 2010; Greytak et al., 2013; Murdock & Bolch, 2005; Seelman, Walls, Hazel, & Wisneski, 2011). When parents and teachers know that youth have a chosen name, they can advocate for this and other aspects of their social transitions. However, in some cases, disclosure of transgender identity may not be voluntary. For example, transgender youth whose birth names and appearance do not match can easily be outed in classroom settings during roll call or other activities. In fact, disclosure to teachers was associated with chosen name use whereas disclosure to classmates was not, which suggests that some transgender students could be approaching teachers to ask that they use their chosen name in classroom contexts to avoid being outed to classmates.

It was unsurprising that we found that whether transgender youth felt their schools were safe for LGBTQ students predicted chosen name use in schools: Research shows that school environments are often unsupportive, intolerant, or even hostile to transgender youth, and most transgender students report discrimination on high school and college campuses (Greytak et al., 2009; Greytak, Kosciw, Villenas, & Giga, 2016; Sausa, 2005). Negative school climates likely decrease desire among and opportunities for transgender youth to approach school officials about using their chosen name. Despite evidence that transgender youth in schools with inclusive policies and supportive school personnel report better school climate (Greytak et al., 2013; McGuire et al., 2010), many school policies regarding victimization and discrimination often do not acknowledge transgender students (Greytak et al., 2013). Thus, our finding that anti-bullying policies did not predict chosen name use likely reflects how non-inclusive policies leave school staff without guidelines on how to support and respect transgender students and leave transgender students without important protections. These findings suggest that, regardless of whether or not schools have LGBTQ anti-bullying policies, it is critical that school teachers and staff engage in activities that create safe climates for transgender youth in order for them to feel safe using their chosen names.

Youth reported higher self-esteem, lower depressive symptoms, and less negative suicidal ideation when they were able to use their chosen name in more contexts. Our results suggest that support and validation of transgender youths’ chosen name buffer negative mental health outcomes. Our study extends previous research to show that chosen name is a behavior that is associated with better mental health because it affirms one’s gender identity through reducing the discrepancy between one’s identity and presentation. We found that chosen name use appeared to be a stronger buffer of negative mental health rather than a promoter of positive wellbeing. The process of coming out to oneself is stressful (Meyer, 2003) but is also associated over time with higher self-esteem and self-concept (Vaughan & Waehler, 2010). Youth who have developed their gender identity and chosen a specific name may have healthy self-esteem that is less impacted by rejection. However, a lack of affirmation through rejection of their chosen name, and thus the incapacity to be seen the way that they see themselves, may create a perceived identity threat that results in anxiety, depression, and other maladaptive coping strategies (Reisner et al., 2016; Sausa et al., 2007). Further research should explore processes associated with gender affirmation in order to understand its association with both positive and negative mental health outcomes.

We acknowledge limitations of the current study while also emphasizing its strengths as one of the first studies centered on chosen name use among transgender youth. Though a strength of our study is its large sample of transgender youth with items specific to transgender experiences, some analyses had small sample sizes in certain cells (e.g., gender identity) which may have left us underpowered to predict statistically significant differences in study variables between transgender youth with and without chosen names. As far as we are aware, there are no publicly available, population representative datasets available on transgender youth with data on transgender-specific experiences. We also acknowledge limitations to the chosen name use measure that hinders our interpretation of results. A yes/no response to the capacity to use one’s chosen name at home, school, and work does not capture potential nuance in the contexts in which youth use their names. For example, we are unable to examine whether youth are able to use their chosen name in their Gay-Straight Alliance at school but not in their classrooms, or with some family members but not others. Unfortunately, the study also did not contain additional items on chosen name use such as whether youth changed their name legally. This information would have been quite valuable, considering that youth would likely have more control over whether and how their names are used when they have been changed legally. Further, given prior research that shows that transgender people face harassment and discrimination when their identification does not match their gender presentation (Hill et al., 2017; James et al., 2016), legal name changes are probably associated with stronger benefits to mental health. Though not having this information is a limitation, we believe our findings are still quite relevant given that legal name changes are likely difficult for many transgender youth to obtain. Our work suggests that affirming transgender youths’ gender is critical to their mental health and should occur regardless of the extent, timing, or legality of their transition process. Finally, we did not assess whether transgender youth could use their chosen name in the context of medical or behavioral health access; the capacity for transgender youth to use their chosen name could be associated with better access to and care from clinicians and practitioners with subsequent improved mental and physical health outcomes. Future research should examine predictors and outcomes of chosen name use in these settings.

Conclusion

In the current study, we examined whether there were personal and mental health differences between transgender youth with and without a chosen name, which social and environmental factors influence chosen name use, and the mental health benefits of chosen name use. We found that though there were few differences between transgender youth with and without a chosen name, transgender youth with a chosen name were more likely to use that name when parents, teachers, and school environments were supportive. Then, this capacity to use one’s chosen name was associated with better mental health. Our study extends the literature to show that chosen name use is part of the gender affirmation process for transgender people; this affirmation process is associated with better health among these youth.

There are a number of issues relevant to clinical work with transgender youth. First, we find that not all transgender youth desire or need a name different than their birth name. This part of the gender affirmation process may not be necessary for reducing gender dysphoria for all youth. However, for those who have a chosen name that is different from their name given at birth, it is important to refer to them by their chosen name. Clinical practices, procedures, and data systems (which historically privilege legal names) should be reviewed to identify strategies for inclusion of chosen names. In clinical care and treatment with transgender children and adolescents, consider incorporating experiences related to stigma and social transition, including the in/capacity to use their chosen name. Ask transgender clients about their school environment and whether they find it supportive. Finally, health systems—as well as schools and workplaces—should allow chosen names and pronouns in records systems that guide care.

Table 3.

Predictors of Chosen Name Use at School

DV: Chosen name use at school
Model 1 Model 2
AOR 95% CI p AOR 95% CI p
Age 0.91 [0.58, 1.44] .69 - - -
Southwest sitea 0.06 [0.01, 0.63] .02 0.09 [0.01, 0.71] .01
West coast sitea 0.44 [0.08, 2.49] .35 0.50 [0.10, 2.48] .40
Binary gender expression 1.01 [0.56, 1.81] .98 - - -
School support 0.60 [0.36, 1.03] .06 0.60 [0.35, 1.01] .03
Out to teachers 8.09 [0.68, 95.66] .10 4.62 [1.02, 20.97] .02
Out to classmates 0.49 [0.05, 4.57] .53 - - -
School is unsafe for LGBTQ 0.30 [0.09, 1.00] .05 0.25 [0.09, 0.72] <.001
School absences unsafe due to feeling unsafe as LGBTQ 0.67 [0.38, 1.19] .17 0.66 [0.38, 1.13] .14
Harassed at school for gender 0.82 [0.41, 1.65] .58 - - -
Anti-bullying policy 1.06 [0.58, 1.95] .84 - - -
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Note. Model 1 includes all relevant predictors of chosen name use in each context; e.g., parental support predicting chosen name use at home. In Model 2, nonsignificant predictors (p > .20) from Model 1 were trimmed to reduce small sample size issues. Statistically significant predictors (p < .05) are shown in bold. DV = dependent variable; AOR = adjusted odds ratio; CI = confidence interval.

a

Reference category: Northeast site.

Acknowledgements.

Dr. Pollitt acknowledges support from the National Institute on Alcohol Abuse and Alcoholism (F32AA025814) and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (5T32HD007081). 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. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Mental Health or the National Institutes of Health. Administrative support for this research also was provided by grant P2CHD042849 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.

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