Abstract
Purpose: We examined whether health risks among sexual minority youth (SMY) differ by gender identity (transgender, nonbinary, and cisgender).
Methods: Data were collected on suicide attempts (lifetime and someday), depression and post-traumatic stress disorder (PTSD), and minority stress among SMY accessing crisis services.
Results: In the multivariate regression models, compared to their cisgender peers, transgender and nonbinary youth were at higher risk for suicide attempt (lifetime and someday), depression, and PTSD. Minority stress was a significant predictor for all the models.
Conclusion: Crisis service organizations working to reduce suicidality among SMY should be sensitive to diverse experiences of gender identity.
Keywords: transgender, nonbinary, sexual minority youth, behavioral health
Introduction
There is a significant burden of behavioral health disparities for sexual minority youth (SMY: lesbian, gay, and bisexual) compared to their heterosexual peers, including elevated rates of emotional distress, post-traumatic stress disorder (PTSD), and suicidality.1–5 Strikingly, studies have also found rates of suicide attempt as high as 37% among SMY.6,7 In addition, research suggests that among SMY, those who identify as gender diverse (e.g., transgender or nonbinary) may present worse health outcomes when compared to their cisgender SMY peers.8,9 For example, one of the studies found higher levels of mental distress among gender nonconforming gay and bisexual Latino men compared to their cisgender counterparts.10 This may be because of the additional stressors associated with their gender diverse identity (gender-related discrimination, gender-related rejection, gender-related victimization, nonaffirmation of gender identity, and internalized transphobia), beyond the experiences of sexual minority stress.11
To date, very few studies have looked at the diversity of gender identities (cisgender, transgender, and nonbinary) among samples of SMY.8,9 Moreover, studies that have examined gender diversity have generally grouped all gender diverse identities together when comparing against their cisgender counterparts.11,12 However, research suggests vast heterogeneity in gender identification, including labels such as transgender, gender nonconforming, nonbinary, and genderqueer.13,14 Particularly among young people, identifying with a gender outside of the binary is becoming more common. In 2015, the California Health Interview Survey began asking a gender identity question, and found that nearly 27% of adolescents in California (12–17 years of age) identified with nonbinary gender identities15; however data from state and national samples suggest that 0.9% of youth (13–17 and 18–24 years of age) identify as transgender in California.16
Recent studies have examined health risks among gender diverse samples and have reported on nonbinary and transgender youth. For example, one study found 61.4% of nonbinary youth reported self-injury compared to 58.3% of binary transgender youth; additionally, the nonbinary youth presented significantly higher levels of anxiety compared to their binary transgender counterpart.17 However, most samples of gender diverse youth in mental health research come from either schools or general populations, which highlight the need to examine the health disparities among at-risk SMY accessing crisis services.
To address this gap, this study examines suicidality (lifetime suicide attempt and likelihood of attempting someday) and mental health symptoms (depression and PTSD) by gender identity (cisgender, transgender, and nonbinary) in a sample of SMY accessing crisis services. Identifying how diverse gender identities among SMY are associated with mental health outcomes may have important implications for practice, intervention, and future research.
Methods
Participants and procedures
This study was approved by the University of Southern California's institutional review board. Participants were from a national sample of youth (12–24 years of age) recruited from The Trevor Project, a gender- and SMY-focused suicide crisis prevention service provider from September 2015 to April 2017. After crisis contact with the organization, eligible individuals were transferred to an automated survey to complete a brief demographic screener. Eligibility criteria included those (1) for whom a mandated child abuse report was not being made and (2) who were not currently at immediate suicide risk (defined as intent and plan in the next 48 h); and (3) who indicated they would consider participating in a study of the needs of SMY. Of those referred, 96% completed the screener (n=10,979), and 31% (n=3403) of those youth agreed to be contacted for the study.
Upon contact, research staff completed a rescreening to validate eligibility and reviewed an assent form with the participant, and requested verbal (for participants on the phone) or written (for chat, text, and e-mail participants) consent. The waiver for parental consent was obtained through the institutional review board and in accord with national policy recommendations from the Society for Adolescent Medicine, that requiring parental permission for the study would have a number of possible negative effects. In our study, we believe parental permission would have (1) put some SMY at risk regarding disclosure of their sexual orientation to their parents and (2) put some youth at risk for parental harassment, abuse, or expulsion from the parental home; and (3) may decrease the participation rate because some youth will fear that they may be “outed” to their family. All participants completed a brief suicide risk assessment before survey participation, and those with immediate suicide risk (defined as intent and plan in the next 48 h) were immediately connected to a suicide crisis counselor. However, participants referred to the crisis counselor also had the opportunity to return to the survey if they desired at the end of their crisis call. Of those referred to the demographic survey, 2008 participants were found eligible and contacted for study participation. Overall, 33% of referred youth completed the baseline survey (n=657). Sixty-five responses were dropped due to duplicate data (i.e., accessing the survey more than once) or no response on an outcome of interest. The total sample size for analysis was 592. The study also provided an evaluation of current services and recommendations on strengthening these programs and services to The Trevor Project.
Measures
Dependent variables
PTSD symptoms were measured using the Abbreviated PTSD Civilian Checklist, which contains six items about past-month responses to stressful life experiences (1=not at all to 5=extremely) with scores ranging from 5 to 30. The Center for Epidemiologic Studies Depression Scale Short Form (CES-D-4) measured the frequency of depression symptoms within the past week, scores ranging from of 0 to 12. An adapted Columbia-Suicide Severity Rating Scale (C-SSRS) item assessed presence of any lifetime suicide attempt (“Have you ever tried to kill yourself?”) and likelihood of attempting suicide someday (“How likely is it that you will attempt suicide someday?”).
Independent variables
Age, race, and ethnicity, gender identity, and sexual orientation were assessed with items created by the authors. Participants were asked to select all race categories that applied to them; categories included the following: white, Latino/Hispanic, black/African American, Native American/American Indian, Asian/Pacific Islander, and other race/ethnicity. For analytic purposes, race was collapsed into five categories: (1) white and (2) Latino/Hispanic, (3) black/African American, (4) Multiracial, and (5) others race/ethnicity. Gender Identity was assessed using the two-step method, “What sex were you assigned at birth?,” categories included male and female; and “What is your gender identity?,” and categories were male, female, transgender male, transgender female, genderqueer, questioning, don't know, and other. Responses on both questions were combined to assess gender identity. For analytic purpose, the categories were collapsed into three categories: (1) cisgender (cisman and ciswoman whose sex assigned at birth and gender identity were aligned), (2) transgender (male and female), and (3) nonbinary (genderqueer, questioning, don't know, and another gender identity). Sexual Orientation was assessed by asking “What is your sexual orientation?”; and categories were gay, lesbian, bisexual, queer, pansexual, straight, questioning, asexual, and other. Responses on sexual orientation were collapsed into four categories (1) gay/lesbian, (2) bisexual, (3) pansexual, and (4) others (asexual, queer, questioning, and other sexual orientations listed). Minority Stress was measured using a scale developed and validated by the authors, Sexual Minority Adolescent Survey Inventory (SMASI), a 10-factor measure composed of 54 items.18 The lifetime SMASI score measures individuals' endorsement of stressful experiences, scores ranging from 0 to 54.
Analysis
Bivariate analyses were conducted to detect differences in outcome variables by gender identity (i.e., cisgender, transgender, and nonbinary). Differences in means on mental health outcomes by gender were assessed using one-way ANOVA. Multivariate regressions were used to examine the association between gender identity and health outcomes (i.e., suicide, depression, and PTSD) after controlling for sexual orientation, age, race, and sexual minority stress. Data were analyzed using Stata 14.2.
Results
Sample description
The average age of the sample was 17.6 years (SD=3.1), with the majority of participants identifying as white (66.7%), followed by multiracial (10.3%), black/African American (9.3%), Latino/Hispanic (9.3%), and other race/ethnicity (7.0%). In terms of sexual orientation, 39.4% of the sample identified as gay/lesbian, followed by bisexual (17.2%), and pansexual (17.2%) and other identities (e.g., queer, questioning, and asexual; 26.2%). Most participants identified as cisgender (55.7%), followed by gender nonbinary identities (23.9%) and transgender (20.4%).
A large proportion of youth (33.2%) reported having ever attempted suicide, and 8.4% reported that they were likely to attempt suicide someday. Both suicidal outcomes significantly differed for all three gender categories: cisgender, transgender, and nonbinary (χ2=22.9, df=2, p<0.01; χ2=19.5, df=2, p<0.01, respectively). Youth also scored, on average, 6.8 (SD=3.5) on depressive symptom severity and 20.4 (SD=6.0) on PTSD symptom severity. Mean values for both types of symptom severity significantly differed for all three gender categories: cisgender, transgender, and nonbinary (F=8.97, p<0.01; F=15.62, p<0.01, respectively) (Table 1).
Table 1.
Characteristics of the Sample (N=592)
| Variable | Total sample, N (%) | Cisgender, n (%) | Transgender, n (%) | Nonbinary, n (%) | Chi-square (df) | One-way ANOVA |
|---|---|---|---|---|---|---|
| Age, years | ||||||
| 12–17 | 319 (53.9) | 173 (54.4) | 68 (21.4) | 77 (24.2) | ||
| 18–24 | 273 (46.1) | 155 (57.2) | 52 (19.2) | 64 (23.6) | 0.57 (2) | |
| Gender identity | ||||||
| Cisgender | 328 (55.7) | |||||
| Transgender | 120 (20.4) | |||||
| Nonbinary/Others | 141 (23.9) | |||||
| Sexual orientation | ||||||
| Gay/Lesbian | 233 (39.4) | 166 (71.6) | 36 (15.5) | 20 (12.9) | ||
| Bisexual | 102 (17.2) | 72 (71.3) | 16 (15.8) | 13 (12.9) | ||
| Pansexual | 102 (17.2) | 34 (33.7) | 31 (30.7) | 36 (35.6) | ||
| Others | 155 (26.2) | 56 (36.1) | 37 (23.9) | 62 (40.0) | 83.65 (6) | |
| Race | ||||||
| White | 395 (66.7) | 209 (53.2) | 85 (21.6) | 99 (25.2) | ||
| Latino/Hispanic | 55 (9.3) | 33 (60.0) | 10 (18.2) | 12 (21.8) | ||
| Black/African American | 40 (6.8) | 26 (65.0) | 6 (15.0) | 8 (20.0) | ||
| Multiracial | 61 (10.3) | 37 (60.7) | 9 (14.8) | 15 (25.6) | ||
| Other race/ethnicity | 41 (7.0) | 23 (57.5) | 10 (25.0) | 7 (17.5) | 4.23 (8) | |
| Suicidal attempts | ||||||
| Lifetime (yes) | 189 (33.2) | 79 (24.9) | 51 (44.4) | 59 (43.7) | 22.91 (2) | |
| Someday (yes) | 48 (8.4) | 12 (3.8) | 17 (14.7) | 19 (13.9) | 19.53 (2) | |
| Mental healtha | ||||||
| Depression | 6.8 (3.5) | 6.2 (3.6) | 7.5 (3.3) | 7.4 (3.2) | F=8.97 | |
| PTSD | 20.4 (6.0) | 19.2 (6.1) | 22.3 (5.6) | 21.6 (5.4) | F=15.62 | |
For depression and PTSD values of mean and standard deviation are provided; bold indicates significance at p<0.01; and for ANOVA results, F-statistics are provided.
POC, person of color; PTSD, post-traumatic stress disorder.
Regression models
Logistic regression indicated that transgender (OR=2.27) and nonbinary (OR=2.11) youth reported higher odds of lifetime suicide attempt compared to cisgender youth. In addition, transgender (OR=3.79) and nonbinary (OR=2.18) youth also reported greater likelihood of endorsing a future suicide attempt compared to cisgender youth. Both models controlled for age, race, and sexual orientation. Lifetime minority stress experience was a significant predictor in both models: lifetime suicide attempt (OR=1.05) and likelihood of endorsing a future suicide attempt (OR=1.05) (Table 2).
Table 2.
Suicidal and Mental Health Outcomes by Gender Identity
| Logistic regression |
Linear regression |
|||
|---|---|---|---|---|
| Suicide (lifetime attempt), odds ratio (CI) | Suicide (likely to attempt someday), odds ratio (CI) | Depression, β (CI) | PTSD, β (CI) | |
| Gender identity | ||||
| Transgender | 2.27 (1.41–3.67) | 3.79 (1.66–8.65) | 1.03 (0.29–1.77) | 2.53 (1.28–3.79) |
| Nonbinary | 2.11 (1.31–3.38) | 2.18 (1.37–7.40) | 0.92 (0.19–1.64) | 1.73 (0.50–2.97) |
| Sexual orientation | ||||
| Bisexual | 1.11 (0.64–1.92) | 1.11 (0.40–3.10) | −0.25 (−1.05 to 0.56) | −0.39 (−1.75 to 0.97) |
| Pansexual | 0.99 (0.57–1.74) | 1.16 (0.44–3.06) | 0.16 (−0.68 to 1.01) | 0.79 (−0.64 to 2.22) |
| Others | 1.01 (0.62–1.64) | 1.47 (0.66–3.30) | −0.030 (−1.03 to 0.43) | 0.02 (−1.22 to 1.26) |
| Minority stress | 1.05 (1.03–1.07) | 1.05 (1.02–1.09) | 0.08 (0.05–0.12) | 0.16 (0.10–0.21) |
| Age, years | ||||
| 18–24 | 1.03 (0.71–1.50) | 1.60 (0.85–3.04) | 0.42 (−10.15 to 0.98) | 0.93 (−0.03 to 1.89) |
| Race | ||||
| Latino/Hispanic | 1.56 (0.84–2.89) | 1.55 (0.55–4.36) | 0.66 (−0.29 to 1.61) | −0.04 (−1.66 to 1.58) |
| Black/African American | 0.79 (0.37–1.72) | 1.83 (0.61–5.45) | −1.28 (−2.41 to −0.16) | 0.21 (−1.73 to 2.15) |
| Multiracial | 1.46 (0.81–2.63) | 1.77 (0.70–4.45) | −0.27 (−1.18 to 065) | 0.28 (−1.28 to 1.84) |
| Other race/ethnicity | 0.66 (0.30–1.45) | 1.36 (0.42–4.37) | 0.23 (−0.89 to 1.35) | 1.11 (−0.77 to 2.99) |
| Final N in the model | 567 | 566 | 584 | 587 |
| Pseudo/Adj. R2 | 0.0649 | 0.1095 | 0.0709 | 0.0977 |
Reference category for gender identity was cisgender; for sexual orientation was gay/lesbian; for age, it was less than 18 years; and for race, it was white. Bold indicates significance level at p<0.05.
CI, confidence interval.
In the multiple linear regression models, transgender (β=1.03 CI=0.29–1.77) and nonbinary youth reported more depression symptom severity (β=0.92, CI=0.19–1.64) compared to their cisgender counterparts. In addition, compared to cisgender youth, transgender and nonbinary youth also reported more PTSD symptom severity (β=2.53 CI=1.28–3.79; β=1.73 CI=0.50–2.97, respectively). Both models controlled for age, race, and sexual orientation. Lifetime sexual minority stress was a significant predictor to mental health symptoms, PTSD symptom severity (β=0.08, CI=0.05–1.12) and depression (β=0.16, CI=0.10–0.21), in the sample (Table 2).
Discussion
Several important findings emerged from these analyses: (1) distinct health risk profile by gender identity, (2) relationship between minority stress and mental health, and (3) independent effects of gender identity and sexual orientation on mental health outcomes among this unique at-risk population. Our findings demonstrate that gender minority youth (both transgender and nonbinary) are at heightened risk of suicidality and mental health symptomology compared to cisgender SMY. These findings are consistent with the literature on gender diverse analyses among sexual minority samples, where transgender and nonbinary youth have reported higher rates of negative mental health outcomes compared to their cisgender sexual minority peers.8,9,19,20 In addition, our sample comes from at-risk SMY accessing crisis services, hence the participants in our study reported higher rates of mental health symptomology and suicidality compared to others not accessing services in general population. However, these findings are consistent with other samples of transgender and nonbinary youth in mental health research, which come from clinical populations, or youth otherwise engaged in mental health services.17
Unlike many studies where gender minority identities (transgender, nonbinary, and others) have been analyzed together,8,21,22 we identified distinct risk profile for transgender and nonbinary identities on mental health outcomes. In our sample, both transgender and nonbinary youth were at higher risk for suicide and mental health outcomes compared to cisgender peers, highlighting the importance of recognizing diverse experiences among gender minority groups. This finding is contrary to existing literature, where nonbinary and genderqueer youth reported worse negative mental health outcomes compared to transgender youth.9,17 For example, Lefevor and colleagues in their study sample of college students reported that genderqueer individuals experienced more depression, psychological distress, and suicidality than their _binary transgender and cisgender counterparts.9 We believe there is a need for more longitudinal studies to examine these health disparities with gender diverse samples of SMY to understand these associations overtime.
One possible factor underlying these heightened health risks among gender minority groups is the elevated levels of minority stress. Minority stress theory (MST) has been widely used to explain the health disparities found among both sexual minority and gender minority youth. MST argues that the presence of stigma, prejudice, and discrimination creates unique stress experiences for minority individuals, which are correlated with behavioral and mental health outcomes.23 In our sample, even after controlling for sexual minority stress, the rates of health risks remained high for transgender and nonbinary youth, possibly suggesting gender-specific minority stress (e.g., transphobia and gender-based discrimination), which may not have been captured in the Sexual Minority Adolescent Stress Inventory.10 Our results emphasize the need to further examine the gender minority stress mechanisms, which may drive the disparities on health outcomes for different gender identity groups.
These findings have critical implications for practice and intervention. Many programs and practices directed toward SMY do not address the needs of transgender and nonbinary youth. Crisis service organizations working to reduce suicidality among SMY may want to be sensitive to the additional gender minority stressors on top of sexual minority stressors. Furthermore, the gender identity literature on SMY needs further investigation to understand how diverse experiences of gender are related to overall development among adolescents and their risk behaviors, including mechanisms that drive this change.
Limitations
This study had several limitations. The sample featured SMY contacting crisis services, who may present higher rates of suicidality and mental health symptoms. Because the study was cross-sectional, the results only indicate associations and not causality. All data were self-reported; however, anonymity was ensured by not collecting any identifying information, which minimized response bias. Despite the sample presented with diverse gender and sexual identities, categories on gender identity and sexual orientation were collapsed for analytic purpose as some identities had smaller cell sizes. In addition, these results only apply to youth accessing crisis services and may not apply to other SMY.
Conclusion
The aim of this study was to examine differences in suicide attempt, depression, and PTSD by gender identity (cisgender, transgender, and nonbinary) in a sample of SMY accessing crisis services. These results remain the most explicit examination of gender identity and mental health outcomes among SMY accessing crisis services to date and provides a foundation for further studies and intervention. Programs and practices directed toward SMY often do not address issues faced by transgender or nonbinary youth or may not have knowledge to provide gender-specific services, such as, gender identity dysphoria and development, transitioning services, gender-based discrimination and harassment, coping strategies, and need for appropriate referrals. In addition, there is a need to acknowledge the differential risks presented by transgender and nonbinary youth, as more research is needed in identifying unique needs of gender minority subgroups for strengthened interventions.
Abbreviations Used
- CES-D-4
Center for Epidemiologic Studies Depression Scale Short Form
- CI
confidence interval
- C-SSRS
Columbia-Suicide Severity Rating Scale
- MST
minority stress theory
- OR
odds ratio
- POC
person of color
- PTSD
post-traumatic stress disorder
- SD
standard deviation
- SMASI
Sexual Minority Adolescent Survey Inventory
- SMY
sexual minority youth
Author Disclosure Statement
No competing financial interests exist.
Funding Information
The study was funded by a grant from The Trevor Project awarded to Jeremy T. Goldbach, PhD.
Cite this article as: Srivastava A, Rusow JA, Goldbach JT (2021) Differential risks for suicidality and mental health symptoms among transgender, nonbinary, and cisgender sexual minority youth accessing crisis services, Transgender Health 6:1, 51–56, DOI: 10.1089/trgh.2020.0034.
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