Transphobic Adverse Childhood Experiences as a Determinant of Mental and Sexual Health for Young Trans Women in the San Francisco Bay Area

Abstract

This study characterized the prevalence of transphobic adverse childhood experiences (ACEs) among young trans women (YTW) and assessed its relationship with poor mental health and sexual risk. A survey was administered between 2012 and 2014 to 300 YTW aged 16–24 living in the San Francisco Bay Area. Transphobic childhood verbal abuse, physical abuse, and high transphobic childhood adversity were endemic, and we found strong associations with depression, posttraumatic stress disorder, and any and receptive anal intercourse. ACEs may be critical social determinants of mental and sexual health for YTW and validated measures to screen for ACEs are needed, along with interventions that provide gender-affirmative support for parents.

Introduction

Childhood is a critical period for healthy development in adulthood. During childhood, the human brain develops, in which basic systems beget more complex systems. Adverse childhood experiences (ACEs) may bring about atypical brain development; and as a result, impede cognitive structures and heighten vulnerability to mental health disorders.¹ A growing body of evidence shows that ACEs may lead to mental health disorders in adulthood, in particular depression and posttraumatic stress disorder (PTSD).^2,3 Lesbian, gay, and bisexual people, or sexual minorities, are disproportionately affected by ACEs.⁴ Among sexual minority youth, those with ACEs were 9.5 times more likely to have attempted suicide.⁵

Despite the growing literature on ACEs and mental health outcomes among sexual minority populations, there is a gap in the literature specific to ACEs among gender minorities, specifically trans women. One study found that ACEs scores were higher among trans participants compared to sexual minority participants, and that neglect was a common experience for both groups.⁶ One other recent study of ACEs among sexual and gender minority youth in the US and Canada recruited online found that while ACEs were high across all groups, they were significantly high among trans and gender nonconforming youth.⁷ Neither of these two studies utilized ACEs measures specific to trans or gender nonconforming identity. This exacerbates the dearth of contextual specificity needed to characterize intersectional risk for transphobic ACEs among gender minority youth.

A focus on transphobic ACEs may help explain the high prevalence of psychiatric diagnoses of lifetime and current major depressive episodes and PTSD among trans women, 35.4%, 14.7%, and 9.8%, respectively.⁸ This study seeks to address the gap in literature on trans-specific ACEs and mental and sexual health outcomes specifically among trans women. In this study, we assess the association between transphobic ACEs and depression, PTSD, and condomless sex among a cohort of 300 young trans women (YTW) in the San Francisco Bay Area.

Methods

The SHINE study is a longitudinal cohort study of 300 YTW in the San Francisco Bay Area.⁹ The present study analyzes cross-sectional data collected at baseline from the SHINE study (2012–2014). Institutional Review Board approval was obtained at the University of California, San Francisco. Recruitment utilized respondent-driven sampling methods intended for hard-to-reach populations and later incorporated e-referrals and online social network site outreach.

Eligibility for the study included self-identification as any gender other than that associated with their assigned male sex at birth, be aged 16–24 years, and living in the San Francisco Bay Area. Written informed consent was obtained from all participants 18 and over, while written assent was obtained from younger participants in accordance with IRB waiver of parental consent.

Measures

Data on age, race/ethnicity, income in the last month, and education level were collected. History of unstable housing was assessed by asking participants if they ever had to stay one or more nights in a place that was not their home because they could not stay at their home or did not have a home.

We measured two forms of ACEs, transphobic childhood verbal and physical abuse. Participants were asked the following two questions: “How often, before the age of 16, were you physically harmed because of your gender identity or gender presentation?” and “How often, before the age of 16, were you verbally made fun of or called names because of your gender identity or gender presentation?” Response categories included: Never, Rarely, Sometimes, Often, and Most of the time. In multivariate models, responses were dichotomized by collapsing “Never/Rarely” as “No,” and “Sometimes/Often/Most of the time” as “Yes.”

We created a composite measure for transphobic childhood adversity where having one or no form of transphobic childhood adversity was categorized as low, and reporting both verbal and physical abuse was categorized as a high level of transphobic childhood adversity.

Depressive symptoms in the past week was assessed by the short version of the Center for Epidemiologic Studies Depressive Scale where a score of 3 or higher indicated a positive screen for Depression.¹⁰ PTSD was assessed using the Primary Care PTSD Screen (PCPS).¹¹ PCPS is made of four items corresponding to reexperiencing, avoidance, numbing, and hyperarousal, where a score of 3 or more is indicated for high PTSD risk. We also examined sexual outcomes implicated in HIV risk: any condomless anal intercourse and condomless receptive anal intercourse in the last 6 months.

Descriptive statistics were used to characterize the study sample and multivariate logistic regression models assessed associations between transphobic childhood verbal abuse, physical abuse, and adversity level with outcomes, adjusting for sociodemographic factors hypothesized to confound associations.

Results

There were high prevalences of transphobic childhood verbal abuse, physical abuse, and high transphobic childhood adversity (72.0%, 62.7%, and 60.3%, respectively) (Table 1). About one in five YTW screened for depression (21.7%), and over half of the sample screened for PTSD (61.3%). Multivariable models (Table 2) showed that YTW who experienced transphobic verbal abuse had higher odds of all outcomes: depression (adjusted odds ratio, aOR=2.11, 95% confidence interval [CI]=1.02–4.37), PTSD (aOR=2.06, 95% CI=1.17–3.64), any condomless anal intercourse (aOR=2.13, 95% CI=1.15–3.96), and condomless receptive anal intercourse (aOR=1.92, 95% CI=1.15–3.96).

Table 1.

Overall Baseline Demographics of Young Trans Women in San Francisco

	All
	n (%)
Total	300 (100.0)
Sociodemographics
Age at interview (years)
16–18	42 (14.0)
19–21	95 (31.7)
22–24	163 (54.3)
Race
American Indian or Alaska Native	1 (0.3)
Asian	18 (6.0)
Black or African American	36 (12.0)
Hispanic or Latina	93 (31.0)
Pacific Islander or Native Hawaiian	4 (1.3)
White	107 (35.7)
Other	41 (13.7)
Education
High school or less	162 (54.0)
Some college/AA degree/trade school	105 (35.0)
Bachelors and graduate studies	33 (11.0)
Monthly income
$1000 or less per month	219 (73.0)
More than $1000 per month	78 (26.0)
History of unstable housing
Yes	130 (43.3)
No	170 (56.7)
Transphobic childhood adverse experiences
Transphobic childhood verbal abuse
Never	42 (14.0)
Rarely	39 (13.0)
Sometimes	60 (20.0)
Often	62 (20.7)
Most of the time	94 (31.3)
Transphobic childhood physical abuse
Never	58 (19.3)
Rarely	50 (16.7)
Sometimes	67 (22.3)
Often	52 (17.3)
Most of the time	69 (23.0)
Transphobic childhood adversity
Low	116 (38.7)
High	181 (60.3)
Mental health
Depression
Yes	65 (21.7)
No	235 (78.3)
PTSD
Yes	184 (61.3)
No	116 (38.7)
Sexual behaviors
Any condomless anal intercourse, last 6 months
Yes	112 (37.3)
No	178 (59.3)
Condomless receptive anal intercourse, last 6 months
Yes	102 (34.0)
No	185 (61.7)

AA, associate's of arts degree; PTSD, posttraumatic stress disorder.

Table 2.

Multivariable Associations Between Childhood Verbal Abuse, Childhood Physical Abuse, and Trans Childhood Adversity with Depression, Posttraumatic Stress Disorder, or Sexual Risk Behavior Among Young Trans Women in San Francisco

	Depression	PTSD	Any condomless anal intercourse	Condomless receptive anal intercourse
	aORa (95% CI)	aORa (95% CI)	aORa (95% CI)	aORa (95% CI)
Transphobic childhood verbal abuse
No	REF	REF	REF	REF
Yes	2.11 (1.02–4.37)*	2.06 (1.17–3.64)*	2.13 (1.15–3.96)*	1.92 (1.02–3.60)*
Transphobic childhood physical abuse
No	REF	REF	REF	REF
Yes	2.52 (1.26–5.05)**	1.46 (0.86–2.48)	1.74 (1.00–3.01)*	1.61 (0.92–2.81)
Transphobic childhood adversity
Low	REF	REF	REF	REF
High	2.44 (1.26–4.75)**	1.64 (0.97–2.75)	1.93 (1.13–3.30)*	1.76 (1.02–3.04)*

^a Adjusted for age, race/ethnicity, education level, monthly income, and housing situation growing up.

^* p<0.05.

^** p<0.01.

aOR, adjusted odds ratio; CI, confidence interval.

Those who experienced transphobic physical abuse in childhood had greater odds of depression (aOR=2.52, 95% CI=1.26–5.05) and any condomless anal intercourse (aOR=1.74, 95% CI=1.00–3.01). YTW with a high level of transphobic adversity in childhood had greater odds of depression (aOR=2.44, 95% CI=1.26–4.75), any condomless anal intercourse (aOR=1.93, 95% CI=1.13–3.30), and condomless receptive anal intercourse (aOR=1.76, 95% CI=1.02–3.04).

Discussion

Results from this study suggest that exposure to high levels of childhood adversity is detrimental to the mental and sexual health of YTW, extending the critical evidence base on ACEs to gender minority youth. Transphobic ACEs may be a significant social determinant of mental and sexual health in emerging adulthood. While studies have explored ACEs among LGBT youth, they included small proportions of trans youth compared to LGB youth,¹² and disaggregation of gender minority and sexual minority youth in ACEs research will help better understand of their unique risk factors.

Despite study limitations (correlation is not causation, unvalidated instrument for transphobic ACEs, limited generalizability due to cross-sectional data), this study highlights the important need for the development of validated measures to assess ACEs in trans youth and adolescent populations and operationalizing screening for trans-specific ACEs in order to promote early intervention among family and peers.¹³ Future research is needed to examine the relationship between not trans-specific ACEs and transphobic ACEs. Engaging in gender affirmation processes that support the self-determination and identities of trans youth has been found to benefit their mental health.¹⁴ Given this, exploring interventions to address parental barriers and facilitators and their role in supporting trans youth to access comprehensive gender-affirming services.¹⁵

Conclusion

Our study showed that YTW were highly impacted by ACEs during their childhood, including physical and verbal transphobic abuse. The ACE measurements in our study correlated to a host of mental health conditions and unsafe sexual practices among YTW. There is a need to understand how ACEs specifically impact trans women separately from other sexual and gender minorities and determine if addressing trans-specific ACEs can serve as an early point of intervention to help address the factors that lead YTW to be disproportionately affected by substance use, mental health conditions, homelessness, and HIV.

Abbreviations Used

AA

associate's of arts degree

ACE

adverse childhood experience

aOR

adjusted odds ratio

CI

confidence interval

YTW

young trans women

PTSD

posttraumatic stress disorder

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the Institutional and/or National Research Committee and with the Declaration of Helsinki 1964 and its later amendments or comparable ethical standards.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This study was funded by the National Institute of Mental Health (R01MH095598). This study's funding source had no role in study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the article for publication.

Cite this article as: Arayasirikul S, Turner CM, Hernandez CJ, Trujillo D, Fisher MR, Wilson EC (2022) Transphobic adverse childhood experiences as a determinant of mental and sexual health for young trans women in the San Francisco Bay Area, Transgender Health 7:6, 552–555, DOI: 10.1089/trgh.2021.0062.