The Perceived Health Implications of Policies and Rhetoric Targeting Transgender and Gender Diverse Youth: A Community-Based Qualitative Study

Abstract

Purpose:

In early 2021, >50 bills targeting transgender and gender diverse (TGD) youth in the United States were proposed; these policies and the rhetoric surrounding them is associated with TGD health disparities.

Methods:

A community-based qualitative study utilized focus groups with a TGD youth research advisory board to explore their knowledge and perceived impacts of the current policy climate and rhetoric in one Midwestern state.

Results:

Themes revealed (1) mental health, (2) structural impacts, and (3) messages to policymakers.

Conclusions:

Discriminatory policies and rhetoric harm TGD youth; health professionals should denounce the harmful disinformation perpetuated by these policies.

Introduction

Transgender and gender diverse (TGD) youth (whose gender identity is different from their sex assigned at birth) experience minority stress in the form of stigma, marginalization, and victimization.¹ Minority stress theory identifies the mechanisms through which TGD youth experience physical and mental health concerns through stressors in their environments.¹ For example, among TGD youth, experiencing victimization is associated with depression, suicidal ideation and attempts, substance use, stress, and eating disorders.^2–5 Relatedly, the sociopolitical climate contributes toward minority stress and health disparities through public attitudes and discriminatory policies.^6–8

Although TGD and allied communities have advocated for and made political and social progress in recent decades, TGD rights organizations indicate a global recession away from equity and justice for TGD people.⁹ A recent study of individuals in 23 countries found that although support for transgender people and rights was increasing, many still supported restrictions on equal access to care and nondiscrimination policies.¹⁰ In addition, being transgender is still criminalized, formally or informally, in >30 countries.¹¹ In early 2021, legislators in 28 U.S. states proposed >50 bills targeting TGD youth by restricting their access to gender-affirming health care and participation in sports, as well as mandating school staff report TGD youth gender to parents/guardians,¹² the most bills targeting TGD people in a single year.

The backlash against TGD people through anti-TGD policies is harmful to the health of TGD youth³ and adults, including increased depression and suicidality.⁸ In addition, even when these policies are not passed into law, the rhetoric surrounding them creates hostile and unsafe environments for TGD youth, increasing their sense of isolation and thoughts of suicide, and decreasing their self-worth.⁷ Given these risks of serious health concerns, the rise of anti-TGD youth bills and policies across the United States, particularly in the Midwest and South, is concerning. Simultaneously, we lack research on TGD youth in these regions of the United States, limiting our understanding of their experiences and the impact of these policies and rhetoric. This lack of research also limits the ability of policymakers, advocates, and health providers to cite current and geographically relevant research to resist these policies. Therefore, this study explored the perceived health implications of anti-TGD policies and rhetoric among TGD youth in one Midwestern U.S. state. Although specific to a U.S. context, the findings from this study, alongside other recent literature, suggest an urgent need for medical and mental health professionals to counter harmful anti-TGD rhetoric across the world. In addition, future studies of the global impacts of these policy trends are warranted.

Methods

We implemented a community-based qualitative study to explore the impact of anti-TGD policies and the rhetoric surrounding them on the youth they repudiate within one Midwestern U.S. state. In collaboration with a long-standing TGD youth research advisory board, we facilitated focus groups with board members to explore participants' (1) knowledge of current and proposed policies targeting TGD youth, (2) perceived impact of the policies and rhetoric on their health and mental health, and (3) concerns about how the policies and rhetoric would impact TGD youth more broadly. The authors include queer and TGD faculty members, students, a youth advisory board member, and community partners. The University of Kansas provided human subjects ethics approval. Informed assent was obtained from all participants; a waiver of parental consent was approved by the institutional review board.

Participants

A TGD youth research advisory board (“the board”) participated in the conceptualization, data collection, and dissemination of the study (one as a coauthor). The board consists of six TGD youth living in a Midwestern state with several proposed anti-TGD policies in early 2021. At the time of this study, the board had been meeting for more than a year to provide expertise on existing and new TGD research. Board members were contacted to assess their interest in and utility of such a study; all agreed to participate, indicating the study's importance and relevance to their lives. Board members served as participants (N=6; M=16 years old) and identified as transmasculine (n=4) or nonbinary (n=2). Four identified their race/ethnicity as white, one as Asian, and one as Native American.

Focus groups and analysis

Participants engaged in a 60-min Zoom focus group designed to elicit reactions to the aforementioned policies and rhetoric, including those in their state and others. The focus group guide included question prompts to explore their knowledge of policies, experiences with the rhetoric surrounding them, and perceived impacts on themselves and others. Thematic analysis¹³ was used to identify themes related to impacts of the current policy climate and rhetoric on TGD youth.

Results

Two themes illustrate health-related consequences of anti-TGD youth policy and rhetoric: (1) mental health impacts and (2) structural impacts. A third theme emerged with messages from the youth to policymakers.

Mental health impacts

First, TGD youth described how the proposed policies and rhetoric had mental health impacts on them and their TGD peers, including depression, suicidality, and fear. They described how “just the fact that these bills exist…is harmful to mental health.” They expressed feelings of hopelessness and suicidality for themselves and others. One said: “it makes me feel almost hopeless…them passing these bills will definitely make the suicide rate higher.” Another described feeling as if these policies and rhetoric made it hard to think about growing up in this climate. They said: “it's already so hard to envision myself as an adult.” They shared a range of emotions, including pain, sadness, and fear. One youth said that these bills make them “feel like I got stabbed.” Another described feeling fearful: “you keep hearing all of these people that don't want you to exist…it's scary.” All the youth agreed that these policies and rhetoric sent a message that TGD people were not going to be accepted and that message was harmful to them.

Structural impacts

Next, TGD youth shared the perceived structural impacts of these policies on their health. Given the focus of many proposed policies on restricting gender-affirming health care, which supports their well-being and prevents or redresses mental health concerns, youth shared concerns about increased barriers to TGD health care. One said, “having little to no gender-affirming health care will be really bad.” Another described, “it's just like pure ignorance…I don't think cis[gender] people can understand what it's actually like to need to transition for your own mental health.” They also described decreased access to safety because of these policies: “especially with these newer bills, it's just making fewer…spaces that are…genuinely safe for open LGBT people, which is just horrific that we're going so far back in time.” Youth shared how the legislation resulted in contention in their schools, making those spaces feel unsafe. One youth described that “there was this huge debate about whether or not we would be able to play sports…” in their health class.

Messages to policymakers

Finally, TGD youth shared messages urging policymakers to consider how these policies regress social progress and cause harm: “we're literally going back in the past. Why would there be any real reason to do this other than transphobia?” They shared how they lacked bodily autonomy due to these policies: “when I hear people talk about trans youth and our bodies…it feels like it's going back to control…they want to control what other people do.” Finally, a youth sent this powerful message to policymakers: “that's just the bottom line…You're going to kill people [by] passing a law.”

Discussion

This community-based qualitative study explored the perceived impact of anti-TGD policies and rhetoric on TGD youth in the United States during the first half of 2021. Consistent with existing evidence,^8,14–16 TGD youth shared how the proposal or passage of anti-TGD policies and associated rhetoric caused them distress. The policies currently under consideration are contrary to science^2–3,17 and harm TGD youth by restricting access to evidence-based care and opportunities for prosocial development. The science is clear: access to gender-affirming health care is associated with improved well-being and decreased depression, anxiety, and suicidality as youth age.^2–3,17 There is also no evidence to suggest TGD athletes have an advantage over cisgender athletes,¹⁸ yet excluding TGD youth from sports is associated with depression and suicide attempts.¹⁹ Recent studies demonstrate that public rhetoric surrounding discriminatory policies has harmful effects on TGD youth and emboldens peers to perpetuate bias-based bullying and harassment,¹⁵ which itself is associated with poor mental health, suicidal ideation, suicidal behavior, poor academic performance, and substance use among TGD youth.^2,8,14–16 Although currently unstudied in youth populations specifically, transgender adults in states with antitransgender policies report more suicide attempts than in states without such policies.⁸

This study is limited by a small sample of TGD youth in one Midwestern U.S. state with limited racial and gender diversity. Future research should continue to explore how these policies, as well as more affirming policies such as inclusive nondiscrimination laws, impact the well-being of TGD youth across diverse geographic contexts, such as in varying U.S. states and other countries. Given the prevalence of transmisogyny in these bills (such as by targeting trans girls in the sports-related policies) and the intersections of racism and cissexism in violence against trans people of color, future research should emphasize the voices and experiences of black, Indigenous, and other people of color who are TGD, especially transfeminine youth. Despite this limitation, this study's relevance to the current U.S. sociopolitical landscape and broader global recession on TGD rights cannot be understated. Anti-TGD policies cause harm to TGD youth health and lack evidence to support the restrictions imposed. It is essential that medical and mental health professionals advocate for more inclusive nondiscriminatory policies to support the health of TGD youth and denounce the harmful disinformation perpetuated by these policies.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

The funding for this study was provided by the University of Kansas School of Social Welfare. J.N.F. and N.W. are supported by the University of Maryland Prevention Research Center cooperative agreement #U48DP006382 from the Centers for Disease Control and Prevention and the Eunice Kennedy Shriver National Institute of Child Health and Human Development grant P2CH041041, Maryland Population Research Center. N.W. is also supported by the Southern Regional Education Board and Robert Wood Johnson Foundation's Health Policy Research Scholars Program.

Abbreviation Used

TGD

transgender and gender diverse

Cite this article as: Paceley MS, Dikitsas ZA, Greenwood E, McInroy LB, Fish JN, Williams N, Riquino MR, Lin M, Birnel Henderson S, Levine DS (2023) The perceived health implications of policies and rhetoric targeting transgender and gender diverse youth: a community-based qualitative study, Transgender Health 8:1, 100–103, DOI: 10.1089/trgh.2021.0125.