Abstract
Transgender or gender nonconforming (TGNC) adolescents face a wide range of physical and mental health concerns. However, there has been no school-based study to explore the prevalence and mental health status of these adolescents in mainland China. To assess the mental well-being of TGNC adolescents in China by comparing them with their cisgender peers. This was a cross-sectional survey study. Of the 12 354 adolescents who completed the questionnaire, 246 did not specify to which sex they identified and were therefore excluded from further analysis. Therefore, a total of 12 108 adolescents were included from 18 secondary schools in Suzhou city, China, from June 2019 to July 2019. Participants provided consent and answered questions on sex assigned at birth and gender identity. All participants completed questionnaires, including the Patient Health Questionnaire for the measurement of depressive symptoms, a generalized anxiety disorder screening, the Pittsburgh Sleep Quality Index, and a self-harm and suicide risk checklist. The frequency of being bullied at school was also measured. Participants who reported their perceived gender as the opposite of their assigned sex at birth were classified as transgender, those who identified as neither male nor female were classified as nonbinary, and those who were not sure about their perceived gender were classified as questioning. All of these participants were categorized as TGNC adolescents. A total of 12 108 adolescents (mean [SD] age, 15.8 [1.0] years; 6518 [53.8%] assigned male at birth [AMAB]) participated in the study. Of the 6518 participants AMAB in the sample, 5855 (89.8%) were classified as cisgender boys, 208 (3.2%) as transgender girls (transgender youth who perceive their current gender identity to be female), 138 (2.1%) as nonbinary youth AMAB, and 317 (4.9%) as questioning youth AMAB. Of the 5590 participants assigned female at birth (AFAB), 4142 (74.1%) were classified as cisgender girls, 861 (15.4%) as transgender boys (transgender youth who perceive their current gender identity to be male), 112 (2.0%) as nonbinary youth AFAB, and 475 (8.5%) as questioning youth AFAB. Compared with cisgender adolescents, TGNC adolescents reported significantly higher health concerns including lower overall health (t11 872 = -7.36; P < .001), poorer sleep (t11 683 = 10.49; P < .001), higher depression and anxiety symptoms (t11 830 = 12.43 and t11 847 = 11.47, respectively; P < .001), and higher rate of self-harm and suicide ideation (t11 860 = 12.22; P < .001). The TGNC youth who were AMAB were also more likely to be bullied at school than cisgender boys (transgender girls: odds ratio [OR], 2.34 [95% CI, 1.64-3.33]; nonbinary youth AMAB: OR, 1.97 [95% CI, 1.23-3.16]; and questioning youth AMAB: OR, 1.95 [95% CI, 1.43-2.67]). The TGNC groups also reported significantly greater amounts of thoughts of self-harm (transgender girls: OR, 3.06 [95% CI, 2.24-4.19]; transgender boys: OR, 4.06 [95% CI, 3.47-4.74]; nonbinary youth AMAB: OR, 2.86 [95% CI, 1.93-4.23]; nonbinary youth AFAB: OR, 3.71 [95% CI, 2.46-5.59]; questioning youth AMAB: OR, 2.61 [95% CI, 1.98-3.44]; and questioning youth AFAB: OR, 3.35 [95% CI, 2.70-4.16]), thoughts of suicide (transgender girls: OR, 3.93 [95% CI, 2.88-5.38]; transgender boys: OR, 3.71 [95% CI, 3.10-4.21]; nonbinary youth AMAB: OR, 3.13 [95% CI, 2.11-4.63]; nonbinary youth AFAB: OR, 3.78 [95% CI, 2.50-5.71]; questioning youth AMAB: OR, 2.53 [95% CI, 1.93-3.33]; and questioning youth AFAB: OR, 3.94 [95% CI, 3.17-4.88]), suicide plan formation (transgender girls: OR, 4.44 [95% CI, 2.88-6.83]; transgender boys: OR, 2.66 [95% CI, 2.03-3.50]; nonbinary youth AMAB: OR, 5.36 [95% CI, 3.22-8.93]; nonbinary youth AFAB: OR, 4.06 [95% CI, 2.25-7.30]; and questioning youth AFAB: OR, 2.36 [95% CI, 1.63-3.43]), deliberate self-harm during the last month (cisgender girls: OR, 1.49 [95% CI, 1.33-1.68]; transgender girls: OR, 2.74 [95% CI, 1.93-3.91]; transgender boys: OR, 3.06 [95% CI, 2.57-3.66]; nonbinary youth AMAB: OR, 2.56 [95% CI, 1.66-3.94]; nonbinary youth AFAB: OR, 3.06 [95% CI, 1.95-4.81]; questioning youth AMAB: OR, 2.14 [95% CI, 1.56-2.92]; and questioning youth AFAB: OR, 2.53 [95% CI, 2.00-3.01]), and attempts of suicide (transgender girls: OR, 4.35 [95% CI, 2.88-6.56]; transgender boys: OR, 2.92 [95% CI, 2.26-3.76]; nonbinary youth AMAB: OR, 3.94 [95% CI, 2.36-6.55]; nonbinary youth AFAB: OR, 3.06 [95% CI, 1.67-5.63]; questioning youth AMAB: OR, 2.61 [95% CI, 1.73-3.94]; and questioning youth AFAB: OR, 1.93 [95% CI, 1.33-2.81]) compared with cisgender boys. Results of this cross-sectional survey study suggest poor mental health status among TGNC adolescents in China; in addition, findings suggest a compelling need for researchers, practitioners, and policy makers to address these mental health problems. Particular school-based interventions are recommended to support the mental health well-being of TGNC adolescents.
Highlights
Transgender is an umbrella term that refers to individuals whose gender identity is incongruent with their sex assigned at birth.[1]
Of the 5590 participants assigned female at birth (AFAB), 4142 (74.1%) were classified as cisgender girls, 861 (15.4%) as transgender boys, 112 (2.0%) as nonbinary youth AFAB, and 475 (8.5%) as questioning youth AFAB
The transgender or gender nonconforming (TGNC) youth who were assigned male at birth (AMAB) were more likely to be bullied at school than cisgender boys
Summary
Transgender is an umbrella term that refers to individuals whose gender identity is incongruent with their sex assigned at birth.[1]. Gender dysphoria in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) is the psychiatric diagnosis for individuals who have a strong desire to be of the other gender and experience the incongruence as distressing.[6,7,8] Research has shown that a significant proportion of adolescents with gender dysphoria have a history of other psychiatric diagnoses.[5,9] There are a number of studies reporting a high percentage of suicidal ideation, self-harm, and suicide attempts in adolescents with gender dysphoria.[10,11,12,13] Compared with their cisgender peers, TGNC youth are more likely to report mental health problems such as anxiety, depression, and suicidal ideation.[1,14] within the school environment, transgender adolescents are vulnerable to harassment and bullying.[15]
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