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The Mental Health Consequences at the Intersection of Gender and Incarceration

November 17, 2022

Editor’s Note: Eli Cahan is a first-year pediatric resident at University of California, San Francisco and an investigative journalist whose work focuses on the intersection of health equity and social justice.

-Rachel Y. Moon, MD, Associate Editor, Digital Media, Pediatrics

Most pediatricians are used to asking parents or guardians to step out of the room when speaking with adolescents. And in these conversations, pediatricians are used to discussing “taboo” topics—the sex, the drugs, the rock n’ roll—that adolescents may fear bringing up in front of others.

But it wasn’t until more recently that pediatricians far and wide started routinely broaching another dimension of conversation: gender and sexual identity, beyond sexual behaviors themselves. A 2017 review found that prevalence rates of gender dysphoria identity range between 0.5-1.3%—over 1 million Americans, at least—with marked increases in more recent years. As such, many pediatricians now ask about these topics—topics that were generally overlooked in the past.

In particular, pediatricians are increasingly appreciating the importance and plurality of gender pronouns. While not enough pediatricians are asking these questions—self-reported prevalence of gender dysphoria still far exceeds what is documented in medical records—more pediatricians are inquiring about gender pronouns than ever before. That’s in part because pioneering research continues to demonstrate the profound physical and mental health challenges faced by sexual and gender-minority (SGM) youth.

Accordingly, getting one’s pronouns right is no longer an act of compassion or rapport building. It’s an unmissable risk factor—an essential social determinant of health.

That’s why the study by Kirsty Clark PhD at Vanderbilt and colleagues about mental health among incarcerated SGM youth, which will be early released this week in Pediatrics, is so important (10.1542/peds.2022-058158).

SGM youth are considerably overrepresented in the carceral system—composing some 20% of incarcerated youth versus 7-9% of the general population, according to a national survey cited by Clark et al. Their study illustrates just how unhealthy that environment can be for the SGM youth who are disproportionately represented within it.

Specifically, the authors found that rates of mental illness for incarcerated SGM youth far outnumbered those observed in the broader population. For example, rates of self-harm were 4-fold higher in this group than in non-incarcerated, non-SGM youth. Rates of suicidal ideation and suicidal attempts were 2-times and 6-times higher, respectively.

The study, of course, cannot disentangle cause and effect, i.e., whether SGM youth with a tendency towards self-harm and suicidality were more likely to be incarcerated, or whether the carceral setting tipped at-risk youth towards these behaviors.

Nonetheless, as the authors write, SGM youth are “disproportionately impacted by poor mental health in part due to interlocking forces of structural racism, heterosexism, and transphobia…[and] intersectional approaches are needed” to support their wellbeing.

Indeed, for pediatricians interested in better understanding why context matters; how they can better care for SGM youth in their practice; and what the science of intersectionality truly looks like, this study is a must read.

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