Transgender and gender nonconforming (TGNC) adolescents have difficulty accessing and receiving health care compared with cisgender youth, yet research is limited by a reliance on small and nonrepresentative samples. This study's purpose was to examine mental and physical health characteristics and care utilization between youth who are TGNC and cisgender and across perceived gender expressions within the TGNC sample.
Data came from the 2016 Minnesota Student Survey, which consisted of 80 929 students in ninth and 11th grade (n = 2168 TGNC, 2.7%). Students self-reported gender identity, perceived gender expression, 4 health status measures, and 3 care utilization measures. Chi-squares and multiple analysis of covariance tests (controlling for demographic covariates) were used to compare groups.
We found that students who are TGNC reported significantly poorer health, lower rates of preventive health checkups, and more nurse office visits than cisgender youth. For example, 62.1% of youth who are TGNC reported their general health as poor, fair, or good versus very good or excellent, compared with 33.1% of cisgender youth (χ2 = 763.7, P < .001). Among the TGNC sample, those whose gender presentation was perceived as very congruent with their birth-assigned sex were less likely to report poorer health and long-term mental health problems compared with those with other gender presentations.
Health care utilization differs between TGNC versus cisgender youth and across gender presentations within TGNC youth. With our results, we suggest that health care providers should screen for health risks and identify barriers to care for TGNC youth while promoting and bolstering wellness within this community.
Comments
RE: Letter to Editor
Rider et al.1 helped increase our understanding of health and care utilization in their population-based study of Minnesota transgender and gender nonconforming youth.
Within this article, it was revealed that 62.1% of adolescents who identified as TGNC reported their general health as poor, fair or good compared to 33.1% of cisgender adolescents. However, when students were asked to evaluate their general health, their options were limited to two responses of poor, fair or good or the other option of very good or excellent. By limiting the responses to the students, we have no knowledge of what a student meant by their selection or their interpretation of the health terms. Future research should make a greater distinction in health perceptions and include operational definitions.
Additionally, this study found that 60.0% of TGNC obtained a preventive medical check-up within the last year, which were similar in results to 64.7% of cisgender adolescents. However, some research has shown as this population continues to age the proper gender prevention screenings are not routinely done for this population. A study conducted by Tabaac et al2 found transwomen had a lower colorectal cancer screening compared to cisgender men. This study should have specified if the preventive medical check-up addressed screenings pertaining to the student’s birth-assigned gender, the gender they identify as or both. Nonetheless, these studies highlight the critical need to include expansive gender expression questions in all healthcare-related surveillance systems, including EMRs.
As our patient’s perspective of gender identity and gender orientation is changing, we as physicians must adjust the manner of how we provide healthcare services to our patients. Physicians must learn to ask appropriate questions when addressing this population without including their own assumptions. In the article “Caring for the Transgender Patient,”3 the authors found that majority of physicians do not know how to communicate about transgender patients appropriately, which was also addressed within this article. Therefore, as more is learned about TGNC youth, more training is also needed for healthcare providers to provide optimal care for TGNC youth.
Sincerely,
Tiorra Johnson Ross
References:
1. Rider, G., McMorris, B., Gower, A., Coleman, E., Eisenberg, M. Health and Care Utilization of Trangender and Gender Nonconforming Youth: A Population-Based Study. American Academy of Pediatrics. 2018;141(3):1-8
2. Tabaac, A., Suter, M., Wall, C., Baker, K. Gender Identity Disparities in Cancer Screening Behaviors. American Journal of Preventive Medicine. 2018;54(3):385-393
3. Neira, P. Caring for the Transgender Patient. Journal of Radiology Nursing. 2017;36(2):88-89
RE: A Call for More Inclusion and Diversity
I would like to congratulate the authors of the article on successfully highlighting the importance of research and public health measures needed addressing health outcomes, especially mental health, in young gender minorities within the LGBTQ community. Equally, I’d like to offer additional suggestions.
As possible explanation for negative health outcomes, this article refers to gender minority stress and resilience model. Grounded on Meyer's minority stress model, this renowned theory addresses external factors negatively impacting health outcomes on sexual minorities (1). I'd additionally advocate another theory in recent study called the self-discrepancy theory. It proposes individuals compare their situation to internalized standards and if discrepancy, psychological discomfort arises, increasing risks for mental health problems such as depression (2). This theory should be equally addressed alongside the minority stress model for health outcome explanation in gender minority youth as it includes internal with external factors. In reflecting on the complex relationship between TGNC youth and mental health outcomes, multiple theories may be needed. Thus, this implicates multicomponent public health approaches are needed to reduce negative health outcomes in the gender minority LGBTQ youth including mental health conditions (2).
Areas for improvement within this article pertains to LGBTQ youth diversity. The authors address that previous research dichotomized gender into masculine or feminine. They recognize gender complexity, expand with TGNC versus cis-gender, and further separate TGNC by perceived gender expression categories versus biological sex. Though a step in the right direction, the authors failed to address sexual orientation along with gender identity, both often intertwined in LGBTQ youth. They also lump anyone identifying transgender, nonconforming, etc. as TGNC but that doesn’t mean all individuals are treated equally. Furthermore, gender expression in the study came from questioning how others would identify them and listed options, excluding options like androgynous. I’d suggest having a write-in option for more expansive self-identification of gender identity and expression rather than listed options. Finally, gender expression is separated by birth-assigned sex, which was binary male versus female. However, this fails to account for intersex or DSD individuals. I’d recommend categorizing biological sex on a spectrum as well to further include this population. Nevertheless, to its defense, this study is more inclusive than its predecessors and obtains more health information on a complex, diverse community.
Other important determinants of health not well addressed include race and economics. The majority of the study population was white and not impoverished, which doesn’t necessarily fit with other American cities. In my own community in Atlanta, Georgia, racial and economic minorities along with gender and sexual minority status may be more at risk of marginalization by health care or harassment and victimization. Though emphasized as a more generalizable population-based study, this study is not generalizable to every place in America. I would suggest addressing in discussion of limitations these differences that may not reflect the rest of America. Overall, though heightening awareness of mental and general health for TGNC youth, this study still calls for more inclusive research of a diverse population.
References:
1. Testa RJ, Habarth J, Peta J, Balsam K, Bockting W. Development of the gender minority stress and resilience measure. Psychol Sex Orientat Gend Divers. 2015; 2 (1): 65-77
2. Annor FB, Clayton HB, Gilbert LK, Ivey-Stephenson AZ, Irving SM, David-Ferdon C, Kahn LK. Sexual Orientation Discordance and Nonfatal Suicidal Behaviors in U.S. High School Students. American Journal of Preventative Medicine. 2018.
RE: A Call for More Inclusion and Diversity
I would like to congratulate the authors of the article on successfully highlighting the importance of research and public health measures needed addressing health outcomes, especially mental health, in young gender minorities within the LGBTQ community. Equally, I’d like to offer additional suggestions.
As possible explanation for negative health outcomes, this article refers to gender minority stress and resilience model. Grounded on Meyer's minority stress model, this renowned theory addresses external factors negatively impacting health outcomes on sexual minorities (1). I'd additionally advocate another theory in recent study called the self-discrepancy theory. It proposes individuals compare their situation to internalized standards and if discrepancy, psychological discomfort arises, increasing risks for mental health problems such as depression (2). This theory should be equally addressed alongside the minority stress model for health outcome explanation in gender minority youth as it includes internal with external factors. In reflecting on the complex relationship between TGNC youth and mental health outcomes, multiple theories may be needed. Thus, this implicates multicomponent public health approaches are needed to reduce negative health outcomes in the gender minority LGBTQ youth including mental health conditions (2).
Areas for improvement within this article pertains to LGBTQ youth diversity. The authors address that previous research dichotomized gender into masculine or feminine. They recognize gender complexity, expand with TGNC versus cis-gender, and further separate TGNC by perceived gender expression categories versus biological sex. Though a step in the right direction, the authors failed to address sexual orientation along with gender identity, both often intertwined in LGBTQ youth. They also lump anyone identifying transgender, nonconforming, etc. as TGNC but that doesn’t mean all individuals are treated equally. Furthermore, gender expression in the study came from questioning how others would identify them and listed options, excluding options like androgynous. I’d suggest having a write-in option for more expansive self-identification of gender identity and expression rather than listed options. Finally, gender expression is separated by birth-assigned sex, which was binary male versus female. However, this fails to account for intersex or DSD individuals. I’d recommend categorizing biological sex on a spectrum as well to further include this population. Nevertheless, to its defense, this study is more inclusive than its predecessors and obtains more health information on a complex, diverse community.
Other important determinants of health not well addressed include race and economics. The majority of the study population was white and not impoverished, which doesn’t necessarily fit with other American cities. In my own community in Atlanta, Georgia, racial and economic minorities along with gender and sexual minority status may be more at risk of marginalization by health care or harassment and victimization. Though emphasized as a more generalizable population-based study, this study is not generalizable to every place in America. I would suggest addressing in discussion of limitations these differences that may not reflect the rest of America. Overall, though heightening awareness of mental and general health for TGNC youth, this study still calls for more inclusive research of a diverse population.
References:
1. Testa RJ, Habarth J, Peta J, Balsam K, Bockting W. Development of the gender minority stress and resilience measure. Psychol Sex Orientat Gend Divers. 2015; 2 (1): 65-77
2. Annor FB, Clayton HB, Gilbert LK, Ivey-Stephenson AZ, Irving SM, David-Ferdon C, Kahn LK. Sexual Orientation Discordance and Nonfatal Suicidal Behaviors in U.S. High School Students. American Journal of Preventative Medicine. 2018.