Although reports of health disparities are sobering, poor physical and mental health is not inevitable for transgender and gender nonconforming (TGNC) youth. It is true that data from a retrospective cohort study quantify disparities in mental health outcomes, revealing a two- to threefold increase in the risk of negative mental health outcomes in transgender youth, including depression, suicidal ideation, and suicide attempt.1 It is also true that the National Transgender Discrimination Survey, which is administered to adults, revealed the disheartening statistic that 41% of TGNC respondents had attempted suicide in their lifetimes in contrast with ∼1.6% of the general population who have done so.2 However, research that is focused on well-supported TGNC youth helps dispel the idea that simply being transgender is the cause of poor health outcomes. For example, long-term outcome data from the Netherlands demonstrate that children with gender dysphoria who were treated in a comprehensive gender center with gender-affirming treatment during adolescence and young adulthood grew to become well-functioning adults with an overall mental health status similar to that of the general Dutch population.3 Data from the TransYouth Project was used to establish that transgender children who have socially transitioned and are well supported in their social environments have levels of depression that are similar to those of cisgender controls, with only slightly higher levels of anxiety than the controls.4
Given the tremendous disparities that are known to exist for these youth and the knowledge that these disparities are not inevitable, solutions to bridge this gap and eliminate these disparities are desperately needed. However, to create solutions, a clear understanding of the at-risk population is required.
In this issue of Pediatrics, Rider et al5 present population-based data from 9th- and 11th-graders that highlight the poorer self-perceived heath status of TGNC youth. Of particular interest is how the researchers in this study were able to provide a window into how high school–aged youth understand and redefine gender.
First, 2.7% of the studied population self-defined as TGNC. This level of prevalence of TGNC youth supports recent findings that reveal that previous estimates of the size of the TGNC population have been underestimated by orders of magnitude6,7 and serve to inform school administrators, mental health professionals, and medical professionals that they will see youth with diverse gender identities and expressions in their schools and offices. Second, within the TGNC cohort, the plurality of both male-assigned and female-assigned respondents perceived their gender expression as equally feminine and masculine. This is in stark contrast to the way that current medical guidance has focused almost exclusively on the treatment of transgender people with binary views of gender.8,9 Youth are rejecting this binary thinking and are asking adults to keep up.
Additional information gleaned from the study’s sample characteristics is noteworthy. Within the TGNC cohort, the number of respondents who were assigned a female gender at birth outpaced the number who were assigned a male gender at birth, which is a phenomenon that has been seen recently in referrals to gender clinics.10 Youth of color were more likely to identify as TGNC, a finding that is especially important given the known risks related to the compounding effects of gender- and race-based discrimination.11 Finally, rural youth were equally likely to identify as TGNC as youth who live near the Twin Cities, which serves as a reminder that the unique experience of being TGNC in a potentially isolated environment requires further study and understanding and should not be overlooked.12
The authors of the January 2017 special issue of National Geographic Magazine proclaimed that a gender revolution13 is occurring. Given the health disparities facing TGNC youth that were identified by Rider et al,5 strategies to address these disparities are required. However, to create effective solutions, we need to understand this revolution. Rider et al5 were able to do what reasonable adults should do when confronted with something new and difficult to understand: they asked the children themselves. Continued work to build understanding of how youth understand and express gender is a critical step toward reducing health disparities in this important and valued population.
Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
FUNDING: No external funding.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2017-1683.
I thank Sara Wiener, LMSW, for her review of the article.
POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The author has indicated he has no financial relationships relevant to this article to disclose.