In 2018, the Human Rights Campaign sounded the alarm that antitransgender violence in the United States had become a “national epidemic,” on the basis of the increasing number of transgender fatalities that year.1 In the context of coronavirus disease 2019, there is a greater appreciation for the significance of a national public health crisis and how it can lead to feelings of grief, vulnerability, and fear. In this month’s Pediatrics, Thoma et al2 show that violence and victimization is not only widespread among a national sample of transgender and gender diverse (TGD) individuals but that it is often first encountered early in life as childhood abuse.2
Thoma et al2 conducted an online survey of TGD adolescents over 4 months in 2018. Although initial advertisements generated 8747 clinics, only 5642 assented and responded. On the basis of their inclusion criteria and after multiple means of controlling for validity, duplicate responses, and survey incompletion, data from 1836 participants remained. Thoma et al2 found that TGD adolescents experienced higher rates of psychological, physical, and sexual abuse, compared with that of their cisgender peers, with identical results after controlling for covariates. Generally, those assigned female at birth (AFAB) had experienced more psychological (now identifying as transgender and nonbinary) and sexual abuse (now identifying as nonbinary), whereas those currently questioning their gender identity had experienced more physical abuse than other demographics.2 With post hoc analysis, it was confirmed that increased psychological abuse among transgender males AFAB was an independent finding and not a consequence of other types of abuse.2
The “click through” rate of their advertisement or number of clicks per number of impressions was comparable to that of other studies. Thoma et al2 discuss whether adolescent social media users with a history of abuse would be more likely to click on an advertisement for a “health study,” leading to overrepresentation.2 Yet there is also a considerable possibility of abuse victim underrepresentation because of the bias inherent in the difference between the initial advertisement clicks and survey completions, particularly given the stigma and emotional toll of disclosing trauma. Nearly 1500 participants who were eligible did not complete the survey through to the abuse questions. There is limited demographic information or justification available for those who did not complete the survey. Among those completing the survey, they were racially diverse and from all 50 states, but it was not a nationally representative sample assuring all groups are included by matching national demographics.2 This means the findings, although important, cannot be generalized to the national level and, in this situation, minority groups are often disproportionally underrepresented.
Early gender stereotypes may also be a factor in survey completion, especially among those assigned male at birth (AMAB), who may have encountered notions of masculinity incompatible with victimhood and vulnerability.3 In fact, those completing the survey and reporting psychological and sexual abuse were more likely to be AFAB.2 Because of the overrepresentation of AFAB participants early on, additional measures were put into place to only recruit AMAB participants later in the study.2 However, rather than reaching the desired sample, this strategy may have only served to screen out AFAB participants who were abused but originally reluctant to disclose, ultimately leading to an underrepresentation of victims.
The higher physical abuse among those currently questioning their gender identity points to the fact that this population may be the least likely to fit traditional gender stereotypes, which, in previous research, researchers suggest is an independent risk factor for experiencing childhood abuse.4,5
Overall, Thoma et al2 may underestimate trauma experiences among TGD adolescents, but the message is clear that TGD adolescents are more likely to report psychological, physical, and sexual abuse than cisgender peers.2 Thoma et al2 did not identify the perpetrators of the abuse (ie, family members, peers, etc), which would have implications for intervention, but they provide important evidence from a large sample to the growing body of research in which researchers emphasize that TGD adolescents’ experiences often include childhood trauma.5–8 This necessitates not just access to mental health resources but full adoption of trauma-informed care9 as a fundamental element of the interdisciplinary gender affirmative care approach to reduce morbidity.
Thoma et al2 demonstrate an association. It would be erroneous and potentially harmful to assume any causal relationship from these findings. Yet the findings can be conceptualized within minority stress theory,10 in which it is stated that adverse outcomes among stigmatized populations emerge through 2 forces: distal stressors from the external social environment (eg, discrimination, stigma, abuse, and violence) and internal proximal stressors (eg, fear of rejection, suppressing one’s identity, or internalizing negative beliefs about one’s identity). Distal stressors activate proximal stressors by a reinforcing process that increases the risk for negative mental health outcomes disproportionately prevalent in TGD populations, such as anxiety, depression, and suicidality.10 Abuse early in the lives of TGD individuals and gender-based discrimination are cumulative distal stressors. Safe and supportive connections, activism, and other resiliency factors can combat internalized stigma and activation of proximal stressors.10 This underlies the importance of early screening and access to trauma-informed, gender affirmative interventions.
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.2020-016907.
POTENTIAL CONFLICTS 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.