Gender-Affirming Policies Support Transgender and Gender Diverse Youth’s Health
- Russell B. Toomey, Ph.D., University of Arizona
- Jenifer K. McGuire, Ph.D., University of Minnesota
- Kristina R. Olson, Ph.D., Princeton University
- Laura Baams, Ph.D., University of Groningen
- Jessica N. Fish, Ph.D., University of Maryland
Transgender and gender diverse youth (TGD) (i.e., children and adolescents whose gender identity and/or expression differs from their sex assigned at birth) are more likely to experience poor health than their peers whose gender identity aligns with their assigned sex at birth (i.e., cisgender youth) due to stigma and marginalization. Fortunately, school policies that protect, include, and affirm TGD youth’s gender identity are associated with positive mental health and academic outcomes. TGD youth who have access to gender-affirming medical care experience improvements in mental health and often show mental health comparable to their cisgender peers. Some legislative efforts have attempted to block transgender youth’s access to gender-affirming medical care (e.g., puberty blockers) and school resources (e.g., sports teams that align with their gender identity). Policymakers, along with school personnel, must enact non-discrimination and anti-bullying policies that allow TGD youth equal access to school facilities and resources, and protect youth on the basis of their gender identity and expression. In this brief, we term policies and practices that recognize and support TGD youth’s identities and expression “gender-affirming care” and highlight opportunities to ensure the healthy development of all TGD youth. We highlight how medical and school contexts are critical for TGD youth’s development and health and offer evidence-informed policy and practice recommendations to guide efforts that support youth.
Transgender and gender diverse youth (TGD), which includes non-binary youth, are 2-3 times more likely than their cisgender peers to experience discrimination and a lack of safety in schools.1-4 TGD youth are also 2-3 times more likely to report suicidality, depression, and anxiety than cisgender youth.5-8 Studies document that 30-50% of TGD youth report attempting suicide.8 Conversely, transgender youth with supportive families and who have socially transitioned show normative rates of depression and only slightly more anxiety compared to their cisgender peers.9-12 The more contexts (e.g., home, school, work) in which TGD youth experience gender-affirming support (i.e., chosen name use) the less they experience depressive symptoms and suicidal ideation and behavior.6 It is therefore necessary to ensure that TGD youth receive protection and support that affirm their gender identity and expression across multiple contexts. Notably, youth’s experiences with family, school, and medical care settings also vary by race/ ethnicity, geography, and socioeconomic status, which may exacerbate health disparities for TGD youth (e.g., youth without private health insurance may not have access to affirmative medical and mental health care).13-15 Further, including questions about gender identity and expression in electronic medical records and state and national school-based surveys enables TGD youth to share their identity and experiences, and creates a better understanding of health disparities.16 Given the focus of recently proposed legislation, we highlight the importance of affirming policies and practices for youth in two contexts: medical care and school settings.
Transgender youth who have access to gender-affirming medical care experience improvements in mental health and often show mental health comparable to their cisgender peers.
Access to Medical Services Promotes TGD Youth’s Health and Well-Being
Leading health associations deem gender-affirming health care to be appropriate and medically necessary for TGD youth who meet internationally recognized guidelines for care.17 Before puberty begins, no hormonal or surgical care is provided to TGD youth; rather, gender-affirming care focuses on youth’s social transition (i.e., change of name, pronouns, appearance, and use of spaces like restrooms that align with youth’s gender). When puberty begins the first hormonal intervention for which some TGD youth are eligible is puberty blocking (which temporarily delays puberty), the effects of which are reversible. These “blockers” are provided under the supervision of a licensed medical provider. Typically, a few years later, TGD youth might be prescribed hormones to begin puberty that aligns with the youth’s gender.18
Before puberty blocking, TGD youth often have high rates of depression, anxiety, and suicidality. On average, after puberty blockers and gender affirming hormones, levels of depression are no longer elevated,19-22 anxiety is reduced,19,20 body image improves,19,23 and suicidality drops to levels typical for all youth.21,22 The positive effects of gender-affirming health care have been found in adolescence during the initial medical transition,20 and have been found to last for years into adulthood.19, 24-26 For example, TGD youth receiving puberty blockers showed similar mental health to their cisgender peers,19,22 and better mental health than TGD youth not yet receiving treatment.20,22 Studies find poorer mental health20 and twice as many suicidal thoughts and attempts22 among youth not yet receiving gender-affirming care when compared to youth who are receiving care. Counseling and psychological support also contribute to improved mental health for TGD youth;19 however, they can not replace the benefit of medical care, when indicated, for TGD youth’s well-being.20,21
For TGD youth, parents and providers collaborate and reference international standards to determine the best course of care.16,26 Starting medical care before puberty is complete can often lead to a physical transition that better reflects TGD youth’s gender,28 likely increasing social opportunities like friendships, dating, and employment in the future. In contrast, barriers to gender-affirming medical care due to lack of health insurance,14 limited family support, or health insurance exclusions13-15 are associated with poorer mental health in adulthood.20, 21-24
Transgender youth are 3.7 times more likely than cisgender youth to experience bullying and are 3.3 times more likely to miss school due to safety concerns.
Schools Play an Important Role in TGD Children and Youth’s Positive Development and Mental Health
Transgender youth are 3.7 times more likely than cisgender youth to experience bullying and are 3.3 times more likely to miss school due to safety concerns.3 58% of TGD youth also report having been prevented from using bathrooms that aligned with their gender identity.7 Many TGD youth are sent home or to detention for their gender expression (e.g., wearing make-up or nail polish or clothing that the school deems inappropriate for their gender).29,30 When schools limit participation in sports and equal access to school facilities, TGD youth may miss out on important learning experiences (e.g., physical education classes),1,31 be unable to use the bathroom for an entire day,32-34 miss days of school,3,32 and experience poorer mental health (e.g., depressive mood).7
By contrast, states and schools can implement policies that protect TGD youth from these harmful experiences.3 For example, anti-bullying and nondiscrimination policies that specifically name gender identity or expression as a protected status enable the monitoring of bias-based bullying and intervention, and are linked to lower rates of bullying and victimization.35-37 Further, teacher training on gender identity and expression is associated with less school-based victimization.38 School personnel can also support TGD students with their social transition by using the name and pronouns denoted by the student6,39,40 and allowing them to use school facilities32,33 and participate on sports teams that align with their gender identity.1,2,31 When schools support TGD student’s social transition, they report better mental health.6,32 One study found that transgender youth who could use their name in school were 56% less likely to report suicidal behavior.6 In addition, TGD adults who were able to have their name and gender marker on their passport or state ID, reported lower depression, anxiety, and suicidality,39,40 and they were less likely to report feeling emotionally upset as a result of gender-based mistreatment.39 Ultimately, transgender youth show more positive outcomes in school environments that implement and enforce policies and practices that affirm youth’s gender identity and protect them from discrimination.
Policymakers and school personnel can support TGD youth’s well-being by prohibiting discriminatory policies and implementing affirmative actions.
Policy and Practice Implications
Policymakers need to ensure TGD youth’s access to developmentally appropriate, gender-affirming health care and supportive school environments. More specifically, policymakers and school personnel can support TGD youth’s well-being by prohibiting discriminatory policies and implementing affirmative actions, such as:
Policies and Practices that Support TGD Youth in Medical Settings
1. Do not ban or penalize the use of developmentally appropriate, gender-affirming health care, including puberty suppression, gender-affirming hormones, surgical interventions, and mental health care for TGD youth.18-22, 26
2. Require insurance coverage of developmentally appropriate, gender-affirming health care, including puberty suppression, gender-affirming hormones, surgical interventions, and mental health care for TGD youth.18-21, 26
3. Standardize the collection and privacy of gender identity and expression data in medical records.41-43
Policies and Practices that Support TGD Youth in Schools
4. Add gender identity and expression to state and federal anti-bullying and nondiscrimination policies in schools as protected statuses (e.g., the Equality Act would address this recommendation nationwide).35-37
5. Allow students to change their name and gender on their legal documents and in their school files.6,39,30
6. Allow students to engage in activities and sports that align with their affirmed gender.2
7. Protect the use of bathrooms and locker rooms that align with student’s affirmed gender, without having to disclose transgender status.7,32,33
8. Implement training for school personnel on topics related to affirming gender identity and expression.6,38
9. Mandate the collection of gender identity and expression data in state and national school-based surveys.16,41
(1) De Pedro, K. T., Shim-Pelayo, H., & Bishop, C. (2019). Exploring physical, nonphysical, and discrimination-based victimization among transgender youth in California public schools. International Journal of Bullying Prevention, 1(3), 218–226. https://doi.org/10.1007/s42380-019-00016-8
(2) Clark, C. M., & Kosciw, J. G. (2021). Engaged or excluded: LGBTQ youth’s participation in school sports and their relationship to psychological well-being. Psychology in the Schools, 1–20. Advanced online publication. https://doi.org/10.1002/pits.22500
(3) Day, J. K., Perez-Brumer, A., & Russell, S. T. (2018). Safe schools? Transgender youth’s school experiences and perceptions of school climate. Journal of Youth and Adolescence, 47(8), 1731–1742. https://doi.org/10.1007/s10964-018-0866-x
(4) Kosciw, J. G., Clark, C. M., Truong, N. L., & Zongrone, A. D. (2020). The 2019 national school climate survey: The experiences of lesbian, gay, bisexual, transgender, and queer youth in our nation’s schools : A report from GLSEN. GLSEN.
(5) Price-Feeney, M., Green, A. E., & Dorison, S. (2020). Understanding the mental health of transgender and nonbinary youth. Journal of Adolescent Health, 66(6), 684-690. https://doi.org/10.1016/j.jadohealth.2019.11.314
(6) Russell, S. T., Pollitt, A. M., Li, G., & Grossman, A. H. (2018). Chosen name use is linked to reduced depressive symptoms, suicidal ideation, and suicidal behavior among transgender youth. Journal of Adolescent Health, 63(4), 503-505.
(7) Price-Feeney, M., Green, A. E., & Dorison, S. H. (2021). Impact of bathroom discrimination on mental health among transgender and nonbinary youth. Journal of Adolescent Health, 68(6), 1142–1147. https://doi.org/10.1016/j.jadohealth.2020.11.001
(8) Toomey, R. B., Syvertsen, A. K., & Shramko, M. (2018). Transgender adolescent suicide behavior. Pediatrics, 142(4), e20174218. https://doi.org/10.1542/peds.2017-4218
(9) Kuvalanka, K. A., Weiner, J. L., Munroe, C., Goldberg, A. E., & Gardner, M. (2017). Trans and gender-nonconforming children and their caregivers: Gender presentations, peer relations, and well-being at baseline. Journal of Family Psychology, 31(7), 889–899. https://doi.org/10.1037/fam0000338
(10) Durwood, L., McLaughlin, K. A., & Olson, K. R. (2017). Mental health and self-worth in socially transitioned transgender youth. Journal of the American Academy of Child & Adolescent Psychiatry, 56(2), 116-123. https://doi.org/10.1016/j.jaac.2016.10.016
(11) Gibson, D. J., Glazier, J. J., & Olson, K. R. (2021). Evaluation of anxiety and depression in a community sample of transgender youth. JAMA Network Open, 4(4), e214739–e214739. https://doi.org/10.1001/jamanetworkopen.2021.4739
(12) Durwood, L., Eisner, L., Fladeboe, K., Ji, C. G., Barney, S., McLaughlin, K. A., & Olson, K. R. (2021). Social support and internalizing psychopathology in transgender youth. Journal of Youth and Adolescence, 50(5), 841-854.
(13) Nahata, L., Quinn, G. P., Caltabellotta, N. M., & Tishelman, A. C. (2017). Mental health concerns and insurance denials among transgender adolescents. LGBT Health, 4(3), 188–193. https://doi.org/10.1089/lgbt.2016.0151
(14) Stevens, J., Gomez-Lobo, V., & Pine-Twaddell, E. (2015). Insurance coverage of puberty blocker therapies for transgender youth. Pediatrics, 136(6), 1029–1031. https://doi.org/10.1542/peds.2015-2849
(15) Gridley, S. J., Crouch, J. M., Evans, Y., Eng, W., Antoon, E., Lyapustina, M., Schimmel-Bristow, A., Woodward, J., Dundon, K., Schaff, R., McCarty, C., Ahrens, K., & Breland, D. J. (2016). Youth and caregiver perspectives on barriers to gender-affirming health care for transgender youth. Journal of Adolescent Health, 59(3), 254–261. https://doi.org/10.1016/j.jadohealth.2016.03.017
(16) Snapp, S. D., Russell, S. T., Arredondo, M., & Skiba, R. (2016). A right to disclose: LGBTQ youth representation in data, science, and policy. In S. S. Horn, M. D. Ruck, & L. S. Liben (Eds.), Advances in child development and behavior, 50, 135–159. https://doi.org/10.1016/bs.acdb.2015.11.005
(17) Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., Fraser, L., Green, J., Knudson, G., Meyer, W. J., Monstrey, S., Adler, R. K., Brown, G. R., Devor, A. H., Ehrbar, R., Ettner, R., Eyler, E., Garofalo, R., Karasic, D. H., … Zucker, K. (2012). Standards of care for the health of transsexual, transgender, and gender-nonconforming people, Version 7. International Journal of Transgenderism, 13(4), 165–232. https://doi.org/10.1080/15532739.2011.700873
(18) Jensen, R. K., Jensen, J. K., Simons, L. K., Chen, D., Rosoklija, I., & Finlayson, C. A. (2019). Effect of concurrent gonadotropin-releasing hormone agonist treatment on dose and side effects of gender-affirming hormone therapy in adolescent transgender patients. Transgender Health, 4(1), 300–303. https://doi.org/10.1089/trgh.2018.0061
(19) Vries, A. L. C. de, McGuire, J. K., Steensma, T. D., Wagenaar, E. C. F., Doreleijers, T. A. H., & Cohen-Kettenis, P. T. (2014). Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics, 134(4), 696–704. https://doi.org/10.1542/peds.2013-2958
(20) Costa, R., Dunsford, M., Skagerberg, E., Holt, V., Carmichael, P., & Colizzi, M. (2015). Psychological support, puberty suppression, and psychosocial functioning in adolescents with gender dysphoria. The Journal of Sexual Medicine, 12(11), 2206–2214. https://doi.org/10.1111/jsm.13034
(21) Achille, C., Taggart, T., Eaton, N. R., Osipoff, J., Tafuri, K., Lane, A., & Wilson, T. A. (2020). Longitudinal impact of gender-affirming endocrine intervention on the mental health and well-being of transgender youths: Preliminary results. International Journal of Pediatric Endocrinology, 2020(8), 1–5. https://doi.org/10.1186/s13633-020-00078-2
(22) van der Miesen, A. I. R., Steensma, T. D., de Vries, A. L. C., Bos, H., & Popma, A. (2020). Psychological functioning in transgender adolescents before and after gender-affirmative care compared with cisgender general population peers. Journal of Adolescent Health, 66(6), 699–704. https://doi.org/10.1016/j.jadohealth.2019.12.018
(23) Kuper, L. E., Stewart, S., Preston, S., Lau, M., & Lopez, X. (2020). Body dissatisfaction and mental health outcomes of youth on gender-affirming hormone therapy. Pediatrics, 145(4), e20193006. https://doi.org/10.1542/peds.2019-3006
(24) Turban, J. L., King, D., Carswell, J. M., & Keuroghlian, A. S. (2020). Pubertal suppression for transgender youth and risk of suicidal ideation. Pediatrics, 145(2), e20191725. https://doi.org/10.1542/peds.2019-1725
(25) de Vries, A. L. C., Steensma, T. D., Doreleijers, T. A. H., & Cohen‐Kettenis, P. T. (2011). Puberty suppression in adolescents with gender identity disorder: A prospective follow‐up study. The Journal of Sexual Medicine, 8(8), 2276–2283. https://doi.org/10.1111/j.1743-6109.2010.01943.x
(26) Fontanari, A. M. V., Vilanova, F., Schneider, M. A., Chinazzo, I., Soll, B. M., Schwarz, K., Lobato, M. I. R., & Brandelli Costa, A. (2020). Gender affirmation is associated with transgender and gender nonbinary youth mental health improvement. LGBT Health, 7(5), 237–247. https://doi.org/10.1089/lgbt.2019.0046
(27) Daley, T., Grossoehme, D., McGuire, J. K., Corathers, S., Conard, L. A., & Lipstein, E. A. (2019). “I couldn’t see a downside”: Decision-making about gender-affirming hormone therapy. Journal of Adolescent Health, 65(2), 274–279. https://doi.org/10.1016/j.jadohealth.2019.02.018
(28) Klaver, M., de Mutsert, R., Wiepjes, C. M., Twisk, J. W. R., den Heijer, M., Rotteveel, J., & Klink, D. T. (2018). Early hormonal treatment affects body composition and body shape in young transgender adolescents. The Journal of Sexual Medicine, 15(2), 251–260. https://doi.org/10.1016/j.jsxm.2017.12.009
(29) Snapp, S. D., & Russell, S. T. (2016). Discipline disparities for LGBTQ youth: Challenges that perpetuate disparities and strategies to overcome them. In R. J. Skiba, K. Mediratta, & M. K. Rausch (Eds.), Inequality in school discipline: Research and practice to reduce disparities (pp. 207–223). Palgrave Macmillan US. https://doi.org/10.1057/978-1-137-51257-4_12
(30) Snapp, S. D., Hoenig, J. M., Fields, A., & Russell, S. T. (2015). Messy, butch, and queer: LGBTQ youth and the school-to-prison pipeline. Journal of Adolescent Research, 30(1), 57–82. https://doi.org/10.1177/0743558414557625
(31) Pistella, J., Ioverno, S., Rodgers, M. A., & Russell, S. T. (2020). The contribution of school safety to weight-related health behaviors for transgender youth. Journal of Adolescence, 78, 33–42. https://doi.org/10.1016/j.adolescence.2019.12.001
(32) McGuire, J. K., Anderson, S. O., & Michaels, C. (2021). “I don’t think you belong in here:” The impact of gender segregated bathrooms on the safety, health, and equality of transgender people. Journal of Gay & Lesbian Social Services. Advanced online publication. https://doi.org/10.1080/10538720.2021.1920539
(33) Wernick, L. J., Kulick, A., & Chin, M. (2017). Gender identity disparities in bathroom safety and wellbeing among high school students. Journal of Youth and Adolescence, 46(5), 917–930. https://doi.org/10.1007/s10964-017-0652-1
(34) James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). The report of the 2015 U.S. Transgender Survey. National Center for Transgender Equality. www.ustranssurvey.org/reports
(35) Hatzenbuehler, M. L., Schwab-Reese, L., Ranapurwala, S. I., Hertz, M. F., & Ramirez, M. R. (2015). Associations between antibullying policies and bullying in 25 states. JAMA Pediatrics, 169(10), e152411–e152411. https://doi.org/10.1001/jamapediatrics.2015.2411
(36) McGuire, J. K., Anderson, C. R., Toomey, R. B., & Russell, S. T. (2010). School climate for transgender youth: A mixed method investigation of student experiences and school responses. Journal of Youth and Adolescence, 39(10), 1175–1188. https://doi.org/10.1007/s10964-010-9540-7
(37) Watson, R. J., Fish, J. N., Denary, W., Caba, A., Cunningham, C., & Eaton, L. A. (2021). LGBTQ state policies: A lever for reducing SGM youth substance use and bullying. Drug and Alcohol Dependence, 221, 108659. https://doi.org/10.1016/j.drugalcdep.2021.108659
(38) Ioverno, S., Bishop, M. D., & Russell, S. T. (2021). Does a decade of school administrator support for educator training on students’ sexual and gender identity make a difference for students’ victimization and perceptions of school climate? Prevention Science. Advanced online publication. https://doi.org/10.1007/s11121-021-01276-x
(39) Restar, A., Jin, H., Breslow, A., Reisner, S. L., Mimiaga, M., Cahill, S., & Hughto, J. M. W. (2020). Legal gender marker and name change is associated with lower negative emotional response to gender-based mistreatment and improve mental health outcomes among trans populations. SSM Population Health, 11, 100595. https://doi.org/10.1016/j.ssmph.2020.100595
(40) Scheim, A. I., Perez-Brumer, A. G., & Bauer, G. R. (2020). Gender-concordant identity documents and mental health among transgender adults in the USA: A cross-sectional study. The Lancet Public Health, 5(4), e196–e203. https://doi.org/10.1016/S2468-2667(20)30032-3
(41) Cahill, S. R., & Makadon, H. J. (2017). If they don’t count us, we don’t count: Trump administration rolls back sexual orientation and gender identity data collection. LGBT Health, 4(3), 171–173. https://doi.org/10.1089/lgbt.2017.0073
(42) Donald, C., & Ehrenfeld, J. M. (2015). The opportunity for medical systems to reduce health disparities among lesbian, gay, bisexual, transgender and intersex patients. Journal of Medical Systems, 39(11), 178. https://doi.org/10.1007/s10916-015-0355-7
(43) Streed, C. G., Grasso, C., Reisner, S. L., & Mayer, K. H. (2020). Sexual orientation and gender identity data collection: Clinical and public health importance. American Journal of Public Health, 110(7), 991–993. https://doi.org/10.2105/AJPH.2020.305722