Experts continue to remain concerned about the mental health of youths, particularly sexual or gender minority youths (SGM). When SGM youths are going through transitions—whether physical or social, or both—there is an increased need for attention on these individuals; however, there continues to be a need for evidence that identifies associations between mental health and self-reported gender identity. Authors of a study published in JAMA Network Open aimed to determine whether—and how often—youths changed self-reported gender identities in longitudinal sample of SGM youths, as well as whether trajectories of gender identity were associated with depressive symptoms.
The cohort study assesses the trajectories of gender identity in 366 SGM youths aged 15 to 21 years in a community-based sample. The data come from a longitudinal study of SGM youths in 4 waves of data collection from 2012 to 2015 that occurred every 9 months. Parental consent was waived for participants who were younger than 18 years to assure the youths’ safety who were not out to their parents, and an independent representative was assigned and present to ensure that the participant agreed.
To capture gender identity variability, the investigators focused on youths who participated in 3 or more waves of the study, and at each wave, youths were coded as transgender and gender diverse (TGD) when their gender identity did not match the sex assigned to them at birth. Additionally, the investigators noted that because TGD youths often seek hormone therapy to treat their gender dysmorphia and are often exposed to LGBTQ+ violence associated with the mental health of TGD youths, the analysis accounts for both factors.
To assess youths’ gender identity, a 2-step approach was used: sex at birth was assessed at wave 1 (either male or female); and then during waves 1 to 4, participants were asked to describe their gender identity, with responses including man, woman, genderqueer, transgender woman, transgender man, and write-in responses which were coded as either cisgender, binary transgender (eg, transgender woman or transgender man), or genderqueer and nonbinary. Some examples of write-in responses among participants included “woman, queer,” “gender non-conforming,” and “genderfluid.”
Further, at each wave, the 2 measures were paired and participants were categorized in 1 of 3 potential gender identities: binary transgender, genderqueer and nonbinary, or cisgender. Frequency of gender identity variability was measured as the number of times participants’ identity changed across the 4 study waves (from 0 to 3).
Additionally, depressive symptoms were measured using the Beck Depression Inventory for Youth, which assesses negative thoughts, sadness, and depressive symptoms. Sum scores were calculated, with higher scores indicating more depressive symptomatology. According to the investigators, sum scores of 13 or less were considered “normal” and scores that were 14 or higher is a potential indication of mild to severe depressive symptoms.
At waves 2 to 4, participants were asked to report their history of hormone therapy and puberty blocker use, recording “yes” (indicated with “1”) or “no” (indicated with “0”) depending on their history. Further, exposure to violence related to LGBTQ+ identity was assessed using a 6-item scale that measured the frequency of experienced events (0 meaning “never” and 3 meaning “at least 3 times”). During wave 1, youths were asked to consider experiences in their lifetime, with following waves assessing events that occurred within the past 9 months.
Key Takeaways
- High Variability in Gender Identity Among SGM Youths: The study found that approximately 18.3% of sexual or gender minority (SGM) youths reported different gender identities during the study, highlighting significant gender identity variability within this group. Groups consisted of those who identified as cisgender across all study waves; transgender and gender diverse (TGD, including binary transgender and genderqueer or nonbinary) across all waves; cisgender at either wave 1 or 2 but identified as TGD by wave 4; and TGD at any wave, but identified as cisgender by wave 4 (TGD to cisgender).
- Depressive Symptoms and Gender Identity: Youths in the cisgender to TGD groups reported higher levels of depressive symptoms compared to cisgender youths; however, gender identity changes did not significantly affect the levels of depressive symptoms when accounting for exposure to LGBTQ+ violence.
- Need for Updated and Inclusive Research: The study's limitations include outdated data and the exclusion of specific factors such as social transitions and gender dysphoria. The investigators emphasize that this shows a need for new, comprehensive studies to better understand gender identity development as well as its mental health implications among SGM youths.
The mean age of participants was 18.61 years, and the majority were assigned female at birth (n = 185, 50.6%). Further, approximately 40.7% (n = 149) were Latinx, 23.0% (n = 84) non-Latinx Black, 20.5% (n = 75) non-Latinx White, and 18.9% (n = 58) either did not report their race/ethnicity or marked it as “other.” Of these participants, the majority (74.9%, n = 274) identified as cisgender during all waves and the remaining 25.1% (m = 92) identified as TGD at some point during the study’s duration.
Trajectory patterns among participants were divided into 4 groups: those who were cisgender across all waves (n = 274); TGD, including binary transgender and genderqueer or nonbinary, across all waves (n = 32); cisgender at either wave 1 or 2 but identified as TGD by wave 4 (n = 28; of which 26 [92.9%] identified as cisgender at wave 1) and TGD at any wave, but identified as cisgender by wave 4 (TGD to cisgender: n = 32). According to the investigators, approximately 18.3% of participants (about 1 in 5 participants) reported a different gender identity during the study’s duration.
The authors note that 20 of the 32 participants (62.5%) in the TGD group reported using hormones, and only 6 of 28 participants (21.4%) in the cisgender to TGD group, and 1 of 32 (3.1%) in the TGD to cisgender group reported using hormones. Puberty blocker use was reported by 12 of the 92 participants who identified as noncisgender (eg, nonbinary and genderqueer or binary transgender), of which most were from the TGD group.
Additionally, the participants who were in the cisgender to TGD and TGD to cisgender groups most often identified as genderqueer or nonbinary when they identified as TGD. Changing gender identities was rather common among noncisgender youths, according to the authors, with participants changing at least twice during the study’s duration (n = 28, 30.4%). Additionally, the majority of youths who were in the TGD to cisgender group (n = 19; 59.4%) reported a different gender identity at least twice across waves. Youths in the TGD group reported fewer identity changes; however, the TGD to cisgender and cisgender to TGD groups did not differ from one another.
According to the depressive symptom analysis, approximately 58.5% of the variance of symptoms were at the between-person (BP) level, and the remaining 41.5% at the within-person (WP) level. Hierarchical level modeling (HLM) also indicated that depressive symptoms presented a linear trajectory accounting for random events. Additionally, analyses also assessed the trajectories of depressive symptoms at baseline, showing that participants in the TGD and cisgender to TGD groups reported higher levels of depression compared with the cisgender group (Β = 3.91; SE = 1.98; P = .048; vs Β = 4.66; SE = 2.10; P = .03); however, when adjusted for demographic characteristics, only the cisgender to TGD group differed from the cisgender group (Β = 4.82; SE = 2.10; P = .02). Further, the cisgender to TGD group also reported more depressive symptoms at baseline when compared with the TGD to cisgender group, however, the finding was deemed not significant (Β = 6.02; SE = 2.30; P = .05). Interestingly, the baseline difference in depressive symptoms between cisgender to TGD groups and the cisgender group was not significant after accounting exposure to LGBTQ+ violence (Β = 3.31; SE = 2.36; P = .16).
Further, patterns of depressive symptoms at the BP level did not differ for youths who reported more gender identity variability compared with their counterparts who reported less or no gender identity variability (Β = 2.43; SE = 2.51; P = .33). WP analyses also demonstrated that youths did not report more depressive symptoms at times when reporting more gender identity variability compared with other periods were less or no variability was reported (Β = 0.23; SE = 0.74; P = .75).
Limitations of the study include the inability to examine participants who met the criteria for gender dysphoria, the exclusion of youths’ explanations on gender identity variability, as well as no specific number of TGD youths who underwent social transitions (eg, changing pronouns or changing presentation to better align with their experienced gender), among others. Additionally, the investigators emphasized that their findings may not be applicable to all youths because the sample was specifically recruited from SGM-focused community organizations. Data are also more than a decade old, meaning that new prospective, community-based studies should be conducted to better understand the development and changes within gender identity as well as the associations between mental health for both cisgender and TGD youths.
References
Real AG, Lobato MIR, Russell ST. Trajectories of Gender Identity and Depressive Symptoms in Youths. JAMA Netw Open. 2024;7(5):e2411322. doi:10.1001/jamanetworkopen.2024.11322
