Studies: Trans Youth Need Sexual Knowledge and Gender-Affirming Care

New studies add to a growing pool of research showing that access to gender-affirming medical care, as well as gender-affirming information about sexuality, can bring significant benefits for trans youth and youth who have received a gender dysphoria diagnosis.

A new study published in the October issue of Pediatrics concluded that this information and health care should be provided earlier rather than later. Julia C. Sorbara, M.D., of the Hospital for Sick Children in Toronto, and colleagues studied 300 teens seeking gender-affirming care and found that more adolescents who presented seeking care at age 15 and older reported mental health problems than those who presented before age 15. Differences in mental health issues included depression (46% versus 30%), self-harm (40% versus 28%), suicidal consideration (52% versus 40%), and attempted suicide (17% versus 9%). Overall, a high percentage of all subjects (78%) reported at least one mental health issue.

Sorbara and her team also found that trans youth who sought gender-affirming care at age 15 or older were significantly more likely than younger adolescents to be on psychoactive medications, and that every one-year increase in the age youth presented to the clinic was associated with about a 30% increased risk after adjusting for pubertal age.

It’s the onset of puberty, however, rather than chronological age, that made a bigger difference in mental health issues, according to researchers. Sorbara and colleagues wrote that there’s a “complex relationship among mental health, age, and pubertal development,” but are confident in their assessment that youth who get health care later in age and further along in puberty had more mental health problems than those who presented earlier.

In an accompanying editorial, Annelou L.C. de Vries, M.D., Ph.D., of the Amsterdam University Medical Center in the Netherlands, said the study suggests adolescents with gender dysphoria may benefit from puberty blockers or hormones earlier on, to prevent psychological suffering.

In an email, Sorbara offered a caveat, saying that the design of the study allowed researchers “to identify associations, but not cause-effect relationships, between the presence of mental health problems and age/pubertal stage at presentation to gender-affirming medical care.” She added that further study is required to identify whether age or pubertal stage at initiation of gender-affirming medical care predicts psychological well-being in adulthood.

Supporting Trans and Nonbinary Youth Decreases Suicide Risk

Sorbara’s study is the latest research showing that trans and nonbinary youth are particularly vulnerable to poor mental health outcomes.

Earlier this year, The Trevor Project published a research brief outlining the benefits of gender-affirming care for transgender and nonbinary youth. The brief included a comprehensive review of available empirical evidence on psychosocial outcomes related to social, medical, and legal transitions for transgender and nonbinary youth, and it concluded that supporting transgender and nonbinary youth in their identities has positive mental health outcomes and decreases suicide risk.

The Trevor Project's second annual National Survey on LGBTQ Youth Mental Health, also released earlier this year, found that trans and nonbinary youth faced a higher risk of suicide, compared to their cisgender peers within the LGBTQ community. When accounting for age, family income, and youth race/ethnicity, transgender and nonbinary youth were much more likely to experience depressive symptoms, seriously consider suicide, and attempt suicide compared to their cisgender lesbian, gay, bisexual, queer, and questioning peers. Specifically:

• More than half of transgender and nonbinary youth have seriously considered suicide.

• Nearly half of transgender and nonbinary youth didn’t receive wanted mental health care due to concerns related to the LGBTQ competence of providers.

• Transgender and nonbinary youth who reported having their pronouns respected by all or most of the people in their lives attempted suicide at half the rate of those who did not have their pronouns respected.

• Transgender and nonbinary youth with access to tools such as binders, shapewear, and gender-affirming clothing reported lower rates of attempting suicide in the past year compared to transgender and nonbinary youth without access.

Amy Green, Ph.D., director of research for The Trevor Project, in an email, noted the large gaps in sensitive care for transgender and nonbinary youth, “and that this may be even more compounded for particular subgroups of transgender and nonbinary youth, including those who live in certain regions of the U.S. and who hold multiple marginalized identities.”

“We need greater investment in LGBTQ-inclusive research to fully understand the extent to which trans youth experience challenges in receiving sensitive care and in programs designed to increase access to it,” she wrote.

Affirming Health Care and Sex Information Help Prevent HIV for Trans Youth

Another study, also published in Pediatrics, concluded that support systems, including affirming health care, parents, and other adults, can help reduce rates of HIV among transgender and nonbinary youth.

Conducting three-day focus groups with 30 young people, broken out into the 13 to 17 and 18 to 24 age groups, researchers learned that most participants lacked affirmative and culturally competent resources to understand their sexual health needs. In particular, they lacked LGBTQ-inclusive sexual education courses and gender-affirming peer educators. And most ominously for sexual health, many participants said they got little or no information about HIV pre-exposure prophylaxis (PrEP), gender-affirming or not.

Participants said that health care providers routinely misgendered them and dismissed the need for PrEP. As for sex education, if their schools offered it at all, it was about abstinence or pregnancy prevention. One participant said online pornography provided more sexual information than doctors, nurses, or counselors.

The lack of sexual health information, including PrEP, is a big problem for trans and nonbinary youth, because researchers found this group was more “likely than cisgender youth to report first sexual intercourse before age 13 years, intercourse with four or more partners, drinking alcohol or using drugs before intercourse, and not using a condom at last intercourse.”

Those disparities become even more stark in adulthood: According to the Centers for Disease Control and Prevention, an estimated 14% of trans women have HIV and almost two-thirds of trans people of all genders say they never had an HIV test.

There are many factors that put transgender and nonbinary youth at greater risk for HIV and STDs, according to one of the study’s authors, Sean Cahill, Ph.D., director of health policy research at the Fenway Institute in Boston.

“Those factors include self-esteem and body issues, a lack of information on HIV and help in navigating safer sex, and a difficulty in understanding consent,” Cahill said. “We had responses such as, ‘Dating is scary as hell,’ and one respondent who was so grateful and lucky for the chance to have sex that it would be wrong to ‘push my luck’ to require a condom. A lot of young people across the spectrum face that issue, too.”

Cahill added that, in another survey he coauthored, it was clear that a significant percentage of school guidance counselors didn’t know how to talk about sex, sexual health, and PrEP to trans and nonbinary students. He noted that some of the more progressive school nurses will put up a discreet rainbow flag on their office door, suggesting that it’s OK to come to them with sexual orientation and gender diversity issues.

The quality of sex and gender education depends on the school and the location: Only 28 states and Washington, D.C. mandate HIV education as part of sex education, according to the Guttmacher Institute, a sexual health research and policy nonprofit. Five states—Texas, Oklahoma, Mississippi, Louisiana, and Alabama—have laws prohibiting teachers from discussing LGBTQ people in a positive light, if at all. South Carolina, Arizona, and Utah recently had such “no promo homo” laws repealed.

Cahill, who trains health care providers about LGBTQIA issues, had some recommendations for schools, both secondary and college, across the nation. “They need to teach human development, not just sex. They need to provide information, in an age-appropriate way, on how to have healthy relationships, as well as domestic violence and abuse and neglect. And they need to cover how to develop friendships and trust.”