Safeguarding the health and wellbeing of transgender young people

Abstract

Transgender (hereafter referred to as trans) people have a gender that is different from the sex assigned to them at birth (Box 1). It is estimated that globally, 1.2–2.7% of people under 19 years identify as trans.¹ In recent years, there has been a rise in anti-trans campaigns in Australia and overseas. As a result, young trans people are subject to increasing vitriol and discrimination, which represents a clear and present danger to an already marginalised population. The current pattern of public discourse represents a public health risk and poses similar concerns to the debate surrounding marriage equality in Australia several years ago, which had a negative impact on the mental health of LGBTQIA+ people of all ages.²

In this perspective article, we take a health equity, social justice and minority stress lens to the evidence, examine the barriers to health care arising from the politicisation and marginalisation of trans youth, and call for urgent action to safeguard the health and wellbeing of young trans people.

Despite the documentation of gender diversity in Indigenous cultures over thousands of years,³ its existence in Western societies has remained hidden until recently. As trans people have become more visible, societal awareness of gender diversity has improved and more individuals have felt empowered to live authentically as trans. However, this increase has been accompanied by claims of social contagion and fears that trans people represent a threat to fairness in sport, public safety and equality for women.

This shift in public discourse has been fuelled primarily by disinformation and by accompanying negative and inflammatory media coverage and political debate about young trans people. Media outlets frequently scrutinise trans youth, question their right to socially or medically affirm their gender,⁴ and sensationalise trans identities for “clickbait” (an enticing internet hyperlink, often misleading) and financial gain.⁴ Politicians have similarly engaged in debates questioning the legitimacy of gender-affirming medical treatment for trans youth, inciting division, particularly during election campaigns.⁵ This trend in anti-trans discourse recently culminated in a series of prominent anti-trans rallies across Australia.⁶

These campaigns have largely been powered by anti-trans groups seeking to restrict the rights of trans people internationally. Broadly united by their view that binary sex and gender are immutable and that trans people are a threat to societal values and safety, this diverse range of groups identifies with trans-exclusionary, radical feminist, religious or simply anti-“gender ideology” causes.⁷ Importantly, they are often funded and supported by religious and right-wing organisations, who have spent millions of dollars to promote anti-trans messaging and policies (eg, the European Parliamentary Forum for Sexual and Reproductive Rights found that ten US Christian Right organisations and foundations provided US$81.3 million in funding for European anti-gender causes from 2009 to 2018).⁸ The increasing potency and uptake of anti-trans campaigns has been linked to rising economic and social inequality around the world, which has stoked anxiety, fear and a desire to use trans people as a convenient scapegoat for societal problems.⁹

The impact of anti-trans campaigns has been far-reaching, and they have had a chilling effect on the rights of young trans people globally. This has been apparent in the United States, where 23 states have recently prohibited or limited young trans people from accessing gender-affirming medical treatment, and some states have introduced criminal penalties for providers of gender-affirming care.¹⁰ Some of these legislative bans have now been struck down by judges who have recognised that they violate the rights of trans youth and threaten their mental health and wellbeing.¹⁰ In Australia, vitriol and disinformation in the public sphere is escalating, and with it, attempts to restrict the rights of trans people. For example, the 2023 Childhood Gender Transition Prohibition Bill (not passed) aimed to ban gender-affirming medical treatment for young people aged under 18 years,¹¹ and the 2022 federal Religious Discrimination Bill (not passed) would have allowed schools to discriminate against trans students.¹²

Against this backdrop, trans youth continue to experience disproportionately high rates of psychological distress, self-harm and suicidality.¹³ In an Australian study of 859 young trans people aged 14 to 25, 80% of participants reported having self-harmed, 82% had experienced suicidal ideation, and 48% had attempted suicide,¹⁴ which is much higher than rates found in the general population.¹⁵ This is linked to the adversity, discrimination and stigma that young trans people commonly endure. The same study found that 89% of participants reported having experienced peer rejection, 74% had experienced bullying, 66% had experienced lack of family support, and 22% had experienced housing insecurity.¹⁴ There was a clear association between exposure to these negative experiences and poor mental health.¹⁴ This finding is consistent with other studies that also found an association between adversity and mental health difficulties in trans youth.^{16, 17}

Rigorous, peer-reviewed evidence from prospective and retrospective cohort studies and cross-sectional studies shows that trans youth thrive when able to access gender-affirming care in all its forms.^{13, 18-25} In paediatrics, gender-affirming care describes a non-judgemental and respectful model of care underpinned by the view that gender diversity is not abnormal and that a young trans person's gender should be affirmed.²⁶ Gender-affirming care may involve providing social or medical treatments that support a person in their gender,²⁶ but also includes general care delivered in a way that considers, explores and validates gender identity without any a priori preference for either a cis or trans identity. Consistent with other areas of paediatrics, care is considered in the context of the individual's development and goals, and decision making is shared between the young person, their family, and their clinicians.²⁶

Young people being supported to affirm their gender is associated with improved quality of life. A recent study investigated the self-reported mental health of 148 young trans people who had socially transitioned.²⁷ The study found that these trans youth had similar or only marginally elevated rates of depression and anxiety when compared with their siblings and age- and gender-matched controls.²⁷ This study is supported by other research that similarly demonstrates the association between social transition and better mental health and quality of life.^28-30

Trans youth who undertake medical transition also report improved mental health and wellbeing. Findings from two of the largest studies that examined the effects of puberty blockers and gender-affirming hormones in young trans people with gender dysphoria found that gender-affirming care was associated with better mental health and wellbeing. A study of 450 young trans people attending a specialist gender service found that those who were receiving gender-affirming medical treatment through puberty suppression had better mental health than those who were referred for care but had not yet received such treatment, and that the individuals receiving treatment had similar mental health to cisgender young people.¹³ Additionally, a multicentre prospective study of 315 young trans people attending specialist gender services found that use of testosterone or oestradiol was associated with better mental health over a two-year period.¹⁸ These studies are part of the growing evidence base that demonstrates the positive association between medical affirmation and improved quality of life and mental health for those young people with marked and sustained gender incongruence who seek and are eligible for treatment according to national and international guidelines.^19-25 These studies do not include control groups due to ethical and methodological concerns associated with withholding interventions for trans youth.³¹

Based on the best available evidence, the Endocrine Society,³² American Academy of Pediatrics³³ and American Academy of Child and Adolescent Psychiatrists³⁴ recommend gender-affirming care as best practice for young trans people with gender dysphoria. Although there is a need for more high quality research in this emerging area of health care and efforts in this regard are ongoing,³⁵ existing data support the benefit of gender-affirming care on the mental health and quality of life of trans youth.

The surge of anti-trans discourse represents a public health risk for young trans people and their families. Ongoing exposure to vitriol and discrimination compounds the adversity already experienced by trans youth and contributes to the worsening of their mental health and feelings of depression, anxiety and lack of safety.^{36, 37}

The politicisation and marginalisation of young trans people in legislation, policy, media coverage and health care is unethical and harmful. As a health care community, we are in a position of privilege, not only to provide gender-affirming care, but to advocate to protect the rights, dignity and health of trans youth. Trans kids are just kids, and like all kids, they need and deserve our respect, love and support, not our vitriol. To prevent further harm, we all must act now against transphobia.

Carmen Pace is a member of the Australian Professional Association for Trans Health and a member of its research committee. Alessandra Chinsen is a member of the World Professional Association for Trans Health. Ada Cheung has received product (oestradiol and progesterone) for investigator-initiated trials from Besins Healthcare. Besins Healthcare have not provided any monetary support nor had any input into the design and analysis of research studies or the writing of any manuscripts. S. Rachel Skinner is affiliated with the NSW Ministry of Health, Australian Association of Adolescent Health, Society of Adolescent Health and Medicine, Australian Professional Association of Transgender Health, World Professional Association of Transgender Health. Michelle Tollit is a member of the Australian Professional Association for Trans Health and is the co-chair of its research committee. Ken Pang is a member of the Australian Professional Association for Trans Health and the World Professional Association for Trans Health, and is an associate editor of the journal, Transgender Health.

Not commissioned; externally peer reviewed.