Transgender youth found to have higher rates of mental health disorders

1. Transgender and/or gender nonconforming (TGNC) children and adolescents had higher prevalence of mental health disorders compared to their cisgender peers.

2. Anxiety disorders, attention deficit disorders, and depressive disorders were the most common diagnoses, while suicidal ideation, self-inflicted injuries, and hospitalizations for mental health diagnoses were also more prevalent than in matched reference groups.

Evidence Rating Level: 2 (Good)

Study Rundown: Previous studies estimated that TGNC youth are more likely to suffer from mental health disorders. However, previous data often rely on specialized clinics and small sample sizes, making comparison to the underlying population difficult. In this retrospective cohort study, researchers used electronic medical records from a large health system to compare the prevalence of mental health disorders in TGNC children and adolescents to those in a similar cisgender cohort. The results showed that nearly all mental health diagnoses were significantly more common among TGNC children and adolescents than in matched reference groups. The most common diagnoses among TGNC children were attention deficit disorders and anxiety disorders. These diagnoses remained common among TGNC adolescents, with depressive disorders having the highest prevalence in that age group. Suicidal ideation, self-inflicted injuries, and hospitalizations for mental health diagnoses were also more common among TGNC children and adolescents. The study is limited by ascertainment bias, as identification of the TGNC cohort was based on healthcare use, though prevalence ratios remained similar or slightly attenuated after adjusting for that factor. This study supported previous findings and improved the evidence due to its relatively large cohort from a heterogeneous health care system across a wide geographic region. These data emphasize the importance of identifying TGNC children and adolescents and evaluating their mental health needs in order to begin necessary interventions. 

Click to read the study, published today in Pediatrics

Click to read an accompanying editorial in Pediatrics

Relevant reading: Psychiatric Comorbidity in Gender Dysphoric Adolescents

Study author, Tracy A. Becerra-Culqui, PhD, MPH, talks to 2 Minute Medicine: Kaiser Permanente Southern California Department of Research & Evaluation.
This article is an important read for medical students/residents/and fellows because it raises awareness about the need for immediate mental health evaluation and urgent implementation of clinical, social, and educational gender identity support for children and adolescents displaying distress related to their gender identity, or self-identify as transgender or gender non-conforming. This is the first study of its kind based in a large integrated healthcare system and we hope in the future to prospectively measure whether interventions reduce the occurrence of mental health conditions. 

In-Depth [retrospective cohort]: Researchers used electronic medical records at 3 Kaiser Permanente sites (Georgia, Northern California, Southern California) to identify 2164 TGNC cohort candidates based on International Classification of Diseases, Ninth Edition (ICD-9) codes and keywords in clinical notes. 1333 subjects ages 3-17 were included in the final cohort after verifying TGNC status and excluding subjects with unknown gender assigned at birth or evidence of disorders of sex development. Each TGNC subject was matched to 10 male and 10 female peers, assumed to be cisgender, in the same health system on the basis of birth, race and/or ethnicity, site, and year of index date (first evidence of TGNC status. Prevalence ratios (PR) of mental health conditions were calculated by dividing proportion of TGNC subjects with an ICD-9 mental health diagnosis by the corresponding proportion in each reference group. PRs were calculated separately for transfeminine and transmasculine subjects within 2 age groups: 3 to 9 years (children) and 10 to 17 years (adolescents). Prevalence of anxiety disorders, attention deficit disorders, autism spectrum disorders, conduct and/or disruptive disorders, depressive disorders, and eating disorders were estimated in children, and additionally prevalence of bipolar disorders, psychoses, personality disorders, schizophrenia spectrum disorders, self-inflicted injuries, substance use disorders, and suicidal ideation were estimated for adolescents.

The results showed higher prevalence (PR > 1.0) of mental health disorders of every category among TGNC children and adolescents compared to reference males and females. TGNC children most commonly had attention deficit disorders (15% transfeminine; 16% transmasculine) and anxiety disorders (12 transfeminine; 6% transmasculine). Among TGNC adolescents, depressive disorders had the highest prevalence (49% transfeminine; 62% transmasculine). There was higher prevalence of suicidal ideation (PR: 54, 95% CI: 18-218) and self-inflicted injuries (PR: 70, 95% CI: 9.0-15) among transfeminine subjects compared with reference males; prevalence was similarly increased in transmasculine subjects.

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