Mental health studies lump transgender teens under one umbrella — and miss clues to help them in the process

The disparities are staggering: A growing body of research suggests that transgender teens experience suicidal thoughts and attempt to take their own lives far more often than their cisgender peers.

But in many studies and surveys on adolescent mental health, transgender teens are lumped together in one big group. A transgender teen boy is treated the same, in terms of the research, as a non-binary teen who was assigned male sex at birth, or as a transgender girl. Many other studies and surveys don’t ask about gender identity at all.

A handful of researchers are pushing to change that by making research more detailed when it comes to gender identity — and they are armed with evidence that suggests that doing so is critical to unraveling health disparities.

“Transgender adolescents have been treated as this homogenous, monolithic group,” said Dr. Brian Thoma, a University of Pittsburgh psychiatrist who has studied mental health among transgender teens. His research suggests it’s critical to start studying the intersection of gender identity and mental health with more nuance.

In a paper published last month in Pediatrics, Thoma and his colleagues analyzed mental health among 2,000 teens, more than half of whom were transgender. They asked teens to answer two key questions: What is your current gender identity, and what gender were you assigned at birth?

That two-step question revealed disparities lurking beneath the umbrella definition of transgender used in health research. Transgender boys were at the highest risk of a suicide attempt requiring medical attention, followed by non-binary teens assigned male at birth. Transgender girls were six times more likely than cis boys to have suicidal thoughts.

“None of that [increased risk] surprises us — we see that every day,” said Dr. Mandy Coles, a pediatrician at the Child and Adolescent Transgender Center for Health, or CATCH, at Boston Medical Center. Coles was not involved in the research.

But little research has been done on the disparities within those subgroups, in part because many studies rely on large, national data sets like the Youth Risk Behavior Survey, a biannual, anonymous questionnaire the Centers for Disease Control and Prevention uses to keep tabs on a slew of health measures among adolescents. The 2019 questionnaire asks five questions about suicide, but only asks teenagers whether their sex is female or male. The National Survey on Drug Use and Health, another sweeping survey that collects data on young people and mental health, only asks whether a participant is male or female.

That’s a massive missed opportunity, experts say. Thoma said it’s critical for datasets like the YRBS to start asking more comprehensive questions.

“I’m hoping that work like ours can help to start that conversation,” he said. “The wheels are in motion, but we have a long way to go.”

There are encouraging signs of a shift toward that practice. Thoma and other experts pointed to a 2018 paper that examined suicide attempts among teens in six different gender identity groups. The study tapped into survey data from more than 120,000 adolescents and found transgender boys were at highest risk of suicide attempts — more than half reported having attempted suicide, as well as more than 40% of non-binary teens and 30% of transgender girls.

“The field is fairly new to looking at this,” said Amy Green, director of research at the Trevor Project, a nonprofit focused on suicide prevention in sexual and gender minority youth. Green and her colleagues also have a similar paper to Thoma’s currently under review.

“The next question becomes why [those disparities exist] — and that’s a question we really don’t have answers to,” said Green. She and other experts agreed there’s an urgent need for more research into the factors that might be behind those disparities, including victimization, access to gender-affirming care, and the use of mental health services.

But the findings also beg another question: What can curb those disparities?

“Great, you’ve identified that this exists. What are the interventions we can use to help improve mental health outcomes?” asked Boston Medical Center’s Coles.

Curry Kautz, an 18-year-old student at the University of Massachusetts, Amherst, who identifies as transgender non-binary, said they see a need for more detailed research on the health of people who are transgender or intersex. Kautz has had a string of negative — and deeply frustrating — experiences with the health care system before becoming a patient of Coles’ at Boston Medical Center.

One provider mixed up the doses on their psychiatric prescriptions and didn’t write them on time, leaving Kautz feeling like the provider wasn’t paying much attention to their care. Another provider asked Kautz when they “stopped feeling like a girl” — a feeling Kautz never had.

Coles has heard from a number of young, non-binary patients who have been asked such questions. Those interactions — and their lasting potential impact — leave her worried.

“How does that feel? And how is that going to make you interact with the medical system as you’re growing up and you start to have more control?” she said.

Having more options for gender identity in research studies — and on common health care forms — would be “incredible,” Kautz said. For them, more inclusive research would mean more clinicians can provide better care.

Kautz knows what that kind of care can look like. They have wanted top surgery — a procedure to alter the appearance of the chest — for years. Kautz was floored when they had a consult with a surgeon who presented Kautz with a wide range of options. They could have a male chest, or a male-ish chest, or a female-ish chest, or other choices.

Kautz deeply appreciated having a provider so carefully lay out their options — and being given so much control over their care.

“It was incredible. I was gleaming,” they said.