Transgender identity and mental health in adolescence: a scoping review

ABSTRACT Background Global health guidance has identified gender minorities and adolescents, respectively, as being at elevated risk of mental disorders. The aim of this systematic scoping review was to examine the association between mental distress and transgender status in adolescents, to reflect on how global policy might specifically address the mental health of transgender adolescents. Methods A systematic search was conducted in six databases – Medline, Embase, CINAHL Plus, ADOLEC, PsychINFO and PsychEXTRA – for published quantitative and qualitative studies examining a range of mental disorders, suicidality and non-suicidal self-injury (NSSI) among adolescents with gender dysphoria or who identify as transgender. The search was limited to original research studies published in Afrikaans, Dutch, English, French and Spanish, but not limited by date. Studies’ prevalence estimates of mental disorders, suicidality and NSSI were abstracted. Meyer’s minority stress model was used as a framework to map risk and protective factors associated with mental distress, grouping by distal stressors, proximal stressors and resilience factors. Results 49 studies met inclusion criteria. 33 observational studies reported prevalence of depression, anxiety, suicide attempt, suicidal ideation, self-harm, eating disorder and/or disorders of neurodiversity among transgender adolescents. Rates of mental distress were higher among transgender than among both cisgender heterosexual and sexual minority adolescents. Identified risk factors for mental distress were bullying; physical and sexual violence; poor relationships with family and peers; stigmatization by health care providers; internalized transphobia; negative self-concept; and substance use. Factors that appeared to protect against distress included parent-connectedness; peer- and teacher-support; safe school environment; consistent use of chosen names and pronouns; hobbies; and gender-affirming medical treatment. Conclusions Evidence-informed global governance on adolescent health should adopt a comprehensive, integrated approach to promoting mental health among gender minority adolescents. Background Global health guidance has identified gender minorities and adolescents, respectively, as being at elevated risk of mental disorders. The aim of this systematic scoping review was to examine the association between mental distress and transgender status in adolescents, to reflect on how global policy might specifically address the mental health of transgender adolescents. Methods A systematic search was conducted in six databases – Medline, Embase, CINAHL Plus, ADOLEC, PsychINFO and PsychEXTRA – for published quantitative and qualitative studies examining a range of mental disorders, suicidality and non-suicidal self-injury (NSSI) among adolescents with gender dysphoria or who identify as transgender. The search was limited to original research studies published in Afrikaans, Dutch, English, French and Spanish, but not limited by date. Studies’ prevalence estimates of mental disorders, suicidality and NSSI were abstracted. Meyer’s minority stress model was used as a framework to map risk and protective factors associated with mental distress, grouping by distal and proximal stressors, and resilience factors. Results 49 studies met inclusion criteria. 33 observational studies reported prevalence of depression, anxiety, suicide attempt, suicidal ideation, self-harm, eating disorder and/or disorders of neurodiversity among transgender adolescents. Rates of mental distress were higher among transgender than among both cisgender heterosexual and sexual minority adolescents. Identified risk factors for mental distress were bullying; physical and sexual violence; poor relationships with family and peers; stigmatization by health care providers; internalized transphobia; negative self-concept; and substance use. Factors that appeared to protect against distress included parent-connectedness; peer- and teacher-support; safe school environment; consistent use of chosen names and pronouns; hobbies; and gender-affirming medical treatment. Conclusions Evidence-informed global governance on adolescent health could encourage countries both to strengthen information systems to support research on transgender adolescent health and to adopt a comprehensive, integrated approach to promoting mental health among gender minority adolescents.