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Health and Care Utilization of Transgender and Gender Nonconforming Youth: A Population-Based Study

G. Nicole Rider, Barbara J. McMorris, Amy L. Gower, Eli Coleman and Marla E. Eisenberg
Pediatrics March 2018, 141 (3) e20171683; DOI: https://doi.org/10.1542/peds.2017-1683
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Abstract

BACKGROUND: Transgender and gender nonconforming (TGNC) adolescents have difficulty accessing and receiving health care compared with cisgender youth, yet research is limited by a reliance on small and nonrepresentative samples. This study's purpose was to examine mental and physical health characteristics and care utilization between youth who are TGNC and cisgender and across perceived gender expressions within the TGNC sample.

METHODS: Data came from the 2016 Minnesota Student Survey, which consisted of 80 929 students in ninth and 11th grade (n = 2168 TGNC, 2.7%). Students self-reported gender identity, perceived gender expression, 4 health status measures, and 3 care utilization measures. Chi-squares and multiple analysis of covariance tests (controlling for demographic covariates) were used to compare groups.

RESULTS: We found that students who are TGNC reported significantly poorer health, lower rates of preventive health checkups, and more nurse office visits than cisgender youth. For example, 62.1% of youth who are TGNC reported their general health as poor, fair, or good versus very good or excellent, compared with 33.1% of cisgender youth (χ2 = 763.7, P < .001). Among the TGNC sample, those whose gender presentation was perceived as very congruent with their birth-assigned sex were less likely to report poorer health and long-term mental health problems compared with those with other gender presentations.

CONCLUSIONS: Health care utilization differs between TGNC versus cisgender youth and across gender presentations within TGNC youth. With our results, we suggest that health care providers should screen for health risks and identify barriers to care for TGNC youth while promoting and bolstering wellness within this community.

  • Abbreviations:
    MSS —
    Minnesota Student Survey
    TGNC —
    transgender and gender nonconforming

    • What’s Known on This Subject:

    Transgender and gender nonconforming (TGNC) adolescents are significantly affected by mental health disparities and have difficulty accessing and receiving health care compared with cisgender youth. Previous research in this field is limited by reliance on small, nonrepresentative, and adult samples.

    What This Study Adds:

    TGNC adolescents reported poorer health, fewer health checkups, and more nurse visits than their cisgender peers. TGNC adolescents whose gender expression strongly matched their birth-assigned sex had better health and fewer long-term mental health problems compared with other gender presentations.

    Youth who are transgender have a gender identity and/or expression differing from societal expectations based on their birth-assigned sex, whereas youth who are cisgender have a gender identity aligning with their birth-assigned sex. Gender nonconforming describes individuals whose gender expression does not follow stereotypical conventions of masculinity and femininity and who may or may not identify as transgender.1 Although research on youth who are transgender and gender nonconforming (TGNC) is in its nascence, studies indicate that adolescents who identify as TGNC versus cisgender experience significant mental health disparities.2 Additional studies are needed to better understand other health risks, disparities, and access to health care among youth who are TGNC.

    A paucity of health research examines TGNC adolescents’ perceived gender expression (ie, the way others interpret a person’s gender presentation along a spectrum from feminine to masculine). The authors of the gender minority stress and resilience model3 theorize that misperceptions of a person’s gender expression may result in a young individual feeling as if their gendered experience is negated or not affirmed. The young individual may also be placed at an elevated risk for harassment and victimization, which in turn may contribute to a heightened risk for negative health outcomes, such as depressive symptoms, self-harm, posttraumatic stress, disordered eating, and suicidal ideation and attempts.4–9 For example, Roberts et al10 found that youth who reported childhood gender nonconformity were at heightened risk for depressive symptoms during adolescence and early adulthood compared with those reporting childhood gender conformity. Birth-assigned males who reported childhood gender nonconformity were at the greatest risk for bullying victimization and depressive symptoms.

    This vulnerability for poorer health outcomes reveals the importance of access to affordable, competent health care services for youth who are TGNC. However, historical marginalization in health care settings and a lack of competent providers create barriers to treatment and contribute to delayed access to care and longer-term health consequences.11–18 For example, Gordon et al19 found that gender nonconformity was associated with an increased risk for problems with mobility, usual activities, pain or discomfort, anxiety, and depression. Health scores were lower for participants with moderate gender conformity and lowest for those with low gender conformity when compared with participants reporting high gender conformity. Given the limited research on perceived gender nonconformity and health outcomes, Wylie et al20 emphasized the importance of assessing perceived gender expression as a determinant of health disparities, particularly in population-based studies.

    Previously, researchers have most often dichotomized gender into binary categories (exclusively masculine [man or boy] or feminine [woman or girl],13 which minimizes the complexity of TGNC identities.21 In a recent study, researchers found that 41% of a Canadian TGNC sample identified as gender nonbinary (ie, identifying as both, neither, or somewhere between masculine and feminine), which illustrates the importance of investigating the heterogeneity of gender identities and expressions among this group.22 Health researchers who do not incorporate options to indicate nonbinary gender identities and expressions are at risk for having categories that misclassify or exclude certain gender diverse participants.21 This categorical invisibility and erasure of diverse gender identities and expressions contribute to a lack of knowledge and training for health care providers and thereby place youth who are TGNC at risk for poorer health outcomes. In the current study, we address these concerns and illuminate health-related disparities in this underserved youth population.

    Limitations in the extant research include reliance on samples of adults,2 convenience samples, and small sample sizes. Population-based studies with large samples of adolescents are needed to generalize findings and make accurate comparisons between gender identity groups (TGNC versus cisgender). Our purpose in this study was to examine the prevalence of mental and physical health concerns and health care utilization among youth who identify as TGNC versus cisgender and across perceived gender expressions within our TGNC sample, using a large-scale, population-based sample.

    Methods

    Data Source and Study Design

    Data are from the Minnesota Student Survey (MSS), a statewide surveillance system coordinated by the Departments of Education, Health, Human Services, and Public Safety that is used to assess health and well-being among select grades of public school students. In 2016, 85% of the state’s school districts participated. Passive parental consent procedures were used in accordance with federal laws. The analytic sample was composed of 80 929 students in ninth and 11th grade who were asked about their gender identity. The University of Minnesota’s Institutional Review Board determined that this secondary analysis of existing anonymous data was exempt from review.

    Survey Measures

    Gender identity was assessed by using a modified version of the validated 2-item approach recommended by transgender health experts.23–26 Birth-assigned sex was assessed by the question, “What is your biological sex?” (male or female), followed by gender identity: “Do you consider yourself transgender, genderqueer, genderfluid, or unsure about your gender identity?” (yes or no). Adolescents who provided an affirmative response to the gender identity measure comprised the TGNC group. Perceived gender expression was measured by combining 2 items validated with young adults20 to create the following item: “A person’s appearance, style, dress, or the way they walk or talk may affect how people describe them. How do you think other people at school would describe you?” (response options: very or mostly feminine, somewhat feminine, equally feminine and masculine, somewhat masculine, or very or mostly masculine).

    Dependent variables included health status (general health, long-term physical health problems, long-term mental health problems, and staying home sick from school) and care utilization (nurse office visits and preventive medical and dental checkups). A description of these measures is presented in Table 1. Notably, response options for general health were dichotomized into “very good or excellent” versus “poor, fair, or good” because of a skewed distribution.

    View this table:
    TABLE 1

    MSS Health Status and Health Care Utilization Measures

    Demographics and personal characteristics included 4 variables. Students were asked their grade and to endorse 1 or more of 5 racial groups and whether they self-identified with a Hispanic ethnicity. Responses were combined to create a race and/or ethnicity variable (Hispanic or Latino; American Indian or Alaskan Native [non-Hispanic]; Asian [non-Hispanic]; Black, African, or African American [non-Hispanic]; Native Hawaiian or other Pacific Islander [non-Hispanic]; White [non-Hispanic]; and multiple race [non-Hispanic]). An indicator of poverty included whether students received free or reduced-price lunch at school. School location was coded as within or outside the 7-county Minneapolis and St. Paul metropolitan area.

    Data Analysis

    Analyses were conducted by using IBM SPSS version 23 (IBM Corporation, Armonk, NY). First, χ2 tests were used to compare demographic characteristics, health status, and care utilization measures between students who are TGNC and cisgender. A 2-sided significance level of .001 was selected to reduce type I error rate because of the large sample. Second, multiple analysis of covariance (MANCOVA) models were used to estimate least squares means of the 4 health status variables simultaneously and then the 3 care utilization variables simultaneously for TGNC students by their perceived gender expression while controlling for grade, free or reduced-price lunch, race and/or ethnicity, and school location. Pillai’s trace value statistic was used to assess the significant effects of perceived gender expression and control variables on the dependent variables. For dichotomous dependent variables, adjusted least squares means can be interpreted as predicted probabilities. Analyses were conducted separately for birth-assigned male and birth-assigned female adolescents who are TGNC by using an α level of .05. Bonferroni tests were used to correct α for all post hoc comparisons between perceived gender expression groups.

    Results

    Sample Characteristics

    Participants included 2168 (2.7%) students who identified as TGNC and 78 761 (97.3%) students who identified as cisgender. As shown in Table 2, the TGNC sample included a higher proportion of those assigned female at birth, youth of color, and those receiving free or reduced-price lunch than the cisgender sample. No significant differences emerged between students in metropolitan versus nonmetropolitan locations.

    View this table:
    TABLE 2

    Demographic Characteristics of MSS Participants by Gender Identity (N = 80 929)

    Health Statuses and Care Utilization Between Adolescents Who Are TGNC Versus Cisgender

    Almost two-thirds (62.1%) of youth who are TGNC reported their general health as poor, fair, or good as opposed to very good or excellent, which is nearly twice the rate among youth who identify as cisgender (33.1%, P < .001; Table 3). Over half (59.3%) of youth who are TGNC also endorsed having long-term mental health problems compared with 17.4% of cisgender youth (P < .001). Over half (51.5%) of youth who are TGNC reported staying home from school because of illness at least once in the past month (versus 42.6% of youth who are cisgender; P < .001). Youth who are TGNC visited the nurse’s office more often and reported lower rates of preventive medical and dental checkups during the last year than their cisgender peers.

    View this table:
    TABLE 3

    Health Status and Care Utilization of MSS Participants by Gender Identity (N = 80 929)

    Health Status and Care Utilization by Birth-Assigned Sex and Perceived Gender Expression

    Perceived gender expression among youth who are TGNC is shown in Table 4. We found that youth who are TGNC varied across perceived gender expressions. Notably, the prevalence of TGNC adolescents with an equally feminine and masculine perceived gender expression was highest for both those assigned male (29.3%) and assigned female (41.2%) at birth compared with other perceived gender presentations. In Table 5, we present predicted probabilities and pairwise comparisons for youth who are TGNC by perceived gender expression, stratified by birth-assigned sex. As indicated by Pillai’s trace, there was a significant effect of perceived gender expression for students who are TGNC and assigned male at birth on health status measures (P < .001) after controlling for covariates. Statistically significant differences between at least 2 groups on general health and long-term mental health problems were indicated in our results. Pairwise comparisons revealed that participants perceived as equally feminine or masculine (49.2%) or somewhat masculine (57.5%) were significantly more likely to report poorer general health than those with a very masculine (32.1%) perceived gender expression. When compared with those with a very masculine perceived presentation (15.8%), all other perceived gender expression groups were more likely to report long-term mental health problems (range: 40.7%–45.7%). Although a significant effect for long-term physical disability or health problems (P = .048) was indicated in our results, no statistically significant between-group comparisons were found. By using Pillai’s trace, a statistically significant effect of perceived gender expression on care utilization measures (P = .52) was not indicated after controlling for covariates.

    View this table:
    TABLE 4

    Perceived Gender Expression of TGNC Students by Birth-Assigned Sex (n = 2095)

    View this table:
    TABLE 5

    Predicted Probabilities of TGNC Students’ Health Status and Health Care Utilization, Stratified by Perceived Gender Expression and Birth-Assigned Sex (n = 2095)

    For adolescents who are TGNC and were assigned female at birth, a significant effect of perceived gender expression on health status measures (P = .001) was indicated by using Pillai’s trace after controlling for covariates. Pairwise comparisons revealed that participants with a somewhat feminine (69.5%), equally feminine and masculine (70.4%), or somewhat masculine (71.7%) perceived gender expression were significantly more likely to report poorer general health than those with a very feminine (54.0%) perceived gender expression. Compared with participants assigned female with a very feminine perceived gender expression (55.4%), participants with all other perceived gender expressions were more likely to report long-term mental health problems (range: 68.1%–76.7%). No other pairwise comparisons were statistically significant. The effect of perceived gender expression on care utilization measures was also not statistically significant.

    Discussion

    Population-based research in which both binary and nonbinary gender categories are examined is essential for a more comprehensive understanding of health disparities and health care needs of adolescents who are TGNC.13 In this study, we address research gaps related to health status and care utilization of youth who are TGNC by describing a variety of physical and mental health indicators in a large, population-based sample of adolescents and identifying perceived gender expression as an important factor in understanding health disparities for this understudied group.

    We found that students who are TGNC reported significantly poorer health status, lower rates of preventive health checkups, and more visits to the nurse’s office than their cisgender peers. Although youth who are TGNC reported an overall worse health status compared with their cisgender peers, nearly three-quarters of youth who are TGNC did not experience long-term physical disabilities or health problems, which is consistent with previous findings that this group typically does not struggle with chronic physical health concerns.2 Over half of adolescents who are TGNC have received preventive medical and dental care; these rates are slightly lower than those reported previously, but with this information, we can continue to highlight the importance of health care providers addressing health risk while promoting wellness within this community.29,30

    Among the TGNC sample, important differences emerged across perceived gender expressions by birth-assigned sex. Youth who are TGNC with perceived gender expressions that are incongruent or that somewhat deviate from societal expectations for their birth-assigned sex were at higher risk for poorer health outcomes. This is not surprising given the social pressures to conform to gender roles and stereotypes associated with one’s birth-assigned sex and is consistent with previous studies.10 Comparisons between perceived gender expression groups were not significantly different for any care utilization measure.

    School nurses are uniquely positioned to promote, educate, and advocate for optimal health for students who are TGNC. For example, school nurses can promote antibullying policies and clubs such as Gay-Straight Alliances to improve school climate.31,32 School nurses can assist adolescents by providing resources and information about gender identity and expression. When appropriate, school nurses can also discuss with parents of self-disclosing adolescents who are seeking support that family support is protective and rejection is potentially detrimental to health. In addition, nurses can assist with health promotion by referring to appropriate resources.32

    Consistent with gender minority and resilience theory, individuals perceived as gender nonconforming may be vulnerable to discrimination and have difficulty accessing and receiving health care compared with their cisgender peers.14,29,30,33 Perceived gender nonconformity may be a risk factor for minority stressors (eg, nonaffirmation, victimization, discrimination, or rejection), which may in turn elevate adverse health outcomes for these youth.3,13 Youth who are perceived or identify as gender nonconforming or nonbinary must also overcome unique barriers to accessing affirming health care compared with other TGNC adolescents, such as mistrust of health care providers because of fear of the youth’s own gender identity or expression being misunderstood.34,35 These barriers contribute to delays in seeking services, which may result in poorer health outcomes. More research with a focus on differences across gender identities and expressions is needed to better understand associations contributing to health risk disparities among youth who are TGNC.

    To our knowledge, this is the first large, population-based study of TGNC adolescents in the United States conducted to describe prevalence rates of health status and care utilization compared with cisgender youth and to explore perceived gender expression. Because of the census-like recruitment strategy in which all schools in the state were invited to participate, findings are more generalizable than results from previous studies in which convenience samples were used. The numerous measures of health status (including both mental and physical health) and care utilization are considerable strengths of the survey, with which we address a gap in the literature for youth who are TGNC.

    Although valuable information about health status and care utilization for youth who are TGNC is provided in our results, it is important to note limitations. First, asking about biological sex may be confusing for some students more accustomed to the phrase “sex assigned at birth,” which is commonly used in this population. Likewise, the measure of gender identity does not allow for differentiation of students who identify as transgender, genderqueer, or unsure. We were also unable to assess whether youth were interested in being perceived as a different gender, had received any gender-affirming medical interventions (ie, puberty blockers, gender-affirming hormones), or had socially transitioned to their affirmed gender, which may impact how their gender expression is perceived and how they feel about particular perceptions of their gender. Furthermore, we lack a measure of actual gender expression (ie, how youth perceive and present themselves in society through dress, mannerisms, and personal style). Instead, students were asked about how they think others at school perceive them, which might be interpreted as a question more reflective of gender affirmation than personal gender expression and/or presentation. Missing data (whether due to nonresponse or missed opportunities because of school absence) may result in an underestimation of TGNC identity and health status. Lastly, youth who are TGNC often use the bathroom in the nurse’s office36; thus, students may have overreported the frequency of nurse office visits.

    Conclusions

    Health status and care utilization differ between youth who are TGNC versus cisgender and across perceived gender presentations. With our results, we suggest that health care providers should screen for health risks and identify barriers to care for youth who are TGNC while promoting and bolstering wellness within this community. Although youth who are TGNC generally appear healthy and many are using health care services, continued research and advocacy are needed to decrease barriers to care and improve health outcomes for these young people, particularly those whose perceived gender expressions transgress societal expectations. As such, it is important that providers develop competency to work with adolescents with diverse gender identities and expressions because health needs may differ across and within gender groups.

    Acknowledgments

    MSS data were provided by public school students in Minnesota via local public school districts and are managed by the MSS Interagency Team.

    Footnotes

      • Accepted November 30, 2017.
    • Address correspondence to G. Nicole Rider, PhD, Program in Human Sexuality, Department of Family Medicine and Community Health, University of Minnesota Medical School, 1300 S 2nd St, Suite 180, Minneapolis, MN 55454. E-mail: gnrider{at}umn.edu

    • Preliminary findings from this study were summarized in a symposium presentation at the Rainbow Health Initiative’s Opportunity Conference; February 27, 2017; Saint Paul, MN.

    • FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

    • FUNDING: Supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (award R21HD088757). The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Funded by the National Institutes of Health (NIH).

    • POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

    • COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2017-4079.

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    Pediatrics
    Vol. 141, Issue 3
    1 Mar 2018
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    Health and Care Utilization of Transgender and Gender Nonconforming Youth: A Population-Based Study
    G. Nicole Rider, Barbara J. McMorris, Amy L. Gower, Eli Coleman, Marla E. Eisenberg
    Pediatrics Mar 2018, 141 (3) e20171683; DOI: 10.1542/peds.2017-1683
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