More LGBTQ-inclusive sex ed reduces odds of bullying, depression, suicidal thoughts, and victimization (J Adolesc Health)

Title: Associations of LGBTQ-inclusive sex education with mental health outcomes and school-based victimization in U.S. high school students

Journal: Journal of Adolescent Health

Public access URL: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6478545/pdf/nihms-1516132.pdf

Summary: Students with a greater proportion of LGBTQ-inclusive sex education have lower odds of experiencing school-based victimization and adverse mental health [such as depressive symptoms, suicidal thoughts, or making a plan to commit suicide

Doctor's Rec: WPATH Standards of Care for “Transsexual, Transgender, and Gender Nonconforming People”

The overall goal of the SOC is to provide clinical guidance for health professionals to assist transsexual, transgender, and gender nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment. This assistance may include primary care, gynecologic and urologic care, reproductive options, voice and communication therapy, mental health services (e.g., assessment, counseling, psychotherapy), and hormonal and surgical treatments.

While this is primarily a document for health professionals, the SOC may also be used by individuals, their families, and social institutions to understand how they can assist with promoting optimal health for members of this diverse population.

Kaiser Permanente Transgender Care follows the WPATH standards of care and the 2009 Endocrine Society Guidelines, as well as a companion document for voice and communication change. Click through to access this file in 18 different languages.

Doctor's Rec: Puberty blockers can be life-saving for transgender teenagers. (Pediatrics)

Summary: Pubertal suppression therapy could significantly diminish their chances of suicide and mental health problems.

Title: Trends in the use of puberty blockers among transgender children in the United States.

Authors: Lopez CM, Solomon D, Boulware SD, Christison-Lagay ER

Journal: Journal of Pediatric Endocrinology and Metabolism

Publication date: 2018 Jun 27;31(6):665-670. doi: 10.1515/jpem-2018-0048.

Pub Med ID: 29715194 DOI: 10.1515/jpem-2018-0048. Available at https://www.ncbi.nlm.nih.gov/pubmed/29715194 .

BACKGROUND:

The objective of the study was to identify national trends in the utilization of histrelin acetate implants among transgender children in the United States.

METHODS:

We analyzed demographic, diagnostic and treatment data from 2004 to 2016 on the use of histrelin acetate reported to the Pediatric Health Information System (PHIS) to determine the temporal trends in its use for transgender-related billing diagnoses, e.g. "gender identity disorder". Demographic and payer status data on this patient population were also collected.

RESULTS:

Between 2004 and 2016, the annual number of implants placed for a transgender-related diagnosis increased from 0 to 63. The average age for placement was 14 years. Compared to natal females, natal males were more likely to receive implants (57 vs. 46) and more likely to have implants placed at an older age (62% of natal males vs. 50% of natal females were ≥;13 years; p<0.04). The majority of children were White non-Hispanic (White: 60, minority: 21). When compared to the distribution of patients treated for precocious puberty (White: 1428, minority: 1421), White non-Hispanic patients were more likely to be treated with a histrelin acetate implant for a transgender-related diagnosis than minority patients (p<0.001). This disparity was present even among minority patients with commercial insurance (p<0.001).

CONCLUSIONS:

Utilization of histrelin acetate implants among transgender children has increased dramatically. Compared to natal females, natal males are more likely to receive implants and also more likely to receive implants at an older age. Treated transgender patients are more likely to be White when compared to the larger cohort of patients being treated with histrelin acetate for central precocious puberty (CPP), thus identifying a potential racial disparity in access to medically appropriate transgender care.

"Individual self-esteem, healthy relationships w/ parents & peers, and GSAs are most common protective factors." (J Prim Prev)

Protective Factors Among Transgender and Gender Variant Youth: A Systematic Review by Socioecological Level

From abstract

Transgender and gender variant (GV) youth experience elevated risk for poor health and academic outcomes due mainly to social experiences of stigma and discrimination. To supplement the growing evidence on health risks encountered by transgender/GV youth, we identified factors theorized to be protective for these youth across all four levels of Bronfenbrenner's socioecological model (individual, relationship, community, societal). We conducted a systematic search of peer-reviewed research. The articles included in this review were published in peer-reviewed journals in English or Spanish between 1999 and 2014, analyzed data from a sample or subsample of transgender or GV participants with a mean age between 10 and 24 years, and examined the relationship of at least one theorized protective factor to a health or behavioral outcome. Twenty-one articles met inclusion criteria. Transgender/GV youth in included articles ranged from 11 to 26 years of age, were racially/ethnically diverse, and represented varied gender identities. Within these articles, 27 unique protective factors across four levels of the ecological model were identified as related to positive health and well-being. Self-esteem at the individual level, healthy relationships with parents and peers at the relationship-level, and gay-straight alliances at the community level emerged as protective factors across multiple studies. Our findings underscore the relative lack of research on transgender/GV youth and protective factors. Novel recruitment strategies for transgender/GV youth and better measurement of transgender identities are needed to confirm these protective relationships and identify others. Growth in these areas will contribute to building a body of evidence to inform interventions.

Citation

Johns et al. (2018) Protective Factors Among Transgender and Gender Variant Youth: A Systematic Review by Socioecological Level. Journal of Primary Prevention. 2018 Jun;39(3):263-301. doi: 10.1007/s10935-018-0508-9.

W. Canada schools w/ GSAs of 3+yrs consistently reduces suicidal ideation for ALL students regardless of orientation (Int'l Journal of Child Youth Family Studies)

School-Based Strategies to Reduce Suicidal Ideation, Suicide Attempts, and Discrimination among Sexual Minority and Heterosexual Adolescents in Western Canada.

Excerpt from abstract:

Analyses of the province-wide random cluster-stratified 2008 B.C. Adolescent Health Survey (n =21,70 8) compared students in schools with GSAs or policies implemented at least 3 years, and less than 3 years, with those in schools without GSAs or anti-homophobia policies, using multinomial logistic regression, separately by gender. LGB students had lower odds of past year discrimination, suicidal thoughts and attempts, mostly when policies and GSAs had been in place for 3+ years; policies had a less consistent effect than GSAs. Heterosexual boys, but not girls, also had lower odds of suicidal ideation and attempts in schools with longer-established anti-homophobic bullying policies and GSAs. 

Citation

Saewcy EM, Konishi C, Rose HA, Homma Y. School-based strategies to reduce suicidal ideation, suicide attempts, and discrimination among sexual minority and heterosexual adolescents in Western Canada. External  International Journal of Child, Youth and Family Studies 2014;1:89‒112.

"The presence of a GSA correlates with fewer depressive symptoms & mental health referrals for suicidal thoughts." (Journal of Youth & Adolescence)

School Climate & Sexual and Gender Minority Adolescent Mental Health.

Excerpt from abstract:

This study uses a survey that measures all four measures of school environment with a national sample of 240 sexual/gender minority high school students ages 14-18 (mean age 15.77) where 53% of participants had a Gay-Straight Alliance in their school. The sample is 53% cisgender, 100% sexual minority and 62% white. Adjusting for demographics and presence of a Gay-Straight Alliance, fewer depressive symptoms were associated with lower help-seeking intentions for suicidal thoughts. The presence of Gay-Straight Alliance was not statistically associated with past-month help-seeking intentions or behaviors. Additionally, a more supportive school climate was associated with lower anxiety and depressive symptoms. However, the presence of a Gay-Straight Alliance was not statistically associated with anxiety or depressive symptoms. These findings suggest that a supportive school climate and supportive school personnel may be important for supporting the mental health of sexual/gender minority students.

Citation

Colvin et al. (2019) School Climate & Sexual and Gender Minority Adolescent Mental Health. (2019) J. Youth Adolesc. 2019 Oct;48(10):1938-1951. doi: 10.1007/s10964-019-01108-w. Epub 2019 Aug 24.

"School connectedness & school adult support were associated w/ 22% decrease in drug use in LGB California public school students." (LGBT Health)

Article title:

School Protective Factors and Substance Use Among Lesbian, Gay, and Bisexual Adolescents in California Public Schools.

From the abstract:

A secondary analysis of the 2013-2015 California Healthy Kids Survey (CHKS) was conducted to examine associations between school protective factors (i.e., school connectedness and adult support) and substance use among LGB youth, above and beyond a key risk factor, school victimization. The study outcomes were past 30-day and in-school use of cigarettes, alcohol, marijuana, inhalants, prescription pain medication, and other illegal drugs.

Overall, school connectedness and school adult support were associated with lower odds of substance use. For example, higher levels of school connectedness were associated with 22% decreased odds of past 30-day inhalant use (adjusted odds ratio [AOR] = 0.78; 95% confidence interval [CI] = 0.72-0.86), and 25% decreased odds of past 30-day prescription pain medication use (AOR = 0.75; 95% CI = 0.69-0.82). Higher levels of adult support in school were also associated with 17% decreased odds of marijuana use on school property in the past 30 days (AOR = 0.83; 95% CI = 0.77-0.91).

Citation

De Pedro KT, Esqueda MC, Gilreath TD. School Protective Factors and Substance Use Among Lesbian, Gay, and Bisexual Adolescents in California Public Schools. LGBT Health External . 2017 Jun;4(3):210-216. doi: 10.1089/lgbt.2016.0132. Epub 2017 May 12.

Psychologists recognize that TGNC people are more likely to experience positive life outcomes when they receive social support or trans-affirmative care. (APA)

Source: American Psychological Association. (2015). Guidelines for Psychological Practice with Transgender and Gender Nonconforming People. American Psychologist, 70 (9), 832-864. doi: 10.1037/a0039906

Guideline 11. Psychologists recognize that TGNC people are more likely to experience positive life outcomes when they receive social support or trans-affirmative care.

Research has primarily shown positive treatment outcomes when TGNC adults and adolescents receive TGNC-affirmative medical and psychological services (i.e., psychotherapy, hormones, surgery; Byne et al., 2012; R. Carroll, 1999; Cohen-Kettenis, Delemarre-van de Waal, & Gooren, 2008; Davis & Meier, 2014; De Cuypere et al., 2006; Gooren, Giltay, & Bunck, 2008; Kuhn et al., 2009), although sample sizes are frequently small with no population-based studies. In a meta-analysis of the hormone therapy treatment literature with TGNC adults and adolescents, researchers reported that 80% of participants receiving trans-affirmative care experienced an improved quality of life, decreased gender dysphoria, and a reduction in negative psychological symptoms (Murad et al., 2010).

In addition, TGNC people who receive social support about their gender identity and gender expression have improved outcomes and quality of life (Brill & Pepper, 2008; Pinto, Melendez, & Spector, 2008).

Several studies indicate that family acceptance of TGNC adolescents and adults is associated with decreased rates of negative outcomes, such as depression, suicide, and HIV risk behaviors and infection (Bockting et al., 2013; Dhejne et al., 2011; Grant et al., 2011; Liu & Mustanski, 2012; Ryan, 2009).

Family support is also a strong protective factor for TGNC adults and adolescents (Bockting et al., 2013; Moody & Smith, 2013; Ryan et al., 2010).

TGNC people, however, frequently experience blatant or subtle antitrans prejudice, discrimination, and even violence within their families (Bradford et al., 2007). Such family rejection is associated with higher rates of HIV infection, suicide, incarceration, and homelessness for TGNC adults and adolescents (Grant et al., 2011; Liu & Mustanski, 2012). Family rejection and lower levels of social support are significantly correlated with depression (Clements-Nolle et al., 2006; Ryan, 2009).

Many TGNC people seek support through peer relationships, chosen families, and communities in which they may be more likely to experience acceptance (Gonzalez & McNulty, 2010; Nuttbrock et al., 2009).

Peer support from other TGNC people has been found to be a moderator between antitrans discrimination and mental health, with higher levels of peer support associated with better mental health (Bockting et al., 2013).

Works cited:

  1. Bockting, W. O., Miner, M. H., Swinburne Romine, R. E., Hamilton, A., & Coleman, E. (2013). Stigma, mental health, and resilience in an online sample of the US transgender population. American Journal of Public Health, 103, 943–951. http://dx.doi.org/10.2105/AJPH.2013 .301241

  2. Brill, S., & Pepper, R. (2008). The transgender child: A handbook for families and professionals. San Francisco, CA: Cleis Press.

  3. Byne, W., Bradley, S. J., Coleman, E., Eyler, A. E., Green, R., Menvielle, E. J., . . . American Psychiatric Association Task Force on Treatment of Gender Identity Disorder. (2012). Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder. Archives of Sexual Behavior, 41, 759 –796. http://dx.doi.org/10.1007/ s10508-012-9975-x

  4. Carroll, R. (1999). Outcomes of treatment for gender dysphoria. Journal of Sex Education & Therapy, 24, 128 –136.

  5. Clements-Nolle, K., Marx, R., & Katz, M. (2006). Attempted suicide among transgender persons: The influence of gender-based discrimination and victimization. Journal of Homosexuality, 51, 53– 69. http://dx .doi.org/10.1300/J082v51n03_04

  6. Cohen-Kettenis, P. T., Delemarre-van de Waal, H. A., & Gooren, L. J. G. (2008). The treatment of adolescent transsexuals: Changing insights. Journal of Sexual Medicine, 5, 1892–1897. http://dx.doi.org/10.1111/j .1743-6109.2008.00870.x

  7. Davis, S. A., & Meier, S. C. (2014). Effects of testosterone treatment and chest reconstruction surgery on mental health and sexuality in femaleto-male transgender people. International Journal of Sexual Health, 26, 113–128. http://dx.doi.org/10.1080/19317611.2013.833152

  8. De Cuypere, G., Elaut, E., Heylens, G., Van Maele, G., Selvaggi, G., T’Sjoen, G.,... Monstrey, S. (2006). Long-term follow-up: Psychosocial outcomes of Belgian transsexuals after sex reassignment surgery. Sexologies, 15, 126 –133. http://dx.doi.org/10.1016/j.sexol.2006.04.002

  9. Dhejne, C., Lichtenstein, P., Boman, M., Johansson, A. L. V., Långström, N., & Landén, M. (2011). Long-term follow-up of transsexual persons undergoing sex reassignment surgery: Cohort study in Sweden. PLoS ONE, 6(2), e16885. http://dx.doi.org/10.1371/journal.pone.0016885

  10. Gooren, L. J., Giltay, E. J., Bunck, M. C. (2008). Long-term treatment of transsexuals with cross-sex hormones: Extensive personal experience. Journal of Clinical Endocrinology & Metabolism: Clinical and Experimental, 93, 19 –25. http://dx.doi.org/10.1210/jc.2007-1809

  11. Grant, J. M., Mottet, L. A., Tanis, J., Harrison, J., Herman, J. L., & Kiesling, M. (2011). Injustice at every turn: A report of the national transgender discrimination survey. Washington, DC: National Center for Transgender Equality & National Gay and Lesbian Task Force. Retrieved from http://endtransdiscrimination.org/PDFs/NTDS_Report .pdf

  12. Kuhn, A., Brodmer, C., Stadlmayer, W., Kuhn, P., Mueller, M. D., & Birkhauser, M. (2009). Quality of life 15 years after sex reassignment surgery for transsexualism. Fertility and Sterility, 92, 1685–1689. http:// dx.doi.org/10.1016/j.fertnstert.2008.08.126

  13. Liu, R. T., & Mustanski, B. (2012). Suicidal ideation and self-harm in lesbian, gay, bisexual, and transgender youth. American Journal of Preventive Medicine, 42, 221–228. http://dx.doi.org/10.1016/j.amepre .2011.10.023

  14. Moody, C. L., & Smith, N. G. (2013). Suicide protective factors among trans adults. Archives of Sexual Behavior, 42, 739 –752. http://dx.doi .org/10.1007/s10508-013-0099-8

  15. Murad, M. H., Elamin, M. B., Garcia, M. Z., Mullan, R. J., Murad, A., Erwin, P. J., & Montori, V. M. (2010). Hormonal therapy and sex reassignment: A systemic review and meta-analysis of quality of life and psychosocial outcomes.Clinical Endocrinology, 72, 214 –231. http:// dx.doi.org/10.1111/j.1365-2265.2009.03625.x

  16. Pinto, R. M., Melendez, R. M., & Spector, A. Y. (2008). Male-to-female transgender individuals building social support and capital from within a gender-focused network. Journal of Gay and Lesbian Social Services, 20, 203–220. http://dx.doi.org/10.1080/10538720802235179

  17. Ryan, C. (2009). Supportive families, healthy children: Helping families with lesbian, gay, bisexual & transgender children. San Francisco, CA: Family Acceptance Project, Marian Wright Edelman Institute, SanFrancisco State University. Retrieved from http://familyproject.sfsu.edu/files/FAP_English%20Booklet_pst.pdf

  18. Ryan, C., Russell, S. T., Huebner, D., Diaz, R., & Sanchez, J. (2010). Family acceptance in adolescence and the health of LGBT young adults. Journal of Child and Adolescence and the Health of LGBT Young Adults, 23, 205–213.

Doctor's Rec: 64,000+ pediatricians recommend gender-affirming treatment for children based on best available evidence

A September 2015 presentation from the American Academy of Pediatrics notes that treatment recommendations are based on the best available evidence. Their guidance defined three approaches to gender dysphoria in children: “corrective,” “supporting,” and “affirming,” with the AAP advising the “affirming” approach to gender dysphoria in children.



Sources:

  1. Kim Lacapria. (2016) American Pediatricians Issue Statement That Transgenderism Is ‘Child Abuse’? It was an official-sounding but fringe group of politically motivated pediatricians who issued a statement on gender, not the respected American Academy of Pediatrics. Snopes (6 May 2016) (pdf).

  2. Robert Garofalo. (2015) Understanding Gender Nonconformity in Childhood and Adolescence. American Academy of Pediatrics (September 2015). (pdf).

Doctor's Rec: Statement from American Academy of Pediatrics

The official American Academy of Pediatrics published (link to summary article) 9 clear recommendations for caring for youth and adolescents who identify as transgender or gender-diverse.

I highlight the portions that specify providing health care according to what the youth wants, especially to match the youth’s gender expression. Not parent, guardian, teacher, staff member, administrator, guidance counselor, etc.

[Aside: You may have heard a FoxNews Glenn Beck headline about an anti-gay-marriage hate group calling itself “American Pediatricians” creating a hoax claiming supporting a transgender youth is abuse. Read more about how Snopes debunked this, as well as the American Academy of Pediatrics’ internal presentation recommending affirming a child’s gender expression (pdf). —RXS]

1. that youth who identify as TGD have access to comprehensive, gender-affirming, and developmentally appropriate health care that is provided in a safe and inclusive clinical space;

2. that family-based therapy and support be available to recognize and respond to the emotional and mental health needs of parents, caregivers, and siblings of youth who identify as TGD;

3. that electronic health records, billing systems, patient-centered notification systems, and clinical research be designed to respect the asserted gender identity of each patient while maintaining confidentiality and avoiding duplicate charts;

4. that insurance plans offer coverage for health care that is specific to the needs of youth who identify as TGD, including coverage for medical, psychological, and, when indicated, surgical gender-affirming interventions;

5. that provider education, including medical school, residency, and continuing education, integrate core competencies on the emotional and physical health needs and best practices for the care of youth who identify as TGD and their families;

6. that pediatricians have a role in advocating for, educating, and developing liaison relationships with school districts and other community organizations to promote acceptance and inclusion of all children without fear of harassment, exclusion, or bullying because of gender expression;

7. that pediatricians have a role in advocating for policies and laws that protect youth who identify as TGD from discrimination and violence;

8. that the health care workforce protects diversity by offering equal employment opportunities and workplace protections, regardless of gender identity or expression; and

9. that the medical field and federal government prioritize research that is dedicated to improving the quality of evidence-based care for youth who identify as TGD.

Citation:

Jason Rafferty (2018) Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents. Pediatrics Sep 2018, e20182162; DOI: 10.1542/peds.2018-2162 (direct pdf)

Using a Transgender Person's Name Can Decrease Their Risk of Depression and Suicide (Teen Vogue)

A new study from The University of Texas at Austin has shed light on the importance of name usage for transgender youth. The study, which was published in the Journal of Adolescent Health in preparation for the annual Transgender Day of Visibility, concluded that when young transgender people are able to use their names in areas of everyday life, their risk of suicide and depression decreases.

They found that young people who could use their names in all four scenarios experienced 71% fewer symptoms of depression, 34% fewer symptoms of suicidal ideation, and a 65% decrease in attempted suicide than those who were not able to use their names.

Read the article here: https://www.teenvogue.com/story/using-transgender-persons-name-decrease-risk-of-depression-suicide

Using Chosen Names Reduces Odds of Depression and Suicide in Transgender Youths (Journal of Adolescent Health)

““It’s practical to support young people in using the name that they choose It’s respectful and developmentally appropriate.””
— Stephen T. Russell (University of Texas at Austin)

After interviewing 129 youths in 3 US cities, the researchers found that having even one context in which a chosen name could be used was associated with a 29 percent decrease in suicidal thoughts.

The research was funded by a grant from the National Institute of Mental Health and supported by the UT Population Research Center and a grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development.

Citation: Stephen T. Russell, Amanda M. Pollitt, Gu Li, & Arnold H. Grossman. (2018) Chosen Name Use Is Linked to Reduced Depressive Symptoms, Suicidal Ideation, and Suicidal Behavior Among Transgender Youth. Journal of Adolescent Health, Volume 63, Issue 4, 503 - 505. DOI: https://doi.org/10.1016/j.jadohealth.2018.02.003