In 2022 a record number of anti-LGBTQIA+, and particularly anti-transgender, legislation was introduced in the United States. The Human Rights Campaign estimated that more than 300 anti-LGBTQ+ bills were either passed or introduced in at least 36 states. In 2023, the ACLU is tracking over 269 anti-LGBTQ bills being introduced.
Some of these laws restricted transgender and gender-diverse students’ participation in athletics, while others, such as Alabama were successful in passing a medical care ban for youth (which is being challenged). In February 2022, Texas Governor Greg Abbott ordered the state’s Department of Family and Protective Services to investigate parents that allow minors to socially or medically transition, forcing countless families to flee the state.
Unsurprisingly, these bills were introduced and laws passed in opposition to research informing best practice and best care in gender-affirming mental health and medical practices. Likewise, nearly every major medical and mental health organization (including the American Medical Association, The National Association of Social Workers, The American Psychiatric Association, and the American Academy of Pediatrics) opposes practices that would seek to limit access to gender-affirming care. This article will review some of the research discussing LGBTQ mental health outcomes. This includes specific research for transgender, nonbinary, and gender-diverse youth. As well as offers additional resources for gender-affirming care.
Understanding Terms for Transgender, Nonbinary, and Gender-Diverse Communities
One of the most important things to know is that gender and sexual diversity are normal, naturally occurring types of diversity. Likewise, the LGBTQIA+ community and sub-communities are not monoliths. Thus, the way one person may define their identity may not be the same way another person may define theirs. Two nonbinary people may have very different meanings and understandings of what it means to them to be nonbinary, just as two bisexual people may have different definitions of what it means to them to be bisexual. Relatedly, some people may choose to avoid identity labels and descriptors altogether. Or, may wish to keep their descriptors to themselves. All of the above are valid.
Still, in an attempt to give a general overview, I have included some language and definitions from the Human Rights Campaign’s Glossary of Terms, Gender Spectrum, the It Gets Better Project, and The Trevor Project. I encourage you to further explore the resources offered on each website. Moreso, learning from, following, and compensating transgender, nonbinary, and gender-diverse educators on various platforms such as Instagram, TikTok, and Facebook are also excellent options. Reminder, no place is better than, if appropriate, allowing a person to share directly what any term or identifier means for them.
Sex/sex assigned at birth:
Used to label a person as “male” or “female” (some US states and other countries offer a third option) at birth, this term refers to a person’s external genitalia and internal reproductive organs. When a person is assigned a particular sex at birth, it is often mistakenly assumed that this will equate with their gender; it might, but it might not.
Gender identity:
One’s innermost concept of self as male, female, or a blend of both or neither – how individuals perceive themselves and what they call themselves. One’s gender identity can be the same or different from their sex assigned at birth. It can also be the same or different from their gender expression.
Gender expression:
The external expression of one’s gender identity. It is usually expressed through:
behavior- clothing
- hairstyle
- mannerisms
- body characteristics
- voice
Gender expression may or may not conform to socially defined behaviors and characteristics typically associated with being masculine, feminine, both, or neither.
Gender binary:
A system that constructs gender according to two discrete and opposite categories: boy/man and girl/woman. It is important to recognize that both cisgender and Transgender people can have a gender identity that is binary.
Cisgender:
A term used to describe a person whose gender identity aligns with those typically associated with the sex assigned to them at birth.
Transgender:
Sometimes this term is used broadly as an umbrella term to describe anyone whose gender identity differs from their assigned sex. It can also be used more narrowly as a gender identity that reflects a binary gender identity that is “opposite” or “across from” the sex they were assigned at birth. Being transgender does not imply any specific sexual orientation. Therefore, transgender people may identify as straight, gay, lesbian, bisexual, etc.
Non-binary:
A term describing a person who does not identify exclusively as a man or a woman. Non-binary people may identify as being both a man and a woman, somewhere in between, or as falling completely outside these categories. While many non-binary folks identify as transgender, not all non-binary folks do. Non-binary can also be used as an umbrella term encompassing identities such as agender, bigender, genderqueer or gender-fluid.
Gender non-conforming:
A broad term referring to people who do not behave in a way that conforms to the traditional expectations of their gender, or whose gender expression does not fit neatly into a category. Some gender non-conforming folks may identify as transgender, whereas some gender non-conforming folks may not.
Gender-fluid:
People who have a gender or genders that change. Genderfluid people move between genders, experiencing their gender as something dynamic and changing, rather than static.
What is Gender Dysphoria?
In the broadest sense, gender dysphoria may be used to describe when someone feels very unhappy, dissatisfied, uncomfortable, or uneasy in relation to their gender. This may include feeling the tension between how someone feels about their body compared to how society genders their body, or a conflict between how someone sees themselves in contrast with expected gender roles or expectations. Gender dysphoria can encompass a broad range of feelings, from mild discomfort to unbearable distress. The intensity, pervasiveness, frequency, and triggers for gender dysphoria vary widely from person to person.
Feelings of gender dysphoria can, and often do, change over time. For example, an individual’s experience of gender dysphoria may lessen as greater congruence is achieved. If a person’s discomfort or distress is negatively affecting their quality of life and relationships, they may want to get support from a trained, affirming LGBTQ mental health professional.
Keep in mind that “gender dysphoria” is also a clinical term and is found in the Diagnostic and Statistical Manual of Mental Disorders (commonly referred to as the DSM, or DSM–5). The labeling of gender dysphoria as a disorder or condition has been controversial, but it is helpful to understand the term’s clinical definition and use (i.e., oftentimes being required in order to access gender-affirming medical procedures) if you are considering support from an LGBTQIA+ therapist. In the same way that gender identity varies from person to person, as does the experience of gender dysphoria. A person can absolutely be transgender, nonbinary, or gender-diverse without experiencing gender dysphoria.
What Does it Mean if a Person is Transitioning?
According to Gender Spectrum, “transitioning” is a term commonly used to refer to the steps a transgender, Agender, or non-binary person takes in order to find congruence in their gender. However, it is important to note that this term can be misleading as it implies that the person’s gender identity is changing and that there is a moment in time when this takes place. More accurately, it is others’ understanding of the person’s gender that shifts, and/or it may be that a person is putting additional language and understanding to one piece of who they are and always have been. As such, some transgender, nonbinary, and gender-diverse people do not utilize the word transition to describe their process.
What others see as a “transition” is actually an alignment in one or more dimensions of the individual’s gender as they seek congruence across those dimensions. A shift may be taking place, but it is often other people (i.e., parents, family members, employers, support professionals) who are transitioning in how they view and understand the individual’s gender. The person themselves is simply making some adjustments to further align their gender identity with their gender expression, which might include asking other’s in their lives to make some changes too, such as using a different name or different pronouns when referring to them. As Gender Spectrum puts it, “For the person, these changes are often less of a transition and more of an evolution.” Instead of “transitioning,” a more apt phrase is “pursuing congruence measures.”
A person can seek pursue congruence in many ways:
- Social congruence measures – This might include changes of social identifiers such as clothing, hairstyle, gender identity, name and/or pronouns
- Hormonal congruence measures – The use of medical approaches to promote physical, mental, and/or emotional alignment. This might include hormone blockers or hormone affirming therapy
- Surgical congruence measures – An addition, removal, or modification of gender-related physical traits
- Legal congruence measures – Changing identification documents such as one’s birth certificate, driver’s license, ID card, or passport.
It is important to note, though, that a transition experience can be a very significant event in a person’s life. A public declaration of some kind where an individual communicates to others that aspects of themselves are different than others have assumed, and that they are now living consistently with who they know themselves to be, can be an empowering and liberating experience (and moving to those who get to share that moment with them).
LGBTQ Mental Health And Supportive Environments for Queer, Transgender, Nonbinary, and Gender-Diverse Youth
The Trevor Project’s 2022 National Survey on LGBTQ Youth Mental Health captured the experiences of nearly 34,000 LGBTQ youth ages 13 to 24 across the United States. Forty-five percent of respondents were LGBTQ youth of color and 48% being transgender or nonbinary. The following key findings are highlighted:
45% of LGBTQ youth seriously considered suicide in the past year. This includes more than half of transgender and nonbinary youth (53%) and 1 in 3 cisgender youth (33%).- 14% of LGBTQ youth attempted suicide in the past year. Including nearly 1 in 5 transgender and nonbinary youth (19%) and nearly 1 in 10 cisgender youth (9%).
- 73% of LGBTQ youth reported experiencing symptoms of anxiety. This includes more than three-quarters of transgender and nonbinary youth (78%) and nearly two-thirds of cisgender youth (65%).
- 58% of LGBTQ youth reported experiencing symptoms of depression. Including nearly two-thirds of transgender and nonbinary youth (65%) and nearly half of cisgender youth (47%).
- Fewer than 1 in 3 transgender and nonbinary youth found their home to be gender-affirming.
- 60% of LGBTQ youth who wanted mental health care in the past year were not able to get it. This encompasses nearly 3 in 5 transgender and nonbinary youth (58%) and more than 3 in 5 cisgender youth (62%).
- LGBTQ youth who found their school to be LGBTQ-affirming reported lower rates of attempting suicide.
- LGBTQ youth who live in a community that is accepting of LGBTQ people reported significantly lower rates of attempting suicide.
See the full study and results here.
Gender-Affirming Care Is Associated With More Positive LGBTQ Mental Health Outcomes
Previously, there was limited information regarding the prevalence of gender diversity among adolescents. Over the last few years, studies from high school samples indicate up to 1.2% of participants identifying as transgender (Clark et al., 2014) and up to 2.7% experienced some level of self-reported gender diversity (Kidd et al., 2021; Wang et al., 2020). Moreover, in a sample of more than 300 transgender youth, 94 percent continued to identify as transgender after five years, according to a study published recently in Pediatrics. Just 2.5 percent had reverted to a cisgender identity; the remainder identified as nonbinary.
There are also growing numbers of youth seeking gender-affirming mental health and medical treatment. As such, in assisting youth and their caregivers in making decisions regarding gender-affirming medical treatment, it is important to remain abreast of current research. A short narrative review of United States based available studies with higher sample sizes (over 100 participants) is provided:
Association of gender-affirming hormone therapy with depression, thoughts of suicide, and attempted suicide among transgender and nonbinary youth
This 2021 study by Greene and colleagues was conducted by researchers from The Trevor Project. A total of 5,753 transgender adolescents who expressed a desire in gender-affirming hormone treatment participated in this study. Of these, 1,216 had accessed gender-affirming hormone treatment. After adjusting for potential confounding variables, for those participants under 18, access to gender-affirming hormones was associated with lower odds of recent depression and suicide attempts when compared to those who desired, but did not access, gender-affirming hormones.
Access to gender-affirming hormones during adolescence and mental health outcomes among transgender adults.
This 2022 study by Turban and colleagues was conducted at Harvard Medical School. Researchers examined experiences of 21,598 adults who endorsed ever desiring gender-affirming hormones. Of these, 481 had accessed gender-affirming hormones during adolescence. While 12,257 accessed gender-affirming hormones as adults. And the final 8,860 participants were never able to access gender-affirming hormones. Results found that, regardless of age of initiation, accessing gender-affirming hormones was associated with lower odds of past-year suicidal ideation. In addition to lower severe psychological distress in the past year. Additionally, results indicated that access to gender-affirming hormones during adolescence was associated with lower odds of these same adverse mental health outcomes when compared to not accessing gender-affirming hormones until adulthood.
Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care.
This 2022 study by Tordoff and colleagues followed 104 transgender and non-binary youth who were receiving gender-affirming medical treatment. Results indicated lower odds of depression and suicidality among young people who had started gender-affirming medical care, compared to those who did not.
There are always inherent limitations to every research study. One limitation might be that there have not been any randomized controlled trials. However, there is a general consensus in the scientific community that such a trial who be considered unethical, given the substantial body of research indicating that the control group (i.e., precluded from accessing gender-affirming care) would be likely to suffer adverse mental health outcomes compared to those randomized to the treatment (i.e., accessing gender-affirming care) groups.
Working with a Gender-Affirming Provider in North Carolina
To be clear, this blog post is not meant to suggest that every transgender, nonbinary, gender-diverse, or gender-exploring youth should be automatically and immediately referred for gender-affirming hormone therapy. To the contrary! This is where working collaboratively with an experienced gender-affirming LGBTQ mental health provider who is well-versed in the research, literature, and resources for gender-affirming treatment and care for youth is important.
A gender-affirming provider will spend time with the adolescent. They provide a safer space for exploration and discussion. This also allows the LGBTQIA+ therapist to gain a better understanding of the adolescents:
- Gender identity
- Gender expression
- Experiences of dysphoria and euphoria
- Goals
The discussion and exploration of goals will relate to various ways to achieve greater gender euphoria and congruence via the various avenues available (i.e., exploring social, hormonal, and/or legal avenues) and those that feel appropriate and accessible to the adolescent. Perhaps discussions around accessing and choosing affirming clothing will be a starting place. Or, talking more about name(s) and pronouns that feel best, and helping the adolescent to navigate where, how, or when they might wish to use them. Discussions relating to lowering dysphoria during shower-times, or in the locker room, can also be a topic of discussion.
Gender-affirming hormone treatment may also be a topic of discussion if this appears aligned with the youth’s identity and goals. Parent(s)/guardian(s) would be included in the collaborative, psychoeducational conversation and resource sharing. Ultimately, if the family and youth are agreeable and wish to learn more, the mental health clinician can make a recommendation for the family to further explore these questions with a pediatric endocrinologist specializing in gender-affirming care for adolescents. Such as providers at Duke Child and Adolescent Gender Care and UNC Pediatric and Adolescent Gender Clinic.
Additional Resources for Transgender, Nonbinary, and Gender-Diverse Adolescents in North Carolina
A gender-affirming therapist in North Carolina may also assist the adolescent with connecting to other peer and professionally-led community spaces. Although there can be some great resources found online, there can also be a lot of misinformation. That is why peer-centered support spaces, such as those offered and facilitated by the LGBT Center of Raleigh, LGBT Center of Durham, Youth Outright, and Time Out Youth can be helpful.
Likewise, therapeutic support groups, such as those offered by Be BOLD Psychology and Consulting, can be an additional space for mental health and gender-affirming support
Family support and education is also paramount in offering gender-affirming care and helping to facilitate gender-affirming home and educational spaces. As such, locating spaces for parents and family members to gain support and education is important. One excellent resource in North Carolina includes Transforming Families NC. Along with other offerings for families via the LGBT Centers of Durham and Raleigh. Likewise, Gender Spectrum has resources for parents and families too.
Other resources for transgender, nonbinary, and gender-diverse youth include:
- The Trevor Project
- TrevorSpace; An affirming international community for LGBTQ young people ages 13-24.
A full list of resources for transgender, nonbinary, and gender-diverse adolescents, adults, and families can be found on our Trans/Gender-Diverse Resource Page, updated intermittently!
Affirming Therapy for Transgender, Nonbinary, and Gender-Diverse Teens in North Carolina
Be BOLD Psychology and Consulting specializes in providing affirming therapy for transgender, non-binary, and gender-diverse clients. As well as therapy for the broader queer+ community! Our queer and trans-identified and LGBTQIA+ allied clinicians offer:
individual therapy- family therapy
- couples therapy
- relationship therapy
- group therapy
All of these services are for queer+, transgender, non-binary, and gender-diverse folx. Learn more about Be BOLD Psychology and Consulting!
Start Online Therapy Specializing in Gender-Affirming LGBTQ Mental Health Today
At Be BOLD Psychology & Consulting we are dedicated to providing affirming care. This includes continued training on the best resources and research in LGBTQ mental health care.
Are you wanting gender-affirming, queer-affirming, inclusive therapy, and letter-writing services with an LGBTQ therapist? If the answer is yes then follow these steps:
- Send an email to info@beboldpsychnc.com or submit a request for a free 20-minute consultation here!
- Schedule your first appointment for online LGBTQIA+ affirming therapy
- Start getting the support you deserve in a safer space, affirming ALL parts of you!
Other Online Therapy Services Available Throughout North Carolina
Our mental health services are open to all people, races, abilities, sizes, religious beliefs, and spiritual backgrounds.
Our affirming and experienced therapists offer inclusive individual therapy, couples therapy, and group therapy. These services are inclusive of BIPOC, neurodivergent, and LGBTQ+ mental health. Our online therapy services include trauma therapy, PTSD treatment, and grief counseling. In addition to therapy for chronic pain, and caregiver fatigue.
You can receive support from anywhere in North Carolina with online therapy.
