Mental Health Issues and Complex Experiences of Abuse Among Trans and Gender Diverse Young People: Findings from Trans Pathways

Trans and gender diverse (TGD)* people have a gender that is incongruent with their sex assigned at birth. Between 1.2%¹ and 2.7%² of adolescents are estimated to identify as TGD. TGD young people experience mental health problems at a far higher rate than the general young person population.^2–4 We have shown that TGD young people report high levels of mental distress, including self-harming (79.7%), suicidal thoughts (82.4%), and attempting suicide (48.1%).⁵ In addition, TGD young people are very likely to have been diagnosed with depression and/or anxiety at some stage in their lives (74.6% and 72.2%, respectively).⁵

TGD people are more likely to experience violence than their cisgender peers,⁶ placing them at higher risk for developing post-traumatic stress disorder (PTSD), engaging in high-risk behaviors, and suicidality.⁷ The 2015 U.S. transgender survey report indicates that 47% of transgender adults have been sexually assaulted, 10% have experienced family violence, and 54% have experienced intimate partner violence.⁸ A recent study showed that 72% of transgender and gender nonconforming adults have experienced at least one incident of violence from an intimate partner in their lifetime (32% reporting sexual violence, 71% psychological violence, 42% physical violence, and 29% assault and injury).⁹

Comparatively less is known about the experience of abuse and violence in younger trans populations, with most of the literature focused on the experience of bullying, harassment, and victimization in the school setting. For example, Grant et al.¹⁰ found that 78% of transgender adults recalled harassment and 35% recalled physical assault during their school years. In Australia, 21% of TGD young people have reported physical abuse because of their gender¹¹ and 74% have reported being bullied.¹² A large study of university students in the United States (mean age 22.22 years, standard deviation [SD] = 6.08)⁶ showed that transgender students were more likely to experience all types of victimization compared with cisgender students. These include intimate partner violence, stalking, sexual violence, and other physical or verbal violence.

There is surprisingly little exploration of exposure to abuse and violence and poor mental health outcomes among TGD people of any age. Testa et al.¹³ found that transgender adults exposed to physical and/or sexual violence were more likely to have attempted suicide than respondents without this exposure. In addition, sexual violence was associated with increased alcohol and illicit drug use among transgender women.¹³ In a sample of college students, heavy drinking episodes were more likely among transgender individuals who had been verbally threatened or sexually assaulted.¹⁴ Henry et al.⁹ demonstrated that all types of intimate partner violence (psychological, sexual, and physical) were associated with clinically significant anxiety in a sample of transgender and gender nonconforming adults and all kinds of intimate partner violence (with the exception of physical violence) were associated with clinical depression. Other research has demonstrated that earlier gender-related victimization or trauma (recall of early and late adolescence and, to a lesser extent, early adulthood) was strongly associated with contemporary major depression and suicide.¹⁵

Much of the previous literature has focused on the experiences of trans women, rarely including trans men and nonbinary individuals; information is needed to explore the experiences of abuse across these different identities. Moreover, comprehensive information is needed on experiences of trauma and mental health outcomes among TGD young people. Using data from the Trans Pathways survey,¹² the primary aims of this article were to (1) ascertain the prevalence of physical and sexual abuse (both within and external to the family), abuse within intimate relationships, and any other forms of familial abuse experienced by TGD young people; (2) explore relationships of these experiences of abuse with gender identity, sex assigned at birth, and age; and (3) determine the association between the various types of abuse and mental health outcomes.

This article reports on six specific forms of abuse and their associations with mental health outcomes among TGD young people. The results show that all forms of abuse were associated with poor mental health overall, although there was considerable divergence in the magnitudes of the risk estimates. This research is novel in that it provides direction for interventions to improve the mental health of TGD young people—primarily through increasing societal support and bolstering acceptance within families—by examining the associations between these six forms of abuse and mental health outcomes. Although we recognize the inherent limitations of interpreting cross-sectional data, the findings demonstrate high rates of abuse for TGD young people. The results show elevated rates of abuse occurring both within and outside of the family, as well as within intimate relationships. Almost a quarter of participants (24.3%) reported experiencing extrafamilial sexual abuse in their lifetime. A significant difference for sexual abuse within the family was observed by sex assigned at birth, with participants assigned female at birth more likely to be exposed to this abuse, although these results should be approached with caution given the small sample size. Participants who were aged 18 years or older were more likely to report sexual abuse by someone outside of their family, and more likely to report abuse within an intimate relationship, compared with those under the age of 18 years.

The prevalence proportions for familial physical and sexual abuse (24.8% and 7.5%) are of considerable concern. We estimated a fourfold increase in the OR for the association between familial physical abuse and lifetime suicide attempts. Although we acknowledge that many different experiences play a role in affecting the mental health of TGD young people,⁵ parental support (or lack thereof) is typically one of the vital dimensions of well-being. Research shows that TGD young people who are well supported by their parents tend to have better mental health than young people who are not supported.¹⁹ Future interventions should target this area with a focus on increasing familial acceptance and reducing violence and abuse against TGD young people within families. There are no existing evidence-based interventions specifically focused on increasing familial acceptance of TGD young people; however, an intervention has been developed for parents of TGD young people to increase their knowledge of gender diversity.²⁰ Such interventions could be adapted, or used to inform future interventions, to specifically address acceptance and reduction of violence within the family.

Comparisons with rates of abuse within the general Australian population are difficult due to inconsistent data collection methods as well as differing definitions of abuse. In the general Australian adult population, 48% of men and 34% of women have experienced physical violence and 4.5% of men and 19% of women have experienced sexual violence since the age of 15 years.²¹ Although not directly comparable, intimate partner abuse appears to be more common in this sample of TGD young people (30.9%) compared with the Australian general population, aged 18 years and older, where 23% of women and 7.8% of men have experienced violence by an intimate partner and 23% of women and 16% of men have experienced emotional abuse from an intimate partner since the age of 15 years.²² As noted, the results presented in this article indicate links between the six forms of abuse studied and self-harm, suicide, and psychiatric diagnoses. There is a well-established literature on the association between trauma/abuse and psychiatric disorders in the general population.^23,24 Similar associations have been observed among transgender adults, such as between various types of intimate partner violence (sexual, physical, and psychological) and clinically significant anxiety and depression.⁹

It is difficult to compare our sample with young same-sex attracted and gender-questioning (SSAGQ) young people because of incongruent measures of trauma. An Australian study found that 61% of SSAGQ young people had experienced verbal abuse due to their gender identity or sexuality; 18% had experienced physical abuse due to their gender identity or sexuality; and 24% had experienced verbal and physical abuse within their family.²⁵ A national Australian survey with gay, lesbian, bisexual, and transgender (GLBT) adults provides additional insight. GLBT adults most commonly reported being exposed to verbal abuse, with 25.5% of GLBT adults reporting experiencing this within the previous year.²⁶ Harassment and physical violence were also reported within the prior 12 months at the time of the survey (15.5% and 8.7%, respectively). Additional research needs to be undertaken to clarify exposure to violence within the general population, including specific types of violence enacted against people with diverse genders and sexualities, to inform policy and practice to reduce trauma. More precise and consistent data collection methods will enable more accurate comparisons across and within specific population groups.

In our study, the majority of participants did not attribute abuse to their TGD status, which is in contrast to other studies where transgender adults have commonly reported that the violence experienced was primarily because of their gender identity or expression.^13,27 Despite constituting a minority in our study, participants who attributed abuse to their identity need to be considered because if an individual believes that violence is perpetrated because of their identity, this can lead to internalized transphobia and the expectation of future traumatic events.¹³ Transgender people remain marginalized by society and face systematic discrimination.²⁸ Violence may arise from a general lack of knowledge and understanding of transgender people as well as from fear and stigma.⁸ Social marginalization can also lead to exposure to situations associated with an increased risk for violence, such as homelessness, familial rejection, and poverty.¹²

Our study explores an area of research into the well-being of TGD young people that has previously been neglected. These results add valuable insight into the mental health of TGD young people and the traumatic experiences to which they are exposed. The reported associations between traumatic experiences and adverse mental health outcomes suggest an urgent need for targeted prevention and intervention and, more broadly, enhanced societal support for TGD young people.

Some data from the Trans Pathways study have previously been published, as indicated within the article, including in a report titled Trans Pathways: The mental health experiences and care pathways of trans young people. The results and statistical analyses included within this article are novel; however, some of the descriptive statistics have been reported previously.