Depression and anxiety among transgender-identifying adolescents in psychiatric outpatient care

Definition and prevalence of transgender

Gender incongruence in the ICD-11 refers to a marked and persistent incongruence between one’s experienced gender and their biological sex [1]. It often leads to a desire to transition, i.e. to live and be accepted as a person of the experienced gender. The term gender dysphoria refers to the anxiety and distress associated with the perceived incongruence between one’s body and one’s gender identity according to the DSM-5-TR diagnostic term [2]. The term transgender refers to all gender identities that differ from the person’s sex. Not all individuals who identify as transgender experience gender dysphoria [3]. Individuals whose gender identity corresponds with their sex are referred to as cisgender.

In most Western countries, the indications for and the timeliness of medical gender reassignment are assessed by gender identity services specializing in this field. These services typically involve a comprehensive assessment of identity development by multidisciplinary teams. In the past two decades, there has been a notable increase in the volume of referrals to child and adolescent gender identity services in multiple countries [4], 5]. It is uncertain whether the observed phenomenon indicates an actual rise in gender dysphoria, a lower threshold to seek assistance, or possibly societal changes that encourage the understanding of developmental difficulties as linked to sex and gender [6].

In population-based studies, patient self-identification is the standard method for assessing transgender identities [7]. A recent Finnish study utilizing data from the School Health Promotion Survey estimated that 0.6 % of adolescents self-report identifying with the opposite sex, while 3.3 % self-report identifying with a gender identity that encompasses both boys and girls, neither, or varying perceptions of their own gender [8]. The prevalence of transgender individuals in the population significantly depends on the definition used. Self-reported prevalence tends to be higher than figures recorded in medical documentation and formal transgender diagnoses [9].

For unknown reasons the sex ratio of adolescents referred to specialized gender identity clinics has changed from birth-assigned male favoring to birth-assigned female favoring in most countries [8], [10], [11], [12].

Prevalence of psychiatric diagnoses in transgender-identifying youth

The prevalence of psychological difficulties, including depression and anxiety, is notably higher in both the general population and in samples from specialized gender clinics among transgender-identifying adolescents. A systematic review reported that the prevalence of mental health problems in gender-referred adolescents ranged from 22 to 78 %, with depression (30–78 %) and anxiety (21–63 %) as the most common disorders [13]. A similar phenomenon has been observed in both population and primary care samples, with transgender-identifying adolescents exhibiting depressive and anxiety symptoms and disorders at a rate that is two to three times higher than that observed in cisgender youth [14], [15], [16]. This is commonly associated both to body distress and minority status. Identifying as a part of a minority does not cause mental health issues as such, but the higher prevalence of mental health disorders in minority populations is attributed to the stressful social environment created by stigma, prejudice, and discrimination – a theory known as “minority stress” [17]. For transgender-identifying individuals, facing social stressors related to their gender is linked to adverse mental health effects [18].

Aims of the study

Transgender-identifying youth and those clinically referred for gender dysphoria have higher rates of mental health disorders, particularly depressive and anxiety disorders, than their cisgender peers. It is not known how common it is for adolescents referred to psychiatric care for serious mental disorders to identify as transgender. It is also unclear whether they have depression and anxiety disorders and symptom levels similar or different from cisgender-identifying patients, and whether their levels of perceived gender incongruence correlate with symptoms of depression and anxiety. The aim of this study was to investigate the prevalence of transgender-identification among adolescents in a Finnish general adolescent psychiatric outpatient clinic. Second, based on the existing literature, we aimed to investigate whether transgender-identifying adolescents would show a higher prevalence of symptoms and diagnoses related to depression and anxiety compared to their cisgender-identifying peers. Third, we examined the extent to which transgender-identifying individuals in this population perceive incongruence between their sex and gender identity, and whether the perceived incongruence associates with depression and anxiety. To our knowledge, this is the first study to examine transgender-identifying individuals in a European general adolescent outpatient psychiatric sample.

Study

This study involved analyzing secondary data from the SMART project (“Systemic metabolic alterations related to different psychiatric disease categories in adolescent outpatients”). The SMART project is an ongoing longitudinal study that combines laboratory tests, diagnostic interviews, and self-reported symptoms among adolescent psychiatric patients [19]. All participants provided written informed consent. The study conformed to the most recent revision of the Declaration of Helsinki [20]. The Research Ethics Committee of Kuopio University Hospital approved the study protocol (2. 238/2017).

Participants

Our study population consists of youth aged from 14 to 20 years old (n=2,853). They were referred to the adolescent psychiatric outpatient clinic of Kuopio University Hospital in Finland between June 2017 and June 2023. The specific reasons for non-participation were not systematically documented but included initially declining participation, dropout, transfer to inpatient care before recruitment, and instances where the study was not presented to patients by clinical staff for various reasons, including a lack of in-person visits during the COVID-19 pandemic. Out of the initial cohort, 2099 patients chose not to partake.

Our sample initially consisted of 751 individuals. Five adolescents were excluded from the analysis because they were referred to the adolescent psychiatric outpatient clinic solely to obtain a referral to the gender identity clinic in Finland. Furthermore, they did not exhibit any primary or secondary psychopathological conditions, as stated in their referrals and confirmed in the diagnostic interview and by symptom questionnaires.

Diagnostic interviews

Each participant underwent a comprehensive interview and was subsequently asked to complete self-rated questionnaires at the beginning of the study and on 6-month follow-up. To ensure standardized diagnostic assessments, a trained psychiatric nurse administered the Structured Clinical Interview – Clinician Version (SCID-CV), which is a widely used semi-structured interview tool designed for making research diagnoses according to DSM criteria [21].

Sex and transgender identification

The participant’s sex was recorded at the beginning of the interview by research nurse and here represents both biological and legal sex, as none of the participants had undergone juridical or medical sex reassignment. In this study, we use the terms sex, male, and female to refer to biological sex. Transgender identification was evaluated using a single item ‘Do you perceive yourself to be transgender?’ The participants were presented with the response options ‘Yes, transgender male to female’, ‘Yes, transgender female to male’, ‘Yes, nonbinary, or gender nonconforming’, and ‘No’. Participants who responded affirmatively to any of the transgender options were considered transgender-identifying. Due to the small size of the different transgender-identifying groups they were all combined in the analyses. Participants who responded that they did not perceive themselves to be transgender were classified as cisgender-identifying. The transgender-identifying adolescents were further asked to rate to what extent they felt incongruent with their body, with response alternatives ranging from 0 (“not at all”) to 7 (“extremely strongly”).

Symptom self-reports

Depressive symptoms were measured utilizing the revised Beck Depression Inventory [22]. Various versions of the BDI are globally used for evaluating the current severity of depressive symptoms [23]. It is also a reliable measure for adolescent psychiatric patients [24]. The validation of the scale has been demonstrated in a Finnish population [25]. The BDI consists of 21 items, each assigned a score ranging from 0 to 3; the sum score is thus between 0 and 63. Symptoms related to anxiety were assessed using the seven-item Generalized Anxiety Disorder Assessment (GAD-7). The GAD-7 is frequently used in clinical practice and research settings to measure anxiety [26]. It is a valid and reliable tool for assessment of anxiety among youth [27] and has been validated in Finland [28]. Each of the seven items within the module is assigned a score ranging from 0 to 3, with the sum score ranging from 0 to 21.

Statistical methods

For statistical tests, the BDI and GAD-7 response patterns were assigned normalized factor scores based on confirmatory one-dimensional item factor analyses of ordered items conducted with version 0.6–16 the lavaan package [29] in version 4.3.2 of the R statistical environment [30] using standard settings. Other analyses were conducted with IBM SPSS (version 27) statistical software. The threshold of statistical significance was set to p<0.05. Listwise deletion in SPSS was used to address missing values, as their proportion was less than 5 %.

Group comparisons between transgender-identifying and cisgender-identifying groups were conducted using the Student’s t-test to examine the differences in scores for the BDI and GAD-7 measures and age. A one-way ANCOVA was conducted to compare the impact of transgender identification on BDI and GAD-7 scores while controlling for age. Levene’s test was carried out, and the assumptions were met. A Student’s t-test was used to examine differences in gender incongruence, age, BDI- and GAD-7 scores between transgender-identifying sexes. Cohen’s d values were calculated for all the groups under comparison to evaluate the effect size. Test values, p-values, and effect sizes were calculated based on the factor scores. A chi-squared test was also conducted to investigate potential differences in DSM-IV diagnoses between trans- and cis-identifying groups. Due to the normal distribution of BDI, GAD-7, and age scores, parametric tests were appropriate. Due to the skewness of perceived Gender Incongruence ratings, rank-order (Spearman) correlations were estimated between Gender Incongruence and symptom scores.

How often did adolescent psychiatric patients identify as transgender?

In this study, 11.3 % (n=74) of the participants identified as transgender, while the majority identified as cisgender (n=653). Among both the cisgender- and transgender-identifying groups, the largest proportion of participants were females (72.3 vs. 86.5 %). There was no significant difference in mean age between the cisgender and transgender groups (Table 1).

Depression and anxiety among transgender-identifying patients

Compared to cisgender-identifying participants, transgender-identifying participants had significantly higher mean BDI and GAD-7 scores. Effect sizes for these differences were small for both BDI and GAD-7 scores (Table 1). After controlling for age, the differences in BDI scores were no longer significant, but GAD-7 scores remained significant among males (Table 2). There were no differences between sexes among transgender-identifying adolescents in BDI and GAD-7 mean scores (Table 3), whereas among cisgender-identifying patients, females had significantly higher scores on both BDI and GAD-7 than males (Table 4). Among cisgender-identifying youth diagnosed depressive and anxiety disorders were more common among females, but among transgender -identifying youth no sex difference was observed (Table 5). The prevalence of diagnosed depressive disorders was 50.5 % among cisgender-identifying and 51.6 % among transgender-identifying youth (p=0.85), and the prevalence of anxiety disorders 54.1 and 58.1 % (p=0.47), correspondingly (Table 5).

The scores for measurements assessing symptoms of depression and anxiety exhibited a strong and statistically significant positive correlation. Neither depressive nor anxiety symptoms correlated with the perceived levels of gender incongruence (Table 6).

Main findings

Among adolescents referred to specialist level psychiatric care for severe mental disorders, transgender-identification was relatively common. Participants identifying as transgender exhibited higher scores on both the BDI and the GAD-7 in comparison to those identifying as cisgender, though the disparities were minimal in Cohen’s [31] terminology, thereby indicating that these variations may be indicative of subthreshold symptomatology rather than substantial disparities in depressive or anxious symptoms. Furthermore, after controlling for age, the difference in depression scores became non-significant, and the difference in anxiety scores remained significant only among males.

There was no difference in the likelihood of a diagnosis of anxiety or depressive disorders between transgender-identifying participants and their cis-identifying peers. There were no sex differences in BDI and GAD-7 scores among transgender-identifying adolescent psychiatric patients, whereas among cisgender patients, females had higher scores than males on both symptom scales. In the same vein, commonly seen sex difference in prevalence of depressive and anxiety disorders did not emerge among transgender-identifying youth.

No statistically significant correlations were found between levels of perceived gender incongruence and BDI and GAD-7 scores.

Comparison with earlier literature

The prevalence of transgender-identification (11.3 %) in our study was almost three-fold that reported in Finnish adolescent population (3.9 %) [8]. To the best of our knowledge, there is no comparable clinical sample. Recent research findings indicate that transgender individuals are more likely to report receiving mental health assistance from healthcare professionals in comparison to cisgender individuals [32]. The high prevalence of transgender-identifying youth in our study population may reflect greater mental health needs in transgender-identifying youth. However, causal associations cannot be concluded based on the present data.

Transgender identification was in the present sample more commonly reported by adolescents with female sex, as has earlier been the case in general population as well as in gender clinic samples [8], 10].

Adolescents who identified as transgender were more likely to experience symptoms associated with depression and anxiety when compared to their cisgender peers. However, effect sizes of these differences were small. The study revealed that up to 51.6 % of the transgender-identifying participants were diagnosed with a depressive disorder and 58.1 % with an anxiety disorder. The prevalences are higher than among adolescents presenting for assessment in specialized gender identity services in Finland [33] or proceeding to medical gender reassignment after the specialized assessments [11]. To our knowledge, a directly comparable sample to ours is currently unavailable. Transgender-identifying adolescents were referred to our clinic primarily due to their psychiatric needs, which explains a significant portion of the observed difference. Furthermore, the national guidelines state that severe psychiatric disorders must be treated to remission before referral to a gender identity service can be considered timely [34]. Finally, it should be noted that not all transgender-identifying adolescents desire medical gender reassignment.

Contrary to expectations, levels of depressive and anxiety symptoms were not associated with strength of perceived gender incongruence among transgender-identifying youth. The absence of a correlation between perceived gender incongruence and depressive or anxiety symptoms may be indicative of the fact that not all forms of distress are gender related. Alternatively, it may be suggestive of the notion that distress is more strongly associated with external factors, such as stigma, social support and access to affirming care, than with incongruence itself.

In summary, the findings of this study demonstrate that transgender-identifying adolescent psychiatric patients exhibit comparable levels of depression and anxiety to cisgender patients. Furthermore, the study establishes that the severity of perceived gender incongruence is not associated with these disorders. This emphasizes the similarity of psychiatric need regardless of gender identity experience. Medical gender reassignment has been proposed to alleviate mental health problems in transgender youth [35], but solid evidence base for this assumption is lacking [12], 36]. Also, the number of people who discontinue transitioning is increasing [37]. All this emphasizes the importance of providing appropriate intensive psychiatric care as in case of cisgender-identifying youth.

Strengths and limitations

Our study’s main strength is a large and up-to-date sample and the use of validated psychometric scales and research diagnoses. The main limitation is that transgender identification was measured with one item. Patient self-identification remains the golden standard for measuring transgender identification in the general population and has been used in previous studies. However, comprehensive identity assessment accounting for gender identity as a facet of identity development at large was not carried out.

A further significant limitation was the high rate of attrition. The reasons for non-participation were not systematically documented, and the non-participators’ data was not collected. Nevertheless, even after the attrition, the sample size remained considerable.

It is important to note that nonbinary and gender nonconforming individuals may differ from transgender individuals in significant ways. A limitation of the study was the relatively small sample size of nonbinary and gender nonconforming group, which necessitated the combination of the groups in the analyzes.

Whilst depressive and anxiety disorders are the most prevalent psychiatric disorders, it is important to consider that other psychiatric diagnoses are likely to be also significant, and possibly overrepresented in the transgender-identifying population. A limitation of the present study was that the former were not accessed.

Based on cross-sectional data, causality cannot be implied, and longitudinal research is needed to explore the relationship between transgender-identification, depressive, and anxiety symptoms.

In Finland, the current process for accessing gender identity services involves psychiatric evaluation at clinics, even if no psychiatric issues are present. By excluding these individuals from our study, we were able to remove any potential bias they might introduce, thus improving the accuracy of our findings. In addition, only individuals of legal age are eligible for juridical sex change in Finland. There are two juridical sex options within the country. It cannot be ruled out that some adolescents might strongly identify with a different gender, leading them to report their perceived gender instead of their biological sex. However, the research nurse of this study recorded biological sex, and errors were corrected.