Discussion
This study presents the first nationally representative prevalence estimates of transgender identity and questioning transgender identity among U.S. high school students, building on previous research among states and local urban school districts that have included the transgender identity item in their YRBSs since 2017 (1). Analysis of 18 states’ 2021 YRBS data found similar prevalence of transgender identity and similar distributions across demographic characteristics of transgender and questioning students (7).
This study found that transgender and questioning students face a higher prevalence of experiencing violence, poor mental health, suicidal thoughts and behaviors, and unstable housing and a lower prevalence of school connectedness compared with their cisgender peers. Approximately 40% of transgender and questioning students were bullied at school. Approximately 26% of transgender and questioning students attempted suicide in the past year, compared with approximately 5% of cisgender males. The prevalence of unstable housing was highest among transgender students (10.7%) and lowest among cisgender females (1.8%). The disparities identified in this study are consistent with those from previous studies using state YRBS, clinical, and convenience samples (1,8). Previous research using 2017 and 2019 state YRBS data demonstrated that the prevalence of unstable housing was more than seven times higher among transgender and questioning students combined, who were also three times more likely to be living “on the streets” (i.e., in a car, park, campground, or other public place) when experiencing unstable housing, compared with cisgender students (9).
Minority stress theory and the gender minority stress framework (10) can be applied to understand the factors that perpetuate these disparities: Transgender and questioning persons experience stigma, discrimination, and social marginalization related to their gender as a result of institutionalized social norms that privilege cisgender persons. The accumulation of stressors, including internalization of stigmatized attitudes, expectations of rejection, and experiences of discrimination and violence, can increase the likelihood that transgender and questioning persons experience poor mental health and lead to disparities in health and well-being. Transgender and questioning students might face stressors in their family life (e.g., adverse childhood experiences, parental rejection, and misgendering) and school life (e.g., bullying, violence, misgendering by peers or teachers, and being denied access to activities aligned with their gender identity) that might increase their risk for poor mental health (8). Furthermore, transgender students of color might face additional marginalization related to their race or ethnicity. According to the GLSEN 2021 National School Climate Survey, approximately 80% of lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ+) students (K–12) experienced verbal, physical, or sexual harassment or assault at school, and approximately half of LGBTQ+ students of color experienced victimization related to race and ethnicity (11).
The structural and interpersonal discrimination, including family rejection, faced by transgender students puts this population at increased risk for experiencing unstable housing (9). Transgender students might experience discrimination, harassment, and assault among foster, shelter, and other social service providers that make this population less likely to be sheltered when experiencing unstable housing, compounding their vulnerability to experiences of violence, poor mental health, and suicidal thoughts and behaviors (9).
The findings in the report demonstrate that transgender and questioning students experience more violence, less school connectedness, more unstable housing, poorer mental health, and more suicidal thoughts and behaviors than their cisgender peers, underscoring the need for interventions to create safe and supportive environments for transgender and questioning students. Having supportive families and peers, feeling connected to family and school, having affirmed name and pronouns used consistently by others, and having a sense of pride of identity are protective factors for transgender students that buffer the effects of minority stressors and promote better mental health (8).
Intervention Opportunities
Schools are in a unique position to create safe and supportive environments, free from violence and bullying, for all students, including transgender and questioning students. Violence, poor mental health, and suicide are not caused by any single factor, and prevention will not be achieved by any single strategy. However, strategies that create safe and supportive environments inclusive of transgender students and promote school connectedness can improve the health and well-being of transgender students across a range of outcomes. Evidence supports the association of CDC’s What Works in Schools (WWIS) approach (https://www.cdc.gov/healthyyouth/whatworks/what-works-overview.htm) with reductions in experiences of violence, poor mental health, and suicidal thoughts and behaviors among high school students (12). WWIS supports districts and schools to implement quality and inclusive health education, connect students to health services, and foster safe and supportive school environments. In particular, school connectedness and activities to promote safe and supportive environments are associated with decreased odds of experiencing violence, poor mental health, and suicidal thoughts and behaviors among high school students (13). Activities that are inclusive of LGBTQ+ students are associated with decreases in the odds of these experiences among all students regardless of sexual identity (14). Inclusive activities might involve implementing genders and sexualities alliances (student-led clubs offering a means for students with LGBTQ+ identities and allies to gather and provide support), providing professional development to educators and school staff members on supporting students with LGBTQ+ identities, providing mental health and other health service referrals that are inclusive of students with LGTBQ+ identities, and implementing policies that are inclusive of students with LGBTQ+ identities. To date, the WWIS approach has not been evaluated specifically among transgender and questioning students. Further research is necessary; however, the possibility of school supports as health enhancing for transgender and questioning students is promising.
CDC’s Dating Matters (https://www.cdc.gov/intimate-partner-violence/php/datingmatters/index.html) is an evidence-based teen dating violence prevention model that educates adolescents on healthy relationships of certain types, including relationships with family and friends, and is effective for reducing risk for both experiencing and perpetrating violence and engaging in substance use. Dating Matters has been adapted to create A Guide to Healthy, Safe Relationships for LGBTQ+ Youth (https://vetoviolence.cdc.gov/apps/dating-matters-toolkit/static/media/Dating_Matters_LGTBQ%20Guide_Youth_v5a_508.fde67eab.pdf), a tailored resource that provides information on healthy relationships specific to the unique needs and experiences of students with LGBTQ+ identities. CDC’s Suicide Prevention Resources for Action (https://www.cdc.gov/suicide/resources/prevention.html) identifies strategies for a comprehensive approach to suicide prevention that addresses the multiple factors associated with suicide risk. The implementation of school-based strategies and community-based supports can serve as the foundation for effective youth suicide prevention. Schools can create safe and supportive environments and promote connectedness by teaching coping and problem solving, providing gatekeeper training to peers, teachers, and other adults at school, and implementing mental health support (the term “gatekeeper” refers to persons trained to identify people at risk for suicide and to respond effectively by facilitating referrals to treatment and support services https://www.cdc.gov/suicide/pdf/preventionresource.pdf). CDC’s Comprehensive Suicide Prevention Program (https://www.cdc.gov/suicide/programs/csp.html) funds 24 programs to implement and evaluate a comprehensive public health approach to suicide prevention, with a special focus on populations disproportionately affected by suicide, including transgender and questioning students.
The McKinney-Vento Homeless Assistance Act† (MVA) is a Federal law that authorizes services that allow students experiencing unstable housing to enroll, attend, and achieve success in school. Certain MVA programs provide training and support for referrals to school- and community-based programs for family counseling, adolescent health and mental health care, and LGBTQ+ programs supported by student-led groups including genders and sexualities alliances (15). Schools can play a pivotal role in supporting transgender and questioning students experiencing unstable housing by implementing and connecting students with such MVA-funded programs tailored to the needs of this population.
