Mental health | Transgender, non-binary and gender diverse children

We surveyed a small number of transgender/non-binary/gender-diverse (TGD) adults and parents of TGD children.

Here are some of their comments related to mental health. 

‘I know that I limit my water intake on days when I will be out and don’t have access to “safe” toilets.’
– Bodhi (28yo trans man, he/him)

‘I was worried because my child has anxiety and school refusal, so I was worried this would mean a challenging path for them.’
– Stephanie (mother of an 18yo trans male adult)

[I was] ‘worried family or school wouldn’t accept her, and I would have to fight for her.’
– Annalise (mother of a 7yo trans girl child)

[I was worried] ‘just for the wellbeing of my child.’
– Rich (father of a 24yo non-binary child, they/them)

‘I am lucky enough that in public, no one is aware that I was assigned another gender at birth. Most of my stress comes from the politicians that are spouting misinformation and have no understanding around trans/gender diverse struggles and needs yet want to implement policies that will cause further harm to this minority.’
– Liam (35yo trans man, he/his)

‘We struggled at first and have become more supportive as he has grown and gotten older. I would say that we always wanted to support him, but we have autism spectrum disorder in a few family members, with very black and white thinking which made it difficult to navigate and to understand.’
– Sara (mother of a 21yo trans man)

‘There are other lil ways that trans folk experience struggles (non-affirmation). I think these are the ones that impact the most. Whenever I get the message that my car needs a service, it says “Mrs”—changing the bank account that I had open since I was 13, and they still call me Mrs. When do you rip the bandaid off and fix these? The answer is that you avoid them, and they compound, and you have to use all your might not to let that little text bother you because you know that addressing the bigger issue is even harder. While I know this doesn’t take away from other forms of minority stress like violence, sexual abuse, stigma, etc., it’s the ones that get you when you are at home in your “safe space”, and the letter or text or email comes, and you weren’t expecting it. Resilience is exhausting when you can’t just turn it off because you assume you’re safe and affirmed.’
– Bodhi (28yo trans man, he/him)

The bad news: time and time again, research into the mental health of trans people shows trans people have significantly poorer mental health outcomes when compared to cisgender people. The good news is that parents can reduce many of the risk factors for poor mental health. Parents are urged to ‘be their protective factor’ (Chan, 2017).

Poorer mental health (and physical health) outcomes for TGD people are often emerging from transgender people’s cumulative experiences of being stigmatised, being marginalised, being discriminated against, microaggressions, non-affirmation, trans hostility/violence, and transphobia. This results in what is referred to as minority stress.

Minority stress is the stress that arises from how minority identities are stigmatised and treated within society. The minority stress model is there to help us better understand the relationship between how gender minorities are treated and the health inequalities TGD people experience. It can be helpful to understand and explore with young people because it can help them, and us, better name up the stressors and not blame the person or being transgender for why they are experiencing mental health issues.

For TGD people who are also from other marginalised groups, such as being disabled, being from a sexual minority group, or being from a culturally or racially marginalised group, the minority-specific stress and oppression can be multiplied. This can result in even worse mental and physical health outcomes than if the person belonged to just one marginalised group. 

Transphobia is not a true phobia. Transphobia is when people have a set of negative beliefs, which may include not believing someone can truly be TGD and negative connotations about TGD people based on prejudice and stereotypes. It can include mistrust, fear, hatred, and aversion to TGD people. It can emerge in behaviours including discriminating, excluding, actively trying to remove the rights of trans people, silencing trans voices, voting for transphobic politicians, disregarding the mistreatment and bullying of trans children/youth, misgendering, refusing someone service, speaking about trans people as a threat, and using someone’s deadname. It can include misrepresenting trans people, transphobic joking, using bad science as propaganda or as a rationale for the denial of human rights, denigrating a trans person with words or actions, swearing at, outing someone, putting children/youth in conversion/reparative therapy, not supporting a child/youth’s gender identity, not allowing someone to use the gendered toilet which aligns with their gender, and outright violence towards trans people. How others treat a TGD diverse person and systems impact their mental health.

Beyond the individual, transphobia can manifest in systems such as legal, government, educational, and medical. For TGD people, structural transphobia can result in restrictions or the removal of access to evidence-based gender-affirming care, the denial of human rights, over-policing, higher costs to access hormonal and surgical affirmation, reduced access to mental health support, higher levels of suicidality, higher levels of distress, and lower life satisfaction.  

Because we can’t just switch society off, gender minorities often internalise the negative views about being trans. This is called internalised transphobia. 

Parents of TGD people may also hold transphobic beliefs they have been socialised into. Much the same way sexist, racist, and ableist beliefs can exist within people. To reduce the risk of shaming and bringing distress to a child, it is important to become increasingly aware of these thoughts and challenge them to learn more (just like you’re doing now). Fear can also arise for parents. Examine your fear, but don’t let fear lead the way. Some parents may genuinely believe being a good parent means not supporting their child’s gender if it doesn’t line up with their sex assigned at birth. This is not only misguided but dramatically increases the risk of poor mental health outcomes for the child, as does gender-shaming, degrading, emotionally abusing, or physically abusing the child/young person.  

Trans people have significantly higher rates of the following mental health outcomes:

• Depression 
• Anxiety
• Deliberate self-injury/self-harm
• Suicidal thoughts and behaviours 
• Body dissatisfaction
• Disordered eating and eating disorders

To highlight the much higher rates of mental health issues experienced by TGD youth, consider the following statistics from the Trans Pathways study of Australian trans youth:

• Deliberate self-injury/self-harm
  • ‘4 out of 5 trans young people have ever self-harmed (79.7%). This is compared to the 10.9% of adolescents (12-17 years) in the Australian general population. 
• Suicide/suicide attempts
  • ‘Almost 1 in 2 trans young people have ever attempted suicide (48.1%). This is 20 times higher than adolescents (12-17 years) in the Australian general population. 
  • The percentage of trans and gender-diverse adolescents who had attempted suicide in the United Kingdom was 45%.
• Depression
  • ‘3 in 4 trans young people have ever been diagnosed with depression (74.6%). This is ten times higher than adolescents (12-17 years) in the Australian general population.
• Anxiety
  • ‘72.2% of trans young people have ever been diagnosed with anxiety. This is ten times higher than adolescents (12-17 years) in the Australian general population.
• Eating disorders
  • ‘22.7% of trans young people had been diagnosed with an eating disorder’.
• Post-traumatic stress disorder
  • ‘25.1% of trans young people had been diagnosed with post-traumatic stress disorder’. 

(Strauss et al., 2017, 1)

Below are some of the statistics from the Trans Pathways report on some of the risk factors Australian trans youth have experienced:

• Peer rejection and bullying
  • ‘89% had experienced peer rejection, and 74% had experienced bullying’.
• Issues with education
  • ‘78.9% had experienced issues with school, university or TAFE’.
• Discrimination
  • ‘68.9% had experienced discrimination’.
• Lack of family support
  • ‘65.8% had experienced lack of family support’.
• Accommodation issues or homelessness
  • ‘22% had experienced accommodation issues or homelessness’.

(Strauss et al., 2017, 1)

Social support ‘refers to the help and assistance we receive from our social network, such as emotional comfort, advice, and practical aid’ (Zimbardo, 2024). Social support can come from family, friendship networks, communities, and workplaces. Social support helps buffer and decrease stress. Social supports contribute to individual resilience.

Transgender/non-binary/gender-diverse  (TGD) people with stronger social support are more likely to experience:

• Less anxiety
• Less depression
• Less deliberate self-injury (for trans men and trans women)
• Higher resilience
• Higher life satisfaction rates
• Lower rates of suicide attempts
• Less depression
• Less likely to feel like a burden to others
• Higher self esteem
• Less inadequate housing

Stronger social support from friendship networks for transgender individuals is associated with:

• Less suicidal ideation
• Less distress
• Fewer symptoms of anxiety
• Fewer symptoms of depression

A transgender person’s connection to a transgender community is associated with: 

• Increased well-being
• Fewer symptoms of anxiety
• Fewer symptoms of depression
• Decreased feeling of isolation if experiencing rejection elsewhere
• Supporting self-actualisation
• Supporting self-acceptance

Stronger family social support for transgender individuals is associated with:

• Higher life satisfaction rates
• Lower rates of suicide attempts
• Less depression
• Less likely to feel like a burden to others
• Higher self esteem
• Less inadequate housing
• Higher resilience

Some studies indicate that family social support may play an even more crucial role than other social supports such as peers.

Parental support can change your child’s life. How much so? The Trans PULSE Project study ‘found that 57% of TGD youth who said their parents were not supportive had attempted suicide compared to only 4% of TGD youth who reported their parents were supportive (Puckett et al., 2019). I repeat 4% compared to 57%. 

As a parent, you are not powerless. You wield influence.

You may be wondering what family support entails. When we asked some transgender/non-binary/gender-diverse (TGD) people and parents of TGD children what some of the actions parents, families and communities took that were perceived as supportive, these were some of their responses:

‘They never pushed girly stuff on me and embraced tomboy-ness through sports. They did let me have whatever interests I wanted to have.’
– Asher (Non-binary/gender-diverse, 28yo, they them)

‘Once they were informed, they just let me be me, no questions. They educated themselves.
– Nina (trans woman, she/hers)

‘He asked us to explain to people before he saw them, so he didn’t have to do this.’
– Stephanie (mother of an 18yo trans man, he/him)

‘Using pronouns correctly, supporting him in his hormone treatment and top surgery.’
– Sara (mother of a 21yo trans man)

[Family] ‘Attended appointments, used my chosen name and pronouns, asked questions, kept loving me.’
– Liam (35yo trans man)

‘We spoke up for him at appointments and asked for name changes, offered to tell extended family, offered to change wardrobe, bedroom decor, etc.’
– Stephanie (mother of an 18yo trans man. He/him)

‘We have always let her play and wear whatever she wanted, even before her transition. So it was mostly just making a pronoun switch by the time she told us. She has also been experimenting with pronouns for months before settling on she/her.’
– Annalise (mother of a 7yo trans girl)

‘My transition occurred as an adult, but I still remember my dad trying to let me know it was okay. Awkwardly, he let me know he followed a Facebook group for parents of transgender children and then told me some of the things he learnt. My parents educated themselves, asked questions and wanted to know more about what was happening to me. They knew that what I was doing was right for me and just showed up and let me know they loved me.’  
– Bodhi (28yo trans man, he/him)

‘I just told the school when she was ready to change pronouns at her pre-school and then I told her kindergarten when she entered elementary.’
– Annalise (mother of a 7yo trans girl)

‘Visible support to our child/family/friends. Continue to learn to be a better ally.’
– Rich (father of a 24yo non-binary child, they/them)

‘Name use, assistance in seeking gender-affirming health care, choice with family and friends; encouraging them to exercise agency, particularly with family, by telling the story in their words and time.’
– Daniel (father of an 18yo trans man, he/him)

‘Use of name and pronouns. Our child went into casual employment in the very early days, and the employer was proactive in enabling gender identity and confirmed choices with us as parents. Our child was fortunate to enter a new social and sporting community (roller skating) having transitioned and was able to establish their identity without the history as someone else.’
– Daniel (father of an 18yo trans man, he/him)

We also asked some TGD people what they would have liked from their parents and systems and what they would have liked more access to in terms of supporting their gender identity.

Here are some of their responses:

‘Understanding, the ability to dress as my chosen gender, counselling, meeting other trans people.’ 
– Nina (trans woman, she/hers)

‘Affordable healthcare and procedures. The out-of-pocket cost is something I will be dealing with for the rest of my life as I have to take hormones until I die. Cis people don’t have to pay for their hormones. Medical procedures are minimally covered under Medicare and are only offered by private specialists. The public health system provides no specialists to support those who cannot afford private cover.’ 
– Liam (35yo trans man, he/his)

‘Safe undergarments, easier access to surgeries etc, easier change of document policies.’ 
– Nina (trans woman, she/hers)

‘Binders and anything of the likes.’
– Max (15yo trans boy, he/they)

‘Open discussion about gender, understanding, curiosity, them to have a basic knowledge base so they could have supported me when I was younger and repressing what I felt’ – Liam (35yo trans man, he/him)

‘Info about gender-affirming care. More role models.’
– Asher (28yo non-binary/gender-diverse person, they them)

‘As an adult, I have been fortunate to go private and pay for my affirming care. Yet there were still so many steps and hoops. My GP is still over 1hr away but knowing he’s a specialist in HRT and transgender health care makes travel/payment a non-negotiable’. 
– Bodhi (28yo trans man, he/him)

‘Care providers are more available and informed. Cost reduction/covered by Medicare…
Cost reduction of affirming products such as STPs, Packers, binders, HRT, etc. They are associated with privilege when, in reality, they are essential for those that can reduce dysphoria and improve MH outcomes.’ 
– Bodhi (28yo trans man, he/him)

‘I didn’t have the language for anything outside the binary, and neither did they. I can’t really imagine things happening any other way. I was in Catholic school so that it would have involved a complete overhaul of my life and I was a pretty awkward kid socially, so that probably wouldn’t have been good either. I would have appreciated more counterbalance to the rigidity of gender roles I was learning in school. Gender was very, very enforced as girls and boys had different uniforms and deviating from that was punished socially. We also just learned and talked about gender a lot, I think probably more than secular people’.
– Asher (Non-binary/gender-diverse, 28yo, they them)

‘I think removing the experiences of cisnormativity and creating a childhood environment where, from day one, there were no expectations of what is “right and wrong” and instead just let me flow through all the different phases that I needed to try to discover my true self’. 
– Bodhi (28yo trans man, he/him)

‘Genuine support, use of pronouns’ 
– Max (15yo trans boy, he/they)

As these quotes indicate, it’s not just about letting your kid get a haircut or wear different clothes. It’s also often about access to gender-affirming health care, which is evidenced to improve mental health outcomes. For example, one study looked at the impact on transgender mental health of accessing hormonal affirmation between the ages of 13-15, between the ages of 16-17, and adults (18 and over) when compared to the same ages for transgender people who wanted to access hormonal affirmation but couldn’t. Earlier access to hormonal affirmation was associated with ‘lower odds of past-year suicidal ideation, past-month severe psychological distress, past-month binge drinking, and lifetime illicit drug use’ (Turban et al., 2022). The positive impact on mental health was greatest for those who started accessing hormonal affirmation between the ages of 13-15, and the 16-17year-olds had better outcomes than the adults. Not every TGD person will want to access hormonal affirmation.

Diagnosis

There are two diagnostic manuals used internationally that have gender identity-related conditions listed:

• International Classification of Diseases –11th Edition (ICD-11) published by the World Health Organisation
• Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-5) published by the American Psychiatric Association

The ICD-11 places gender incongruence under the category of sexual health in acknowledgment that having a TGD identity is not a mental health condition. The following gender identity conditions are listed in ICD-11:

• Gender incongruence of childhood (HA61)
• Gender incongruence of adolescence or adulthood (HA60)

Incongruence means something doesn’t fit or fit well. 

The DSM-5 has one gender identity condition: 

• Gender dysphoria

As the DSM-5’s name suggests, the manual specifically relates to ‘mental disorders’. Gender dysphoria is seen as a mental health condition. Gender dysphoria as a diagnosis has a criterion for children which differs somewhat from adolescent and adult criteria.

Public health, private health, and insurers can require a sexual health or mental health diagnosis related to gender identity to be able to access subsidised specific supports, counselling, specialists, assessments, treatments, tests, surgeries, and correspondingly legal affirmation; diagnosis presents a pivotal door for many TGD people.  

Some locations rely more heavily on one manual than the other. Some options, depending on your location, will require a diagnosis of gender dysphoria. For example, in Australia, the AusPATH standards of care require a diagnosis of gender dysphoria to access hormonal affirmation. 

According to the ICD-11:

• ‘Gender incongruence of childhood is characterised by a marked incongruence between an individual’s experienced/expressed gender and the assigned sex in pre-pubertal children. It includes a strong desire to be a different gender than the assigned sex, a strong dislike of the child’s part of their sexual anatomy or anticipated secondary sex characteristics and/or a strong desire for the primary and/or anticipated secondary sex characteristics that match the experienced gender; and make-believe or fantasy play, toys, games, or activities and playmates that are typical of the experienced gender rather than the assigned sex. The incongruence must have persisted for about two years.’
• ‘Gender Incongruence of Adolescence and Adulthood is characterised by a marked and persistent incongruence between an individual´s experienced gender and the assigned sex, which often leads to a desire to ‘transition’, to live and be accepted as a person of the experienced gender, through hormonal treatment, surgery or other health care services to make the individual´s body align, as much as desired and to the extent possible, with the experienced gender’. 

To read more about gender incongruence diagnoses, the ICD-11 can be accessed for free online. See the link below.

Diagnostically, the DSM-5 diagnosis of gender dysphoria shares many of the same elements as gender incongruence above. Additionally, there must be ‘clinically significant distress or impairment in social, occupational, or other important areas of functioning’ which has emerged from the gender incongruence (American Psychiatric Association APA, 2024). 

For children, adolescents, and adults, gender dysphoria needs to last for six months or longer.

The person needs to meet 2 of 6 criteria for adolescents and adults. The person must meet at least 6 of 8 criteria for pre-pubertal children. One must be ‘A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender)’ (APA, 2024). Though the DSM-5 sits behind a paywall, you can access it for free through some public library catalogues. You could read more about the criterion on the American Psychiatric Association’s page ‘What is Gender Dysphoria?’. The link is below.

Resources

• 5 Things That Helped Me Pre-T by Phoenix Animations 2020. https://www.youtube.com/watch?v=bYcwrONHq_Q United States. YouTube. Animation by a trans man. 00:01:55.
• COLAGE

• Don’t call people out – call them in by Loretta J. Ross  2022. https://www.youtube.com/watch?v=xw_720iQDss United States. TED talk. 00:14:18.
• Family Acceptance Project https://familyproject.sfsu.edu
• Family Acceptance Project – Resources https://lgbtqfamilyacceptance.org/

• Family Acceptance Project – Map of LGBTQ support for youth and families in the USA. Regularly updated. https://trainings-theinstitutecf.umaryland.edu/lgbtqfamily/map.cfm
• Culture-based resources https://lgbtqfamilyacceptance.org/culture-based-resources/
• Faith-based resources https://lgbtqfamilyacceptance.org/faith-based-resources/
• Find a Helpline – International search function for helplines. You enter the country and then pick ‘gender and sexual identity’, among other support needs. https://findahelpline.com
• Free Mom Hugs https://freemomhugs.org
• Free Mum Hugs Australia https://www.instagram.com/freemumhugsaus https://www.facebook.com/FreeMumHugsAus
• Gender Dysphoria by Phoenix Animations 2018. https://youtu.be/wiU4WZiyHA4 United States. Animation by a trans man. 00:01:21.
• How to Cope with Transphobia by Reach Out 2024. https://au.reachout.com/identity/gender/how-to-cope-with-transphobia
• How to Tell Someone You Know They’re Being Transphobic by Amnesty International. https://amnesty.org.nz/how-to-respond-transphobia
• International Classification of Diseases 11^th Edition: The Global Standard for Diagnostic Health Information (ICD 11) by World Health Organisation 2019. https://icd.who.int/en
• HA61 Gender incongruence of childhood https://icd.who.int/browse/2024-01/mms/en#344733949
• HA60 Gender incongruence of adolescence or adulthood https://icd.who.int/browse/2024-01/mms/en#90875286
• Human Rights Campaign https://www.hrc.org/resources
• Mama Bears https://realmamabears.org
• Navigating Microaggressions in Everyday Life by Professor Kevin Nadal 2021. https://www.youtube.com/watch?v=imLb8SCxvsc United States. 00:24:16.
• People with Trans Parents- Colage https://colage.org/wp-content/uploads/2023/01/PTP-Resource-Guide-2.pdf
• Q Chat Space -Helpline/Online community chat for adolescents. https://www.qchatspace.org
• PFLAG https://pflag.org
• PFLAG Australia https://pflagaustralia.org.au/
• QLife (Australia) https://qlife.org.au
• Standing Up: What is calling in versus calling out? By Project Rockit 2014. https://www.youtube.com/watch?v=zYX2CHFT4EM 00:03:08
• The Trevor Project https://www.thetrevorproject.org/
• Trans Parent https://transparentusa.org/
• Trans Pathways: The Mental Health Experiences and Care Pathways of Trans Young People by Strauss et al., 2017. https://www.telethonkids.org.au/projects/past/trans-pathways
• Report summary https://www.telethonkids.org.au/globalassets/media/documents/brain–behaviour/trans-pathways-summary.pdf
• Transphobia by Trans Actual 2024. https://transactual.org.uk/transphobia/
• USA: Crisis and support hotlines – USA https://lgbtqfamilyacceptance.org/crisis-lines/
• What is the Definition of a Microaggression? By The Other Box- Equity, Diversity and Inclusion 2023. https://www.youtube.com/watch?v=19Lk9O6vMCM United Kingdom. 00:05:54.
• What is Gender Dysphoria by American Psychiatric Association 2022 https://www.psychiatry.org/patients-families/gender-dysphoria/what-is-gender-dysphoria Has diagnostic criteria in it.
• What Is Transphobia? By Elizabeth Boskey 2023. https://www.verywellhealth.com/transphobia-5077602
• What is Transphobia? Trans 101 by Alice Quinn Rose 2019. https://www.youtube.com/watch?v=FvPfvaNq-oo
• What is Transphobia, Also Called Transmisia? By Planned Parenthood 2024. https://www.plannedparenthood.org/learn/gender-identity/transgender/whats-transphobia

References

• Access to Gender-Affirming Hormones During Adolescence and Mental Health Outcomes Among Transgender Adults by Turban et al., 2022.
• Analyzing Body Dissatisfaction and Gender Dysphoria in the Context of Minority Stress Among Transgender Adolescents by Brecht et al., 2024.
• Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents by AusPATH 2023.
• Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-5) by the American Psychiatric Association 2013.
• Early Insights: A Report of the 2022 US Transgender Survey by James et al., 2022.
• Impacts of Strong Parental Support for Trans Youth: A Report Prepared for Children’s Aid Society of Toronto and Delisle Youth Services by Travers et al., 2012.
• International Classification of Diseases 11^th Edition: The Global Standard for Diagnostic Health Information (ICD 11) by World Health Organisation 2019.
• Mental Health and Resilience in Transgender Individuals: What Type of Support Makes a Difference? By Puckett et al., 2019.
• Peer support as a protective factor against suicide in trans populations: A scoping review by Hannah Kia et al., 2021.
• Social Support Theories: Psychology Definition, History & Examples by Zimbardo 2024.
• Structural Transphobia is Associated with Psychological Distress and Suicidality in a Large National Sample of Transgender Adults by Price et al., 2024
• Supporting the Mental Health of Transgender and Gender-Diverse Youth by Coyne et al., 2023.
• The Modern Clinician’s Guide to Working with LGBTQ+ Clients by Margaret Nichols 2021.
• Trans-parent Love: 5 Ways to Support Your Transgender Child by Dr. Annabell Chan 2017.
• Trans Pathways: The Mental Health Experiences and Care Pathways of Trans Young People by Strauss et al., 2017.
• Transphobia by Trans Actual 2024.
• What is Gender Dysphoria by American Psychiatric Association 2022.
• What Is Transphobia? By Elizabeth Boskey 2023.
• What’s Transphobia, Also Called Transmisia? By Planned Parenthood 2024.
• What is Transphobia? Trans 101 by Alice Quinn Rose 2019.