Gender Affirmation and Depressive Symptoms Lee Hatcher

The suicide rate for transgender youth between the ages of 10 and 21 is approximately 45%, roughly nine times the suicide rate of the general U.S. population (James et al., 2016; Johns et al., 2019). Further, research has found that a majority of transgender youth have reported suicidal ideations (Austin et al., 2016; Price- Feeny et al., 2019), most often as a result of exposure to victimization, discrimination, and harassment (Austin et al., 2018; Bockting et al., 2013; Johns et al., 2019). The high suicide rates point to increased rates of depression in the transgender youth population (Clark et al., 2014; Olsen et al., 2016). In fact, transgender youth report higher rates of depressive moods than their cisgender counterparts (i.e., 86% vs. 56%; Price-Feeny et al., 2019). Given these statistics, it is crucial to identify protective factors that reduce depressive symptoms for transgender youth (Hass et al., 2014; Johns et al., 2018).

Research has shown that gender affirmations (i.e., the interpersonal confirmation of one’s gender from outside sources; Sevelius, 2017) are pivotal for a transgender person’s development through transition (Doyle, 2022), because they are related to lower depressive systems as well as lower anxiety and overall psychological distress (King & Gamarel, 2021). Gender affirmation includes peer and adult acceptance of a youth’s gender identity, using the correct names and pronouns of a transgender youth, and actively acknowledging a youth’s gender identity (Larry et al., 2002; McGuire et al., 2016; Pollitt et al., 2019). Recent research suggests that gender affirmation supports self-esteem and self-perception, which in turn lowers depressive symptoms (Arcelus et al., 2016; McGuire et al., 2016; Torres, 2020). As such, this review examined how gender affirmations mitigate depressive symptoms among transgender youth through self-esteem and self-perception.

Self-Esteem

Depressive symptoms such as loss of interest in activities, feelings of sadness and hopelessness, and tiredness can result from low self-esteem (Arcelus et al., 2016; Romijnders et al., 2017). Low self-esteem, or confidence in one’s own worth and abilities, affects many aspects of life and can lead to thoughts of death or suicide (Arcelus et al., 2016; Romijnders et al., 2017). Transgender youth report lower self-esteem overall than their non-transgender peers. Further, transgender youth believe that increasing their levels of confidence, self-determination, and feelings of empowerment led to an increase in their self-esteem, which, in turn, served as a mechanism for greater self-accept of their gender identity and expression (Romijnders et al., 2017). This suggests that positive self-esteem might mitigate depressive symptoms through self-acceptance (Romijnders et al., 2017).

Depressive symptoms, as triggered by low self-esteem, can be alleviated by gender affirmations from different social groups, such as friends, family, and figures of authority (Kia et al., 2021; Marraccini et al., 2022; Price & Green, 2021). Affirmations such as preferred pronoun usage and active acknowledgment of their gender identity from adult figures bolster the self-esteem of transgender youth (Kia et al., 2021; Mariccini et al., 2021; Price & Green, 2021). Those whose chosen name is used by authority figures like parents and teachers have more positive mental health outcomes; they experience higher self-esteem, decreased depressive symptoms, and fewer suicidal ideations (Pollitt et al., 2019; Russel et al., 2017). In fact, research has shown that when a youth who is transgender has at least one adult in their life who affirms their gender identity, their risk of suicide is reduced by 33% (Price & Green, 2021).

Similarly, factors that positively impact self-esteem can be significantly increased via gender affirmations (Price & Green, 2021). For example, transgender youth feel safer when a trusted adult affirms their gender identity (Kia et al., 2021; Mariccini et al., 2021; Price & Green, 2021). A greater sense of safety raises self-esteem and, in turn, lowers depressive symptoms (Kia et al., 2021; Marraccini et al., 2022; Price & Green, 2021). Moreover, an affirming body image - having a perception of one’s body that matches the gender that they identify with - can positively impact the self-esteem of transgender youth (McGuire et al., 2016). Body image (i.e., how one perceives their physical appearance) has been shown to be a significant factor in depressive symptoms for all youth but is particularly more prominent for transgender youth (Smolak et al., 2001).

Moreover, a negative body image (i.e., how one perceives their physical appearance) has been shown to be a particularly strong predictor of depressive symptoms for transgender youth (Smolak et al., 2001). Therefore, puberty suppressors that extend the period of prepubescence for transgender youth by blocking the onset of puberty can be particularly important in allowing transgender youth more time to decide the next steps of their gender transition. Puberty suppressors have been shown to raise self-esteem and lower negative thoughts about body image via gender affirmations from peers and adults, thereby improving mental health outcomes (Turban et al., 2020; van der Miesen et al., 2018). At the same time, additional medical interventions that support an affirming body image - having a perception of one’s body that matches the gender that they identify withcan positively impact the self-esteem of transgender youth via promoting gender affirmations, as well (McGuire et al., 2016).

Self-Perception

Another element that can impact depressive symptoms is self-perception, a person’s view of their mental or physical attributes. Self-perception answers the question, “Who am I?” (Torres, 2020). Because of the lack of congruence between their gender identity and how they are perceived socially, answering this question is much more difficult for transgender youth as compared to cisgender youth (Rijn et al., 2012). As a result, they are more unsure of their personhood (Rijn et al., 2012), and their negative self-perception leads to increased depressive symptoms such as suicidal thoughts (Rijn et al., 2012; Durwood et al., 2017; Kuper et al., 2018). Yet, negative self-perception, like selfesteem, can be mitigated by gender affirmations from different social groups (Kia et al., 2021; Price & Green, 2021).

One way to bolster self-perception is by having at least one accepting and gender-affirming peer (Kia et al., 2021; Price & Green, 2021). Through actions such as using the correct name or pronouns, the protective support provided by peers helps to raise transgender youth’s self-perception (Kia et al., 2021; Price & Green, 2021). Furthermore, peers’ affirmation of gendered clothing choices positively impacts transgender youth’s body image (McGuire et al., 2016). This improved positive body image can help boost self-perception, thus improving transgender youth’s mental health by lowering depressive symptoms and suicidal ideations (Kia et al., 2021; McGuire et al., 2016; Price & Green, 2021).

In addition to peers, supportive parents can bolster the selfperception of transgender youth (Grossman et al., 2021; Johns et al., 2018). Parental support through gender affirmations raises the self-perception of transgender youth by easing the perceived burden of being transgender (e.g., feeling embarrassed about having to deal with being transgender in public; Simons et al., 2013) and, thus, lowers depressive symptoms (Grossman et al., 2021; Johns et al., 2018). In fact, transgender youth who have parents who are gender affirming reduce depressive symptoms so much that transgender youth report the same level of selfperception as their cisgender counterparts, and demonstrate a marked improvement in their overall mental health (Alanko & Lund, 2020).

Conclusion

The literature on gender affirmations for transgender youth indicates that gender affirmations promote better selfesteem and self-perception (Boza & Perry, 2014; Durwood et al.; Kaplan et al., 2016; Kia et al., 2021; Kota et al., 2020; Kuper et al., 2018; Marraccini et al., 2022; Moody & Smith, 2013; Price & Green, 2021; Turban et al., 2020; Veale et al., 2017; Zeluf et al., 2018). In turn, improving self-esteem and self-perception helps to alleviate depressive symptoms for transgender youth (Rijn et al., 2012; Grannis et al., 2021; Hayden, 2020; Kuper et al., 2018; McGuire et al., 2016). The importance of gender affirmations for supporting the mental health of transgender youth cannot be understated. Thus, prevention and intervention efforts should be aimed at ways of educating the general public about the simple everyday actions they can take, such as using correct names and pronouns. Future research should also examine more closely the effects of political and social actions that promote gender affirmations on the well-being of transgender youth. This could glean more knowledge regarding how to best support transgender youth.

References

Alanko, K., & Lund, H. (2020). Transgender youth and social support: A survey study on the effects of good relationships on well-being and mental health. Young, 28(2), 199-216. https://doi.org/10.1177/1103308819850039

Arcelus, J., Claes, L., Witcomb, G. L., Marshall, E., & Bouman, W. P. (2016). Risk factors for non-suicidal self-injury among trans youth. The Journal of Sexual Medicine, 13(3), 402–412. https://doi.org/10.1016/j.jsxm.2016.01.003

Austin, A., Craig, S. L., D’Souza, S., & McInroy, L. B. (2020). Suicidality among transgender youth: Elucidating the role of interpersonal risk factors. Journal of Interpersonal Violence, 36(5-6), NP2696–NP2718. https://doi. org/10.1177/0886260520915554

Bockting, W. O., Miner, M. H., Swinburne Romine, R. E., Hamilton, A., & Coleman, E. (2013). Stigma, mental health, and resilience in an online sample of the US transgender population. American Journal of Public Health, 103(5), 943–951. https://doi.org/10.2105/ajph.2013.301241

Boza, C., & Nicholson Perry, K. (2014). Gender-related victimization, perceived social support, and predictors of depression among transgender Australians. International Journal of Transgenderism, 15(1), 35–52. https://doi.org/1 0.1080/15532739.2014.890558

Clark, T. C., Lucassen, M. F. G., Bullen, P., Denny, S. J., Fleming, T. M., Robinson, E. M., & Rossen, F. V. (2014). The health and well-being of transgender high school students: Results from the New Zealand Adolescent Health Survey (Youth’12). Journal of Adolescent Health, 55(1), 93–99. https://doi.org/10.1016/j.jadohealth.2013.11.008

Doyle, D. M. (2022). Transgender identity: Development, management and affirmation. Current Opinion in Psychology, 48, 101467. https://doi.org/10.1016/j. copsyc.2022.101467

Durwood, L., McLaughlin, K. A., & Olson, K. R. (2017). Mental health and self-worth in socially transitioned transgender youth. Journal of the American Academy of Child & Adolescent Psychiatry, 56(2). https://doi.org/10.1016/j. jaac.2016.10.016

Fontanari, A. M., Vilanova, F., Schneider, M. A., Chinazzo, I., Soll, B. M., Schwarz, K., Lobato, M. I., & Brandelli Costa, A. (2020). Gender affirmation is associated with transgender and gender nonbinary youth mental health improvement. LGBT Health, 7(5), 237–247. https://doi.org/10.1089/ lgbt.2019.0046

Grannis, C., Leibowitz, S. F., Gahn, S., Nahata, L., Morningstar, M., Mattson, W. I., Chen, D., Strang, J. F., & Nelson, E. E. (2021). Testosterone treatment, internalizing symptoms, and body image dissatisfaction in transgender boys. Psychoneuroendocrinology, 132, 1–8. https://doi. org/10.1016/j.psyneuen.2021.105358

Grossman, A. H., D’augelli, A. R., & Frank, J. A. (2011). Aspects of psychological resilience among transgender youth. Journal of LGBT Youth, 8(2), 103–115. https://doi.org/10.1 080/19361653.2011.541347

Hayden, L. (2020). Nurturing healthy transitions: Nutrition, exercise, and body image for transgender and gender diverse youth. In Y. N. Evans & A. D. Docter (Eds.), Adolescent nutrition (pp. 95–820). Springer, Cham. https:// doi.org/10.1007/978-3-030-45103-5_26

James, S. E., Herman, J. L., Anafi, M., Mottet, L., Keisling, M., & Rankin, S. (2015). The Report of the 2015 U.S. Transgender Survey. Washington DC: National Center for Transgender Equality.

Johns, M. M., Beltran, O., Armstrong, H. L., Jayne, P. E., & Barrios, L. C. (2018). Protective factors among transgender and gender-variant youth: A systematic review by socioecological level. The Journal of Primary Prevention, 39(3), 263–301. https://doi.org/10.1007/s10935-018-05089

Kia, H., MacKinnon, K. R., Abramovich, A., & Bonato, S. (2021). Peer support as a protective factor against suicide in trans populations: A scoping review. Social Science & Medicine, 279, 114026. https://doi.org/10.1016/j. socscimed.2021.114026

King, W. M., & Gamarel, K. E. (2021). A scoping review examining social and legal gender affirmation and health among transgender populations. Transgender Health, 6(1), 5–22. https://doi.org/10.1089/trgh.2020.0025

Kota, K. K., Salazar, L. F., Culbreth, R. E., Crosby, R. A., & Jones, J. (2020). Psychosocial mediators of perceived stigma and suicidal ideation among transgender women. BioMedCentral Public Health, 20(1), 1-20. https://doi. org/10.1186/s12889-020-8177-z

Kuper, L. E., Adams, N., & Mustanski, B. S. (2018). Exploring cross-sectional predictors of suicide ideation, attempt, and risk in a large online sample of transgender and gendernonconforming youth and young adults. LGBT Health, 5(7), 391–400. https://doi.org/10.1089/lgbt.2017.0259

Marraccini, M. E., Ingram, K. M., Naser, S. C., Grapin, S. L., Toole, E. N., O’Neill, J. C., Chin, A. J., Martinez, R. R., & Griffin, D. (2022). The roles of school in supporting LGBTQ+ Youth: A systematic review and ecological framework for understanding risk for suicide-related thoughts and behaviors. Journal of School Psychology, 91, 27–49. https://doi.org/10.1016/j.jsp.2021.11.006

McGuire, J. K., Doty, J. L., Catalpa, J. M., & Ola, C. (2016). Body image in transgender young people: Findings from a qualitative, community-based study. Body Image, 18, 96–107. https://doi.org/10.1016/j.bodyim.2016.06.004

Moody, C., & Smith, N. G. (2013). Suicide protective factors among trans adults. Archives of Sexual Behavior, 42(5), 739–752. https://doi.org/10.1007/s10508-013-0099-8

Olson, K. R., Durwood, L., DeMeules, M., & McLaughlin, K. A. (2016). Mental health of transgender children who are supported in their identities. Pediatrics, 137(3) 1-3. https:// doi.org/10.1542/peds.2015-3223

Pollitt, A. M., Ioverno, S., Russell, S. T., Li, G., & Grossman, A. H. (2019). Predictors and mental health benefits of chosen name use among transgender youth. Youth & Society, 53(2), 320–341. https://doi.org/10.1177/0044118x19855898

Price, M. N., & Green, A. E. (2021). Association of gender identity acceptance with fewer suicide attempts among transgender and nonbinary youth. Transgender Health https://doi.org/10.1089/trgh.2021.0079

Price-Feeney, M., Green, A. E., & Dorison, S. (2020). Understanding the mental health of transgender and nonbinary youth. Journal of Adolescent Health, 66(6). https://doi.org/10.1016/j.jadohealth.2019.11.314

Reisner, S. L., Biello, K. B., White Hughto, J. M., Kuhns, L., Mayer, K. H., Garofalo, R., & Mimiaga, M. J. (2016). Psychiatric diagnoses and comorbidities in a diverse, multicity cohort of young transgender women. JAMA Pediatrics, 170(5), 481-486. https://doi.org/10.1001/jamapediatrics.2016.0067

Rijn, A. B.-van, Steensma, T. D., Kreukels, B. P. C., & CohenKettenis, P. T. (2012). Self-perception in a clinical sample of gender variant children. Clinical Child Psychology and Psychiatry, 18(3), 464–474. https://doi. org/10.1177/1359104512460621

Romijnders, K. A., Wilkerson, J. M., Crutzen, R., Kok, G., Bauldry, J., & Lawler, S. M. (2017). Strengthening social ties to increase confidence and self-esteem among sexual and gender minority youth. Health Promotion Practice, 18(3), 341–347. https://doi.org/10.1177/1524839917690335

Romito, M., Salk, R. H., Roberts, S. R., Thoma, B. C., Levine, M. D., & Choukas-Bradley, S. (2021). Exploring transgender adolescents’ body image concerns and disordered eating: Semi-structured interviews with nine gender minority youth. Body Image, 37, 50–62. https://doi.org/10.1016/j. bodyim.2021.01.008

Sevelius, J., Dickey, L. m., & Singh, A. A. (2017). Engaging in TGNC-affirmative research. In A. Singh & L. M. Dickey (Eds.), Affirmative counseling and psychological practice with transgender and gender nonconforming clients (pp. 231–246). American Psychological Association. https:// doi.org/10.1037/14957-012

Simons, L., Schrager, S. M., Clark, L. F., Belzer, M., & Olson, J. (2013). Parental support and mental health among transgender adolescents. Journal of Adolescent Health, 53(6), 791–793. https://doi.org/10.1016/j.jadohealth.2013.07.019

Smolak, L., & Levine, M. P. (2001). Body image in children. In J. K. Thompson & L. Smolak (Eds.), Body image, eating disorders, and obesity in youth: Assessment, prevention, and treatment (pp. 41–66). American Psychological Association. https://doi.org/10.1037/10404-002

Turban, J. L., King, D., Carswell, J. M., & Keuroghlian, A. S. (2020). Pubertal suppression for transgender youth and risk of suicidal ideation. Pediatrics, 145(2) 1-8. https://doi. org/10.1542/peds.2019-1725

Van der Miesen, A. I. R., Steensma, T. D., de Vries, A. L. C., Bos, H., & Popma, A. (2020). Psychological functioning in transgender adolescents before and after gender-affirmative care compared with cisgender general population peers.

Journal of Adolescent Health, 66(6), 699–704. https://doi. org/10.1016/j.jadohealth.2019.12.018

Vanhalst, J., Luyckx, K., Scholte, R.H., Engels, R. C., & Goossens, L. (2013). Low self-esteem as a risk factor for loneliness in adolescence: Perceived - but not actual - social acceptance as an underlying mechanism. Journal of Abnormal Child Psychology, 41, 1067–1081. https://doi.org/10.1007/ s10802-013-9751-y

Veale, J. F., Watson, R. J., Peter, T., & Saewyc, E. M. (2017). Mental health disparities among Canadian transgender youth. Journal of Adolescent Health, 60(1), 44–49. https:// doi.org/10.1016/j.jadohealth.2016.09.014

Zeluf, G., Dhejne, C., Orre, C., Mannheimer, L. N., Deogan, C., Höijer, J., Winzer, R., & Thorson, A. E. (2018). Targeted victimization and suicidality among trans people: A webbased survey. LGBT Health, 5(3), 180–190. https://doi. org/10.1089/lgbt.2017.0011