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Transgender and/or gender-nonconforming children and teens are more likely than their cisgender peers to experience anxiety, depression, attention deficits, and other mental health disorders, findings from a retrospective study suggest.

The study was unique because it involved a large number of gender-nonconforming children and teens enrolled in a comprehensive health system. Most past studies of the subject have been much smaller and have included youth identified through their attendance at specialty clinics, the researchers noted.

Gender-nonconforming youth were significantly more likely to experience a range of mental health issues than were cisgender youth, who identified with their assigned gender at birth.

The , was conducted to better understand the magnitude of mental health problems experienced by transgender and/or gender-nonconforming (TGNC) youth, the lead researcher, Tracy Becerra-Culqui, PhD, of the Kaiser Permanente health system in Southern California, told MedPage Today.

The study is one of two now online in that examined the challenges faced by lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth.

In the other study, research by Lauras Baams, PhD, of the University of Groningen in The Netherlands, that were more likely among LGBTQ teens.

The youth were more likely to experience poly-victimization and psychological and/or physical abuse, with higher levels of gender nonconformity predicting a higher likelihood of experiencing these patterns of childhood adversity.

In the STRONG study, Becerra-Culqui and colleagues examined electronic medical records to identify transgender and gender-nonconforming children and teens.

Compared with cisgender children and teens, the TGNC youth had a three- to 13-fold higher incidence of mental health disorders. Attention-deficit disorder was the most prevalent mental health diagnosis among younger children (ages 3 to 9), and depressive disorder was the most prevalent condition among older children and teens (ages 10 to 17).

Becerra-Culqui explained that to identify the TGNC youth, the researchers scanned electronic medical records from children and adolescents enrolled in the Kaiser Permanente health system in Southern California, Northern California, and Georgia for notations consistent with transgender/gender identity issues expressed by either a parent or the enrollee.

A total of 2,164 enrollees were initially identified, and, after validation, 1,333 were confirmed as TGNC and included in the analysis. A total of 44% of the cohort were transfeminine -- i.e., assigned male at birth but identifying closer to female -- and 56% were transmasculine, assigned female at birth but identifying to a greater extent with male gender.

Ten male and 10 female referent cisgender enrollees were matched to each TGNC enrollee by year of birth, race/ethnicity, study site, and membership year of index date (first evidence of gender-nonconforming status).

Research in gender development suggests that gender-typed behavior is both noticeable and stable between the ages of 3 and 8, especially among children with relatively high or low gender-typical behavior, the researchers noted.

"Most of the available data used to address the mental health status of TGNC youth come from specialized clinics providing care to this population. Although researchers in clinic-based studies offer detailed and high-quality data, they often lack information on individuals who have not sought or had no access to specialized care."

The analysis revealed that:

• Common diagnoses for children and adolescents were attention-deficit disorders (transfeminine 15%; transmasculine 16%) and depressive disorders (transfeminine 49%; transmasculine 62%), respectively
• For all diagnostic categories, prevalence was several-fold higher among TGNC youth than in matched reference groups
• Prevalence ratios for a history of self-inflicted injury in adolescents 6 months before the index date ranged from 18 (95% CI, 4.4 to 82) to 144 (95% CI, 36 to 1248)
• The corresponding range for suicidal ideation was 25 (95% CI, 14 to 45) to 54 (95% CI, 18 to 218)

"Our findings support those from previous research in which the sample sizes were much smaller," Becerra-Culqui said.

In an , Stanley Ray Vance Jr, MD, and Stephen Rosenthal, MD, of Benioff Children's Hospital in San Francisco, wrote that the two studies "reinforce the need for clinicians to assess for risk factors for poor psychosocial outcomes that disproportionately affect LGBTQ and gender-nonconforming youth."

"Even before such risk factors can be assessed, a first crucial step is creating clinical environments that promote these youth feeling comfortable with disclosing their sexuality and gender identify."

Vance and Rosenthal added that from residency through continuing medical education, providers "need the tools, skills, and guidance to feel comfortable and confident in their ability to assess for risk factors for poor psychosocial outcomes that disproportionately affect these youth. Only by identifying LGBTQ and gender-nonconforming youth and appropriately screening them can they be provided with specific, potentially lifesaving, supports that may be needed, including gender-affirming treatments for transgender youth, referral to a mental health provider, family engagement, and referrals to community programs for peer engagement."