Abstract
In recent years, there has been a proliferation of research regarding transgender and gender nonconforming (TGNC) people. The stigma and legal discriminations that this population faces have obvious and documented repercussions for mental health. In 2015, the American Psychological Association (APA) published Guidelines for Psychological Practice with TGNC People. The APA noted that due to the nuances of working with TGNC youth and the dearth of related literature, the guidelines focus primarily on TGNC adults. To date, there has not been a systematic review of risk and resilience factors for mental health among TGNC children, adolescents, and young adults under the age of 25. Forty-four peer-reviewed articles met inclusion criteria for this systematic review, and were evaluated for their methodological rigor and their findings. Common risk factors for negative mental health variables included physical and verbal abuse, exposure to discrimination, social isolation, poor peer relations, low self-esteem, weight dissatisfaction, and age. Across studies, older children and adolescents tended to report higher rates of psychological distress. Resilience-promoting factors for mental health were also documented, including parent connectedness, social support, school safety and belonging, and the ability to use one’s chosen name. By synthesizing the existing literature using a resilience-focused and minority stress framework, the present review provides clinicians and researchers with a coherent evidence-base to better equip them to promote psychological adaptation and wellbeing among TGNC youth.

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Aitken, M., VanderLaan, D. P., Wasserman, L., Stojanovski, S., & Zucker, K. J. (2016). Self-harm and suicidality in children referred for gender dysphoria. Journal of the American Academy of Child and Adolescent Psychiatry, 55(6), 513–520. https://doi.org/10.1016/j.jaac.2016.04.001.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). Philadelphia: American Psychiatric Association.
American Psychological Association (2017). The road to resilience. Retrieved online from:
American Psychological Association. (2015). Guidelines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70(9), 832–864.
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.
Bechard, M., VanderLaan, D. P., Wood, H., Wasserman, L., & Zucker, K. J. (2017). Psychosocial and psychological vulnerability in adolescents with gender dysphoria: A “Proof of Principle” study. Journal of Sex & Marital Therapy, 43(7), 678–688. https://doi.org/10.1080/0092623X.2016.1232325.
Bockting, W., Benner, A., & Coleman, E. (2009). Gay and bisexual identity development among female-to-male transsexuals in North America: Emergence of a transgender sexuality. Archives of Sexual Behavior, 38(5), 688–701.
Bramer, W. M. (2016). Variation in number of hits for complex searches in Google Scholar. Journal of the Medical Library Association: JMLA, 104(2), 143.
Budge, S. L. (2015). Psychotherapists as gatekeepers: An evidence-based case study highlighting the role and process of letter writing for transgender clients. Psychotherapy, 52(3), 287–297. https://doi.org/10.1037/pst0000034.
Centre for Reviews and Dissemination. (2019). PROSPERO: International Prospective Register of Systematic Reviews. Retrieved from https://www.crd.york.ac.uk/prospero/
Chodzen, G., Hidalgo, M. A., Chen, D., & Garofalo, R. (2019). Minority stress factors associated with depression and anxiety among transgender and gender-nonconforming youth. The Journal of Adolescent Health: Official Publication of the Society for Adolescent Medicine, 64(4), 467–471. https://doi.org/10.1016/j.jadohealth.2018.07.006.
Cohen-Kettenis, P. T., Owen, A., Kaijser, V. G., Bradley, S. J., & Zucker, K. J. (2003). Demographic characteristics, social competence, and behavior problems in children with gender identity disorder: A cross-national, cross-clinic comparative analysis. Journal of Abnormal Child Psychology, 31(1), 41–53. https://doi.org/10.1023/A:1021769215342.
Connor, K. M., & Davidson, J. R. (2003). Development of a new resilience scale: The Connor-Davidson resilience scale (CD-RISC). Depression and Anxiety, 18(2), 76–82.
Costa, R., Dunsford, M., Skagerberg, E., Holt, V., Carmichael, P., & Colizzi, M. (2015). Psychological support, puberty suppression, and psychosocial functioning in adolescents with gender dysphoria. The Journal of Sexual Medicine, 12(11), 2206–2214.
Dank, M., Lachman, P., Zweig, J. M., & Yahner, J. (2014). Dating violence experiences of lesbian, gay, bisexual, and transgender youth. Journal of Youth and Adolescence, 43(5), 846–857.
De Los Reyes, A., & Kazdin, A. E. (2005). Informant discrepancies in the assessment of childhood psychopathology: A critical review, theoretical framework, and recommendations for further study. Psychological Bulletin, 131(4), 483.
de Vries, A. L. C., Steensma, T. D., Cohen-Kettenis, P. T., VanderLaan, D. P., & Zucker, K. J. (2016). Poor peer relations predict parent- and self-reported behavioral and emotional problems of adolescents with gender dysphoria: A cross-national, cross-clinic comparative analysis. European Child & Adolescent Psychiatry, 25(6), 579–588. https://doi.org/10.1007/s00787-015-0764-7.
Dowshen, N., Matone, M., Luan, X., Lee, S., Belzer, M., Fernandez, M. I., & Adolescent Medicine Trials Network for HIV/AIDS Interventions. (2016). Behavioral and health outcomes for HIV+ young transgender women (YTW) linked to and engaged in medical care. LGBT Health, 3(2), 162–167. https://doi.org/10.1089/lgbt.2014.0062.
Earnshaw, V. A., Bogart, L. M., Poteat, V. P., Reisner, S. L., & Schuster, M. A. (2016). Bullying among lesbian, gay, bisexual, and transgender youth. Pediatric Clinics, 63(6), 999–1010.
Edwards-Leeper, L., Feldman, H. A., Lash, B. R., Shumer, D. E., & Tishelman, A. C. (2017). Psychological profile of the first sample of transgender youth presenting for medical intervention in a U.S. pediatric gender center. Psychology of Sexual Orientation and Gender Diversity, 4(3), 374–382. https://doi.org/10.1037/sgd0000239.
Eisenberg, M. E., Gower, A. L., McMorris, B. J., Rider, G. N., & Coleman, E. (2019). Emotional distress, bullying victimization, and protective factors among transgender and gender diverse adolescents in city, suburban, town, and rural locations. The Journal of Rural Health: Official Journal of the American Rural Health Association and the National Rural Health Care Association, 35(2), 270–281. https://doi.org/10.1111/jrh.12311.
Gower, A. L., Rider, G. N., Brown, C., McMorris, B. J., Coleman, E., Taliaferro, L. A., & Eisenberg, M. E. (2018). Supporting transgender and gender diverse youth: Protection against emotional distress and substance use. American Journal of Preventive Medicine, 55(6), 787–794. https://doi.org/10.1016/j.amepre.2018.06.030.
Grossman, A. H., & D’Augelli, A. R. (2007). Transgender youth and life-threatening behaviors. Suicide and Life-Threatening Behavior, 37(5), 527–537. https://doi.org/10.1521/suli.2007.37.5.527.
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/10.1080/19361653.2011.541347.
Grossman, A. H., Park, J. Y., & Russell, S. T. (2016). Transgender youth and suicidal behaviors: Applying the interpersonal psychological theory of suicide. Journal of Gay & Lesbian Mental Health, 20(4), 329–349. https://doi.org/10.1080/19359705.2016.1207581.
Hall, L. K. (2011). The importance of understanding military culture. Social Work in Health Care, 50(1), 4–18.
Hatchel, T., Valido, A., Pedro, K. T., Huang, Y., & Espelage, D. L. (2018). Minority stress among transgender adolescents: The role of peer victimization, school belonging, and ethnicity. Journal of Child and Family Studies, No Pagination Specified-No Pagination Specified. https://doi.org/10.1007/s10826-018-1168-3.
Heard, J., Morris, A., Kirouac, N., Ducharme, J., Trepel, S., & Wicklow, B. (2018). Gender dysphoria assessment and action for youth: Review of health care services and experiences of trans youth in Manitoba. Paediatrics & Child Health, 23(3), 179–184. https://doi.org/10.1093/pch/pxx156.
Higgins, J. P., Sterne, J. A., Savović, J., Page, M. J., Hróbjartsson, A., Boutron, I., et al. (2019). A revised tool for assessing risk of bias in randomized trials. In J. Chandler, J. McKenzie, I. Boutron, & V. Welch (Eds.), Cochrane methods. Cochrane database of systematic reviews. Hoboken: Wiley. https://doi.org/10.1002/14651858.CD201601.
Hill, D. B., Menvielle, E., Sica, K. M., & Johnson, A. (2010). An affirmative intervention for families with gender variant children: Parental ratings of child mental health and gender. Journal of Sex & Marital Therapy, 36(1), 6–23. https://doi.org/10.1080/00926230903375560.
Hjemdal, O., Friborg, O., Stiles, T. C., Martinussen, M., & Rosenvinge, J.H. (2006). A new scale for adolescent resilience: Grasping the central protective resources behind healthy development. Measurement and Evaluation in Counseling and Development, 39, 84–96. https://doi.org/https://doi.org/10.1080/07481756.2006.11909791. http://www.apa.org/helpcenter/road-resilience.aspx
Human Rights Campaign. (2020). Violence against the transgender community in 2019. Retrieved July 14, 2020, from https://www.hrc.org/resources/violence-against-the-transgender-community-in-2019
Janssen, A., Huang, H., & Duncan, C. (2016). Gender variance among youth with autism spectrum disorders: A retrospective chart review. Transgender Health, 1(1), 63–68.
Jones, T., & Hillier, L. (2013). Comparing trans-spectrum and same-sex-attracted youth in Australia: Increased risks, increased activisms. Journal of Lgbt Youth, 10(4), 287–307. https://doi.org/10.1080/19361653.2013.825197.
Kaltiala-Heino, R., Sumia, M., Työläjärvi, M., & Lindberg, N. (2015). Two years of gender identity service for minors: Overrepresentation of natal girls with severe problems in adolescent development. Child and Adolescent Psychiatry and Mental Health, 9(1), 9.
Kaltiala-Heino, R., Tyolajarvi, M., & Lindberg, N. (2019). Sexual experiences of clinically referred adolescents with features of gender dysphoria. Clinical Child Psychology and Psychiatry, 24(2), 365–378. https://doi.org/10.1177/1359104519827069.
Katz-Wise, S. L., Ehrensaft, D., Vetters, R., Forcier, M., & Austin, S. B. (2018). Family functioning and mental health of transgender and gender-nonconforming youth in the trans teen and family narratives project. Journal of Sex Research, 55(4–5), 582–590. https://doi.org/10.1080/00224499.2017.1415291.
Keuroghlian, A. S., Shtasel, D., & Bassuk, E. L. (2014). Out on the street: A public health and policy agenda for lesbian, gay, bisexual, and transgender youth who are homeless. American Journal of Orthopsychiatry, 84(1), 66.
Kuvalanka, K. A., Weiner, J. L., Munroe, C., Goldberg, A. E., & Gardner, M. (2017). Trans and gender-nonconforming children and their caregivers: Gender presentations, peer relations, and well-being at baseline. Journal of Family Psychology JFP Journal of the Division of Family Psychology of the American Psychological Association (Division 43), 31(7), 889–899. https://doi.org/10.1037/fam0000338.
Le, V., Arayasirikul, S., Chen, Y.-H., Jin, H., & Wilson, E. C. (2016). Types of social support and parental acceptance among transfemale youth and their impact on mental health, sexual debut, history of sex work and condomless anal intercourse. Journal of the International AIDS Society, 19(3 Suppl 2), 20781. https://doi.org/10.7448/IAS.19.3.20781.
Levitan, N., Barkmann, C., Richter-Appelt, H., Schulte-Markwort, M., & Becker-Hebly, I. (2019). Risk factors for psychological functioning in german adolescents with gender dysphoria: Poor peer relations and general family functioning. European Child & Adolescent Psychiatry. https://doi.org/10.1007/s00787-019-01308-6.
Luthar, S. S., Cicchetti, D., & Becker, B. (2000). The construct of resilience: A critical evaluation and guidelines for future work. Child Development, 71, 543–562.
Meyer, I. H. (2003). Prejudice as stress: Conceptual and measurement problems. American Journal of Public Health, 93(2), 262–265.
National Institute of Health. (2014). Study quality assessment tools. Retrieved from https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools
Nguyen, H. B., Loughead, J., Lipner, E., Hantsoo, L., Kornfield, S. L., & Epperson, C. N. (2019). What has sex got to do with it? The role of hormones in the transgender brain. Neuropsychopharmacology, 44(1), 22.
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), e20153223. https://www.pewsocialtrends.org/essay/on-the-cusp-of-adulthood-and-facing-an-uncertain-future-what-we-know-about-gen-z-so-far/
Perez-Brumer, A., Day, J. K., Russell, S. T., & Hatzenbuehler, M. L. (2017). Prevalence and correlates of suicidal ideation among transgender youth in California: Findings from a representative, population-based sample of high school students. Journal of the American Academy of Child and Adolescent Psychiatry, 56(9), 739–746. https://doi.org/10.1016/j.jaac.2017.06.010.
Peterson, C. M., Matthews, A., Copps-Smith, E., & Conard, L. A. (2017). Suicidality, self-harm, and body dissatisfaction in transgender adolescents and emerging adults with gender dysphoria. Suicide and Life-Threatening Behavior, 47(4), 475–482.
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: Baseline findings from project LifeSkills. JAMA Pediatrics, 170(5), 481–486. https://doi.org/10.1001/jamapediatrics.2016.0067.
Reisner, S. L., Jadwin-Cakmak, L., Sava, L., Liu, S., & Harper, G. W. (2019). Situated vulnerabilities, sexual risk, and sexually transmitted infections’ diagnoses in a sample of transgender youth in the United States. Aids Patient Care and Stds, 33(3), 120–130. https://doi.org/10.1089/apc.2018.0249.
Rider, G. N., McMorris, B. J., Gower, A. L., Coleman, E., & Eisenberg, M. E. (2018). Health and care utilization of transgender and gender nonconforming youth: A population-based study. Pediatrics, 141(3), 20171683.
Röder, M., Barkmann, C., Richter-Appelt, H., Schulte-Markwort, M., Ravens-Sieberer, U., & Becker, I. (2018). Health-related quality of life in transgender adolescents: Associations with body image and emotional and behavioral problems. International Journal of Transgenderism, 19(1), 78–91. https://doi.org/10.1080/15532739.2018.1425649.
Rowe, C., Santos, G.-M., McFarland, W., & Wilson, E. C. (2015). Prevalence and correlates of substance use among trans*female youth ages 16–24 years in the San Francisco Bay Area. Drug and Alcohol Dependence, 147, 160–166. https://doi.org/10.1016/j.drugalcdep.2014.11.023.
Roy Rosenzweig Center for History and New Media. (2016). Zotero [Computer software]. Retrieved from www.zotero.org/download
Russell, S. T., Pollitt, A. M., Li, G., & Grossman, A. H. (2018). Chosen Name use is linked to reduced depressive symptoms, suicidal ideation, and suicidal behavior among transgender youth. Journal of Adolescent Health, 63(4), 503–505. https://doi.org/10.1016/j.jadohealth.2018.02.003.
Shamseer, L., Moher, D., Clarke, M., Ghersi, D., Liberati, A., Petticrew, M., & Stewart, L. A. (2015). Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. BMJ, 349, g7647.
Shea, B. J., Reeves, B. C., Wells, G., Thuku, M., Hamel, C., Moran, J., & Henry, D. A. (2017). AMSTAR 2: A critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. Bmj, 358, j4008. Retrieved from https://www.npr.org/sections/health-shots/2020/06/12/868073068/transgender-health-protections-reversed-by-trump-administration
Simons, L., Schrager, S. M., Clark, L. F., Belzer, M., & Olson, J. (2013). Parental support and mental health among transgender adolescents. The Journal of Adolescent Health: Official Publication of the Society for Adolescent Medicine, 53(6), 791–793. https://doi.org/10.1016/j.jadohealth.2013.07.019.
Soeters, J. L., Winslow, D. J., & Weibull, A. (2006). Military culture. In G. Caforio (Ed.), Handbook of the sociology of the military (pp. 237–254). Boston, MA: Springer.
Steensma, T. D., Zucker, K. J., Kreukels, B. P. C., Vanderlaan, D. P., Wood, H., Fuentes, A., & Cohen-Kettenis, P. T. (2014). Behavioral and emotional problems on the Teacher’s Report Form: A cross-national, cross-clinic comparative analysis of gender dysphoric children and adolescents. Journal of Abnormal Child Psychology, 42(4), 635–647. https://doi.org/10.1007/s10802-013-9804-2.
Taliaferro, L. A., McMorris, B. J., & Eisenberg, M. E. (2018). Connections that moderate risk of non-suicidal self-injury among transgender and gender non-conforming youth. Psychiatry Research, 268, 65–67. https://doi.org/10.1016/j.psychres.2018.06.068.
Taliaferro, L. A., McMorris, B. J., Rider, G. N., & Eisenberg, M. E. (2019). Risk and protective factors for self-harm in a population-based sample of transgender youth. Archives of Suicide Research, 23(2), 203–221. https://doi.org/10.1080/13811118.2018.1430639.
Toomey, R. B., Syvertsen, A. K., & Shramko, M. (2018). Transgender adolescent suicide behavior. Pediatrics, 142(4), e20174218.
Valentine, S. E., & Shipherd, J. C. (2018). A systematic review of social stress and mental health among transgender and gender non-conforming people in the United States. Clinical Psychology review, 66, 24–38.
Van Donge, N., Schvey, N. A., Roberts, T. A., & Klein, D. A. (2019). Transgender dependent adolescents in the U.S. Military Health Care System: Demographics, treatments sought, and health care service utilization. Military Medicine, 184(5–6), e447–e454. https://doi.org/10.1093/milmed/usy264.
VanderLaan, D. P., Leef, J. H., Wood, H., Hughes, S. K., & Zucker, K. J. (2015). Autism spectrum disorder risk factors and autistic traits in gender dysphoric children. Journal of Autism and Developmental Disorders, 45(6), 1742–1750. https://doi.org/10.1007/s10803-014-2331-3.
VanderLaan, D. P., Santarossa, A., Nabbijohn, A. N., Wood, H., Owen-Anderson, A., & Zucker, K. J. (2018). Separation anxiety among birth-assigned male children in a specialty gender identity service. European Child & Adolescent Psychiatry, 27(1), 89–98. https://doi.org/10.1007/s00787-017-1018-7.
Veale, J. F., Peter, T., Travers, R., & Saewyc, E. M. (2017). Enacted stigma, mental health, and protective factors among transgender youth in Canada. Transgender Health, 2(1), 207–216. https://doi.org/10.1089/trgh.2017.0031.
Wei, C., & Liu, W. (2019). Coming out in mainland china: A national survey of lgbtq students. Journal of LGBT Youth, No Pagination Specified-No Pagination Specified. https://doi.org/10.1080/19361653.2019.1565795.
Weinhardt, L. S., Stevens, P., Xie, H., Wesp, L. M., John, S. A., Apchemengich, I., & Lambrou, N. H. (2017). Transgender and gender nonconforming youths’ public facilities use and psychological well-being: A mixed-method study. Transgender Health, 2(1), 140–150. https://doi.org/10.1089/trgh.2017.0020.
Wilson, E. C., Chen, Y.-H., Arayasirikul, S., Raymond, H. F., & McFarland, W. (2016). The impact of discrimination on the mental health of trans*female youth and the protective effect of parental support. AIDS and Behavior, 20(10), 2203–2211. https://doi.org/10.1007/s10461-016-1409-7.
Wilson, E. C., Garofalo, R., Harris, R. D., Herrick, A., Martinez, M., Martinez, J., & Interventions, AMTN for H. (2009). Transgender female youth and sex work: HIV risk and a comparison of life factors related to engagement in sex work. AIDS and Behavior, 13(5), 902–913.
Wilson, P. H. (2008). Defining military culture. The Journal of Military History, 72(1), 11–41.
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Dr. Thomas Ollendick served as a preliminary examination committee member for Amelia P. Tankersley, M.S.
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Tankersley, A.P., Grafsky, E.L., Dike, J. et al. Risk and Resilience Factors for Mental Health among Transgender and Gender Nonconforming (TGNC) Youth: A Systematic Review. Clin Child Fam Psychol Rev 24, 183–206 (2021). https://doi.org/10.1007/s10567-021-00344-6
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DOI: https://doi.org/10.1007/s10567-021-00344-6