Transgender children who socially transition early are comparable to other children in measures of mental health, new research shows.

In "striking contrast" to previous work showing high rates of depression and anxiety in nontransitioned children, the current analysis shows that although transgender children who had socially transitioned reported marginally higher anxiety than matched control persons or their sibling peers, they did not differ in reports of depression and self-worth.

"We found remarkably good mental health outcomes in socially transitioned transgender children in the present study," the researchers, led by Lily Durwood, a doctoral candidate at the University of Washington, Seattle, conclude.

"Previous standards of care for gender nonconforming children was to wait until puberty to socially transition, but these findings show normal mental health in younger children, indicating that early social transitions can be associated with good mental health," Durwood told Medscape Medical News.

The researchers compared self-reported anxiety and depression in socially transitioned transgender children aged 9 to 14 years and sense of self-worth in transgender youth aged 6 to 14 years, with age- and gender-matched control persons and siblings. In addition, parents were asked to rate depression and anxiety in their children.

"Previous research has shown that parents of socially transitioned transgender children reported normative levels of depression and slightly elevated anxiety," Durwood said. "We wanted to see if parents were underreporting mental health problems in their socially transitioned children. We also wanted to study self-worth, which has not been studied in this population.

"We found good self-reported mental health outcomes in the transgender youth we studied, which dovetailed with parental reports," she said.

The study was published in the February issue of the Journal of the American Academy of Child and Adolescent Psychiatry.

Social Transition

Many young transgender children have regarded their gender identity as different from their natal sex for months or years. In response, some parents have allowed these children to socially transition — to change his or her first name, pronouns, hairstyle, and clothing so as to live everyday life as the opposite gender. This approach has been regarded with skepticism in lay and scientific communities, the authors explain.

But "previous research has actually found high rates of depression and anxiety in gender-nonconforming children who had not transitioned," Durwood pointed out.

To assess the mental health of socially transitioned transgender children, the researchers studied participants in the TransYouth Project, a national longitudinal study of socially transitioned transgender children from 23 US states and one Canadian province.

Children reported on anxiety and depression using the pediatric short form of the National Institutes of Health's Patient Reported Outcomes Measurement System (PROMIS) scale, and parents completed the proxy version of the anxiety and depression PROMIS scales. Self-worth scores were obtained using the Global Self-Worth Subscale of the Harter Self-perception Profile for Children.

The researchers found no differences in self-reported depressive symptoms between transgender children (n = 63), control persons (n = 63), and siblings (n = 38) (F 2161 = 1.18, P = .311). Marginal differences in self-reported anxiety symptoms across the three groups were nonsignificant (F 2161 = 2.62, P = .076).

For depressive symptoms, the transgender and sibling groups (t 62 = 1.07, P = .290, and t 37 = 1.63, P = .112, respectively) did not differ from national averages. The matched-control group showed lower than average depressive symptoms (t 62 = 3.54, P = .001).

For anxiety, the transgender, control, and sibling groups did not differ from national averages (t 62 = 1.69, P = .096; t 62 = 0.99, P = .328; and t 37 = 1.67, P = .104).

Parents reported no differences among groups in depressive symptoms (F 2161 = 0.32, P = .728), although there were significant differences in anxiety symptoms (F 2161 = 6.22, P = .002).

Post hoc Tukey tests showed higher rates of parent-reported anxiety in transgender participants than in control persons (P = .002) and marginally more than in siblings (P = .073), although siblings and matched control persons did not differ from each other (P = .718). There were no differences from national averages for any group.

"Counter to the hypothesis that parents of social transitioned transgender children are underreporting anxiety and depression, parents of transgender children reported greater anxiety in their children than the children reported (t 62 = 2.11, P = .039), and they did not differ from children's self-reports on depression (t 62 = 0.97, P = .338)," the researchers write.

Because the age range and sample size were considerably larger for self-worth, the researchers divided participants by age: 6 to 8 years (n = 53 transgender, 59 control person, and 35 sibling), 9 to 11 years (n = 49 transgender, 48 control person, and 32 sibling), and 12 to 14 years (n = 14 transgender, 14 control person, and five sibling).

They found no significant effect of condition (F 2300 = 1.96, P = .142), a marginal effect of age group (F 2300 = 2.66, P = .072), and no significant interaction (F 4300 = 0.18, P = .949). In all groups, children's scores for self-worth were higher than the midpoint (2.5) of the scale.

"Significant Debate"

Commenting on the findings for Medscape Medical News, Jack Turban, a candidate for the MD degree at Yale School of Medicine, who is affiliated with the Child Study Center, New Haven, Connecticut, called the study "very exciting."

"It showed that early social transition is viable and that these children are doing quite well, with developmentally normative rates of anxiety and depression," said Turban, author of an editorial that accompanied the study.

Early transition has been a subject of "significant debate, stemming from controversial research suggesting that most prepubertal transgender children will not 'persist,' meaning they will not continue to identify as transgender in adolescence or adulthood," he said.

"Early social transition has therefore been discouraged by some because these children may later desist and will then need to detransition back to living as their gender assigned at birth."

But, "if you do not allow children to socially transition, you might damage their relationships with parents and therapists, because these children feel judged for being transgender," he said. "The resulting inner conflict and sense of stigma can be dangerous and may lead to the high rates of anxiety, depression, and even suicidality that we see in these children."

He said the study was "extremely encouraging," although it was limited by the fact that the authors compared their cohort of children to cohorts in studies that were conducted more than 10 years ago, during a time when society was even less accepting of transgender youth. Thus, "improved mental health in youth in the present study might be due to greater societal acceptance, rather than early transition per se."

Additionally, "these children were studied at one time point after social transition. Their mental scores may change as they progress into later adolescence and adulthood and potentially confront peer bullying or stigma." Further longitudinal research is needed, he emphasized.

Durwood agreed. "Right now, we do not have a large body of data to speak to whether social transition in prepubertal children actually has beneficial long-term outcomes, so it is too early to draw definitive conclusions.

"We cannot say that there is a 'right' decision for any given child, but the take-home message of this study is that it is possible for a child to socially transition before puberty and have normative mental health," she said.

The study was supported by grants from the Royalty Research Fund and the Arcus Foundation. Lily Durwood and Jack Turban have disclosed no relevant financial relationships. The original article contains a listing of sources of funding for other authors.

J Am Acad Child Adolesc Psychiatry. 2017;56:101-102, 116-123. Abstract, Editorial