College students with nontraditional gender identities reported two to four times as many symptoms of mental health conditions as cisgender students, according to cross-sectional survey data.

Among 65,213 students, about half of cisgender students and three-quarters of gender minorities -- including transgender, genderqueer, and self-identifying gender students -- reported symptoms of depression, anxiety, eating disorders, or nonsuicidal self-injury, reported Sarah Ketchen Lipson, PhD, of Boston University School of Public Health, and colleagues.

As shown in the study online in the American Journal of Preventive Medicine, transmasculine students (assigned female sex at birth) were a particularly vulnerable group compared with cisgender men, with a higher odds of meeting at least one mental health condition (odds ratio 3.9, 95% CI 2.9-5.1), including suicidal ideation (OR 2.6, 95% CI 2.1-3.2) and suicide attempts (OR 2.31, 95% CI 1.4-3.9) after adjusting for sociodemographic variables and sexuality.

Also vulnerable were genderqueer individuals, who, relative to transgender students and individuals with self-identified genders, had a higher prevalence of seven of the eight conditions evaluated, excluding suicide attempts, the team added.

The stigmatization of gender minorities produces stressors that can trigger psychological responses, leading to mental health vulnerabilities, said co-author Sara Abelson, MPH, of the University of Michigan in Ann Arbor.

This can include stigmatization at the structural level, such as discriminatory policies, or at the interpersonal level, such as harassment or family rejection, Abelson told MedPage Today.

Gender minority youth have previously been identified as having an increased risk for mental health problems, including suicide, noted Elizabeth Boskey, PhD, MPH, of Boston Children's Hospital, who was not involved with the study.

But much of the prior data comes from clinical settings, and therefore overlooks people who don't have access to mental healthcare, Boskey told MedPage Today. Looking at symptoms rather than diagnoses is particularly important in this population, she said, "given that many gender-diverse people have been turned off from engaging with healthcare because of experiences of discrimination and stigma."

However, it's possible that survey participants had more mental health problems than nonparticipants, and relying on self-reported symptoms may make it difficult to compare this study's findings with others that measured clinically diagnosed mental health conditions, Boskey said.

On the other hand, studying college-age students is particularly important because many mental health conditions emerge at this time, Abelson said. College campuses also have an important role to play in shaping student mental health, she added.

For example, implementing gender-neutral bathrooms (the lack of which has been linked with suicidality) or allowing students to change their given name in campus registries may mediate this mental health risk, the authors noted.

Future research should focus not only on gender minority vulnerabilities, but also on what is causing them, Abelson said.

"Too often when confronted with data and evidence about health inequalities, researchers and practitioners even without meaning to will put blame or unfair focus on what the population that's facing the disproportionate burden of concerns might be able to do to improve their health," she said. "I think we need greater focus and attention on how our transphobic society and strictly enforced gender-binary [society] results in these heartbreaking mental health burdens that we're seeing."

Study Details & Additional Findings

The mobile Healthy Minds Study involved 71 geographically diverse colleges. On each campus, 4,000 students 18 or older were incentivized to participate in the survey for the chance to win gift cards. Researchers looked at four semesters of responses from 2015 to 2017.

Overall, there were eight mental health outcomes, including the likelihood to meet criteria for one or more conditions. Depression symptoms were measured through the Patient Health Questionnaire, anxiety symptoms were analyzed through the Generalized Anxiety Disorder 7-item, and eating disorders were detected through the SCOFF screen.

The survey also asked about self-harm (without intentions of dying), as well as suicide attempts, plans, and ideation.

The vast majority of the sample was cisgender (98%) and two-thirds were white. Overall, 78% of gender minority and 45% of cisgender youth reported at least one symptom of a mental health problem.

The odds of meeting at least one mental health condition was also higher for trans feminine students relative to cisgender men (OR 1.9, 95% CI 1.44-2.56). Suicidal ideation (OR 1.8, 95% CI 1.33-2.46) and nonsuicidal self injury (OR 1.6, 95% CI 1.24-2.16) were also higher, the researchers added.

In an analysis comparing genderqueer students with other subgroups of gender minorities and cisgender students, genderqueer individuals had higher rates of meeting at least one mental health condition (OR 6.2, 95% CI 4.7-8.3), including non-suicidal self harm (OR 5.7, 95% CI 4.6-7.1) and suicidal ideation (OR 5.2, 95% CI 4.1-6.2).

In this analysis, 49% of transgender students, 66% of genderqueer respondents, and 54% of individuals with another self-identified gender reported depressive symptoms. Comparatively, 28% of cisgender respondents did.

Compared with 8% of cisgender students, 13% of transgender individuals, 14% of genderqueer respondents, and 12% of students with self-identified genders reported symptoms of eating disorders.

Lastly, anxiety symptoms were reported by 48% of transgender participants, 55% of genderqueer students, 48% of those with self-identified gender, and 24% of cisgender respondents, the authors reported.

The campuses included in the study volunteered to participate, which is a limitation, Lipson and co-authors noted. Categorizing gender identities may have also been complicated by binary campus registries. Lastly, although the response rate (24%) was "typical for online surveys," the data is subject to non-response bias, particularly since individuals may be less likely to respond if they have a mental health condition.

Elizabeth Hlavinka covers clinical news, features, and investigative pieces for MedPage Today. She also produces episodes for the Anamnesis podcast. Follow