Mental Health Status of Cisgender and Gender-Diverse Secondary School Students in China

This cross-sectional study uses data from questionnaires completed by adolescents in secondary schools in Suzhou city, China, to investigate the mental health challenges of youth identifying as transgender and gender nonconforming compared with cisgender adolescents.


Introduction
Transgender is an umbrella term that refers to individuals whose gender identity is incongruent with their sex assigned at birth. 1 Gender roles vary across societies, although the majority of people conform to their culture's gender norms. 2 Those who do not tend to be either rendered invisible or vulnerable to harassment and bullying. 3 Today, the number of transgender adolescents appears to be increasing around the world, and there is an increasing number of adolescents being referred to specialized gender identity clinics. 4,5 The decreased stigmatization of sexual and gender minorities, the availability of information on the internet, and increased media attention may be increasing the likelihood of adolescents self-identifying as transgender or gender nonconforming (TGNC).
Transgender and gender nonconforming individuals experience various mental health challenges. Gender dysphoria in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) is the psychiatric diagnosis for individuals who have a strong desire to be of the other gender and experience the incongruence as distressing. [6][7][8] Research has shown that a significant proportion of adolescents with gender dysphoria have a history of other psychiatric diagnoses. 5,9 There are also a number of studies reporting a high percentage of suicidal ideation, self-harm, and suicide attempts in adolescents with gender dysphoria. [10][11][12][13] Compared with their cisgender peers, TGNC youth are more likely to report mental health problems such as anxiety, depression, and suicidal ideation. 1,14 Moreover, within the school environment, transgender adolescents are vulnerable to harassment and bullying. 15 Transgender and gender nonconforming youth are a diverse group and face considerable obstacles to health and well-being. 13,[16][17][18][19] To our knowledge, there have been no school-based surveys to examine the prevalence and mental health status of TGNC adolescents in mainland China.
In surveying a nonclinical sample of adolescents, this study aimed to compare the mental health

Study Design and Setting
This was a cross-sectional survey study. Students attending 18 public secondary schools (grades [7][8][9][10][11] in Suzhou, a metropolitan city in China, were invited to participate. None of the schools declined to participate in this study. Data were collected between June 2019 and July 2019. We used cluster sampling of 18 public middle and high schools in one of the districts in Suzhou city. Ethical approval was obtained from Suzhou Guangji Hospital. School teachers led the recruitment, and it was made clear to potential participants that participation was voluntary and that there were no adverse consequences if they refused to participate or later withdrew. Students, who provided written consent, were informed that their school teachers were not able to access the completed questionnaires. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

Participants and Exposure Variable
All students in the 18 schools received information about the study. A total of 12 354 questionnaires were returned, and the response rate was 83.2%. The student's gender identity was measured by 2 questions: (1) biological sex: "What was your biological sex assigned at birth (choose from male or female)?" and (2) perceived gender: "What do you perceive your gender to be (choose from male, female, neither, or not sure)?" Students were categorized into 8 gender groups based on sex assigned at birth and perceived gender. Those who identified their present gender as congruent with their sex assigned at birth were classified as cisgender. Those who identified their gender clearly as the opposite of their sex assigned at birth were classified as transgender; those who identified as neither male nor female were classified as nonbinary; and those who were not sure about their gender were classified as questioning. These 4 gender groups were further subdivided as a function of sex assigned at birth: assigned male at birth (AMAB) or assigned female at birth (AFAB). This method of categorization using 2 questions has been used to assess gender identity in previous Chinese and European studies. 20,21 Dependent Variables

Overall Physical Health and Patient Health Questionnaire
Participants were asked about their physical health using item 1 from the 36-Item Short Form Survey Instrument ("In general, would you say your health is…?"), 22 and participants could choose an answer that ranged from poor to excellent. The Patient Health Questionnaire 9 (PHQ-9) 23 was used to measure the severity of depressive symptoms. There were 9 items (eg, "little interest or pleasure in doing things"). Participants were asked to rate how often they had been bothered by any of the problems over the previous 2 weeks. The total score of the 9 items was calculated.

Generalized Anxiety Disorder Screening
The Generalized Anxiety Disorder 7-item scale (GAD-7) 24 was used to measure anxiety symptoms.
There were 7 items (eg, "worrying too much about different things"). Similar to the PHQ-9, participants were asked to report any of the problems over the previous 2 weeks. The total score of the 7 items was calculated.
asked to rate each item on the frequency of experiencing these sleep problems. The total score of the 10 items was calculated.

Frequency of Being Bullied at School
The frequency of being bullied at school was questioned with 1 item: "How often have you been bullied at school in this academic year?" 26 In the analyses, responses were dichotomized as being bullied or not being bullied at school.

Suicide Risk Checklist
Self-harm and suicidality were assessed by asking participants to indicate their behaviors and thoughts. Items used by Chen et al 27 were modified, and there were 5 binary yes-or-no questions that asked about participants' self-harm thoughts and behavior, suicidal thoughts, suicide plan, and suicide attempts. Self-harm thoughts and behavior were measured using the questions, "Did you want to harm yourself in the last month?" and "Did you deliberately harm yourself in the last month?" A suicidal thought was measured by, "Did you think about suicide in the last month?" Suicide plan was measured by, "Did you have a suicide plan in the last month?" Participants were asked whether, in their lifetime, they had ever made a suicide attempt.
As in Chen et al, 27 5 specific questions were used to calculate a self-harm and suicidal ideation score: (1) "Did you think you would be better off dead or wish you were dead in the last month?" If yes, the score was 1; (2) if yes to self-harm thoughts in the last month, the score was 2; (3) if yes to suicide thoughts in the last month, the score was 4; (4) if yes to a suicide plan in the last month, the score was 10; and (5) if participants ever attempted suicide in the past, the score was 4. Then, an overall score of self-harm and suicidal inclination was calculated for each participant.

Statistical Analysis
All analyses were carried out from December 2019 to August 2020 using Mac R software, version 4.0.1 (R Foundation). Given the large sample size, P < .01 was taken to indicate statistical significance in all analyses (some analyses adopted a more stringent P < .001 criterion). All P values were 2-sided.
Missing data were deleted listwise in all analyses.
To assess the difference in the physical and mental health status among the different sex and TGNC groups, a series of linear mixed-model analyses were tested with participants' self-reported overall health, depression, anxiety, sleep quality, frequency of being bullied, and suicidal ideation as the outcome variables, whereas sex (male as the baseline), gender identity (cisgender youth as the baseline), and their interaction were the explanatory variables. School was added in as a randomeffect term to account for the potential difference of school policy and culture affecting the tolerance for gender minority groups.
To assess the possible associated risk of being bullied and tendency toward self-harm and suicidal ideation in association with the different gender identity groups, a series of mixed-effects logistic regressions were conducted with the 8-gender identity group category used as the exposure variable (the cisgender boys were treated as the reference group) and school as a random-effects term. The dichotomous (yes or no) response to questions regarding self-harm thoughts and selfharm actions, suicidal thoughts, suicide plans, suicide attempts, and being bullied were used as outcome variables. The same regressions were also conducted with cisgender girls as the reference group, and the results are available in eTable 1 in the Supplement.

Participants
All students who completed the questionnaire (6688 boys and 5666 girls) answered the question about their sex assigned at birth; however, there were 170 boys (2.5%) and 76 girls (1.3%) who did not specify to which sex they identified and were therefore excluded from further analysis. A total of

Descriptive Statistics
The Cronbach α for each measure was as follows: 0.93 for the PHQ-9, 0.94 for GAD-7, and 0.83 for the CPSQI. The mean (SD) values of the health-related indicators by gender groups are shown in Table 1.

Physical and Mental Health Status and Frequency of Being Bullied Among Sex and Gender Identity Groups
The linear mixed-model analysis results are shown in Table 2

Association of Gender Groups With Risk of Self-Harm, Suicide, and Being Bullied
As shown in Table 3, compared with cisgender boys, the gender minority groups as well as cisgender girls had a significantly higher likelihood of reporting self-harm thoughts (cisgender girls: odds ratio

Discussion
To our knowledge, this is the first study to assess the occurrence of mental health problems in TGNC adolescents in mainland China. The findings suggest that TGNC students reported more difficulties and problems on all of the measures. Results suggest that TGNC adolescents reported significantly higher health-related problems than cisgender adolescents, including higher depressive and anxiety symptoms as well as poorer overall health and sleep quality. In addition, compared with cisgender adolescents, TGNC adolescents reported a significantly higher frequency of being bullied at school, having self-harm thoughts, deliberately participating in self-harm behavior, having suicidal thoughts, making suicide plans, and attempting suicide. We also found a relatively high prevalence rate of those who identify as TGNC in the current sample. Consistent with previous research, self-harm thoughts and behaviors were endorsed more frequently in the TGNC group. 28 Our study also explored factors associated with risk behaviors, Abbreviations: AFAB, assigned female at birth; AMAB, assigned male at birth. a School was added as a random-effects term. including self-harm and suicidal ideation. Not surprisingly, depressive symptoms, lower overall physical health, and being bullied at school were all positively associated with risk of self-harm behavior and suicide attempts. Similarly, a previous study also reported that bullying in gender dysphoric adolescents was significantly associated with self-reported behavioral and emotional problems. 29 Such distress could be both from the gender dysphoria per se and from external factors, such as discrimination and victimization in the social environment. 29,30 A previous survey in New Zealand with a sample of 8166 adolescents found that 1.2% of participants self-identified as transgender, and 2.5% of participants self-reported as gender nonconforming. 16 Also, a study conducted in Taiwan 31 showed that gender dysphoria was more prevalent in female young adults (7.3%) than in male young adults (1.9%). The current study found a much higher prevalence of a TGNC identity. The method used to classify the adolescents to different gender identity categories was established in a few previous studies. 21 In particular, participants were asked which gender they perceived themselves to be; when the perception was incongruent with their sex assigned at birth, they were classified as TGNC. This method is different from those that ask the participants to choose their gender identity directly from a choice of male, female, transgender, or not sure, etc. Thus, this method presents a less strict definition of transgender. In future studies, an additional item asking participants to directly self-report their gender identity would facilitate a more precise classification. Our study supported claims that being bullied at school is a significant risk factor for self-harm behaviors and suicide attempts. 37 In addition, our study also found that transgender girls, questioning AMAB, and nonbinary youth AMAB were more likely to report being bullied at school in comparison with cisgender adolescents. Conversely, within the TGNC group, transgender boys, nonbinary youth AFAB, and questioning youth AFAB had a much lower risk of being bullied at school.

JAMA Network Open | Psychiatry
As previously mentioned, this outcome may reflect greater societal tolerance toward women behaving "manly" than men behaving "girly." 5 For the TGNC group, the vulnerability of bullying resulted from the sex-atypical expression of gender identity. 29 This pattern may also reveal a cultural element in Chinese schools in which femininity is not encouraged. This attitude can be traced back to the Cultural Revolution era in China, illustrated in the famous Mao slogan, "The time has changed; men and women are the same." 38p62 In other words, both girls and boys in China, to some extent, are not encouraged to behave in a feminine manner. Indeed, there is a Chinese expression, niang qiang, that describes highly effeminate males, and the term almost always has negative connotations. It is important to further investigate the gender or sexual forms of bullying in order to identify its specific triggers. 29

Limitations
There were several limitations in the current study. First, due to the nature of the cross-sectional survey design, causality of the assessed factors cannot be confirmed. Second, it was difficult to determine the exact proportion of TGNC adolescents due to considerable variations in definitions and the method of sample estimation. 16 It is possible that we had fewer transgender females than transgender males in the current sample because transgender females may identify and disclose their transgender identity at later ages. Participants' interpretation of the gender identity questions could be affected by social and cultural factors. There is a possibility that participants could have interpreted the questions ambiguously. However, these questions have been used in European 21 and Chinese populations 20 before and have been tested as culturally appropriate for Chinese TGNC populations. Third, the data were collected in an economically developed region of China, which may not be generalizable to all Chinese TGNC adolescents. Fourth, this study investigated sensitive topics on gender minority status and suicidality. We used a school-based survey, and it is possible that adolescents have underreported on these topics. Moreover, the data were collected in schools, and adolescents excluded from schools were not accessed. Compared with the school sample, TGNC adolescents excluded from schools may have even more severe mental health issues. We suggest that future studies use large national samples in order to more rigorously estimate the size of the Chinese TGNC adolescent population.

Conclusions
The current study results suggest poorer mental and physical conditions among TGNC adolescents compared with cisgender adolescents in China. The findings indicate the need for researchers, practitioners, and policy makers to address these mental health risks. School-level intervention is recommended to support the well-being and equity of gender minority youth.