Diverse Sexual and Gender Identity, Bullying, and Depression Among Adolescents

Data used was from the 2019 Minnesota Student Survey (MSS), a triennial, anonymous survey of the state’s public and charter school students in select grades. The University of Minnesota Instituional Review Board exempted this study from review because of the use of anonymous, existing data. All districts are invited to participate (81% participated in 2019), and passive parental consent procedures are used. Students reported their sex (“biological sex”: male or female), grade (8th, 9th, or 11th), race and ethnicity (see Table 1), and whether they received free or reduced price lunch (yes, no, or not sure). The MSS team recorded the location of the school as within the 7-county Twin Cities metropolitan area or other areas of Minnesota.

Response options for sexual orientation were: heterosexual (straight), bisexual, gay or lesbian, questioning or not sure, pansexual, queer, I don’t describe myself in any of these ways, and I am not sure what this question means. A modified 1-step question asked if students were “transgender, genderqueer or genderfluid,” (responses: yes; no; I am not sure about my gender identity; and I am not sure what this question means).¹⁰  Students answering no were considered cisgender. For those who answered yes, a follow-up question provided specific identity terms: (1) male, transmale, transman, or transmasculine; (2) female, transfemale, transwoman, or transfeminine; (3) nonbinary, genderqueer, or genderfluid, or (4) I prefer to describe my gender as something else. Participants could only select 1 response option for each question.

Youth also completed the Patient Health Questionnaire-2 (PHQ-2), a commonly used screener for depressive symptoms in the past 2 weeks.¹⁹  Responses to the 2 questions (0 to 3 scale) were summed. Scores of 3 or more were considered a positive screen for depressive symptoms, indicating the need for additional assessment. Respondents also reported their experiences of bullying on the basis of (1) sexual orientation (“because you are gay, lesbian, bisexual or because someone thought you were”) and (2) gender (“your gender [being male, female, transgender, etc.]”) in the past 30 days (recoded to none or any).²⁰ 

Analyses used data from 9th and 11th graders for sexual orientation (N = 79 793) and 8th, 9th, and 11th graders for gender identity (N = 124 778), based on question availability. Within those grades, we employed list-wise deletion by analysis. To understand the full range, we calculated the prevalence of all sexual and gender identity responses for the analytic sample and by sex, grade, and race and ethnicity. χ² tests identified significant differences in prevalence by these key demographic characteristics. Multifactor analysis of variance (ANOVA) with the full sample examined sexual and gender identity differences in positive depression screens and bias-based bullying, adjusting for grade, sex, race and ethnicity, free or reduced-price lunch, and region. ANOVAs allow for comparison among all groups without the need to specify a reference group; estimated marginal means can be interpreted as predicted prevalences.^21,22  Posthoc Bonferroni tests probed significant main effects. α was set to 0.05, and IBM SPSS v27 was used.

Overall, 9.4% of high schoolers identified as lesbian, gay, bisexual, queer, or pansexual (4.5% of those reporting their sex as male and 14.2% of those reporting their sex as female), 9.1% of 9th graders and 9.8% of 11th graders. An additional 2.1% (1.0% reporting male sex, 3.2% reporting female sex) questioned their sexual orientation, 2.3% of 9th graders and 1.8% of 11th graders. Of note, 8.4% of youth indicated that they did not use any of the sexual orientation terms (8.7% of those reporting male sex, 8.0% of those reporting female sex). Table 1 documents prevalence of each specific identity separately.

For gender identity, 1.4% of 8th, 9th, and 11th graders indicated they were transgender, genderqueer, or genderfluid (0.7% of those reporting male sex, 2.0% of those reporting female sex), which was consistent across grades. Overall, 1.7% of youth were unsure of their gender identity (1.2% of those reporting male sex and 2.1% of those reporting female sex), 2.1% of 8th graders, 1.6% of 9th graders, and 1.2% of 11th graders. Among those who identified as transgender, genderqueer, or genderfluid and also reported their sex as male, almost one-half identified as male, transman, or transmasculine, almost one-quarter as nonbinary, and ∼14% each as female, transwoman, transfeminine, or another identity. For transgender, genderqueer, or genderfluid youth who identified their sex as female, one-half identified as nonbinary, one-third as male, transman, or transmasculine; and 11% as female, transwoman or transfeminine; and ∼6% as another identity. χ² tests indicated these response patterns differed significantly by sex.

Table 2 describes preliminary exploration of the intersection of sexual orientation and gender identity. Bisexual (20.5%) and pansexual (28.8%) were common sexual orientation identities among those who identified as transgender, genderqueer, or genderfluid. Prevalence of sexual and gender identities varied by race and ethnicity as well (Table 3). Among American Indian and multiracial youth, bisexual (10.7% and 9.3%, respectively) and pansexual (4.0% and 3.6%) were common sexual identities, and rates of transgender, genderqueer, or genderfluid identity (2.7% and 2.5%) were higher relative to other race and ethnicity groups. Race and ethnicity differences emerged for not understanding the sexual orientation and gender identity questions as well, with White and multiracial youth less likely to choose this option than other groups.

Results from multifactor ANOVAs indicated significant differences in depressive symptoms and bias-based bullying experiences by sexual orientation (Table 4) and gender identity (Table 5). Pansexual and queer youth had similar rates of depression and bias-based bullying, and their rates of gender-based bullying were higher than any other group. Students who identified as gay or lesbian had the highest predicted prevalence of sexual orientation-based bullying. Youth selecting “I don’t describe myself in any of these ways” for their sexual orientation did not differ from youth who did not understand the question on both forms of bias-based bullying and were the same as straight youth on depression.

Among youth who identified their sex as male, those identifying as nonbinary had higher rates of depression and bias-based bullying than those identifying as male, transman, transmasculine, and unsure about their gender identity. Over 70% of youth reporting their sex as female and identifying as nonbinary or male, transman, or transmasculine screened positive for depression, higher than all other groups. Gender-based bullying was also particularly high among nonbinary and male, transman, or transmasculine youth reporting their sex as female. Youth who identified with a gender identity not listed on the survey had rates of depression and bias-based bullying in line with youth identifying as transmasculine, transfeminine, nonbinary, or unsure of their gender identity and higher than cisgender respondents.

This study is the first to report on statewide youth surveillance data that includes more contemporary response options for sexual and gender identity. Results indicate these identities are relatively common and important to capture among LGBTQ+ youth. Similar proportions of students indicated they were pansexual (1.7%) as gay or lesbian (1.6%). Nonbinary youth comprised about one-half of transgender or gender diverse youth who reported their sex as female and about one-quarter of youth reporting male sex. Critically, rates of depression and bias-based bullying differed by identity, sometimes dramatically, demonstrating the importance of examining specific sexual and gender identities in clinical practice and research. These findings underscore the need to include updated response options, such as pansexual and nonbinary, in epidemiologic surveys and in clinical encounters.

Some unexpected findings emerged regarding gender identity. One-half of transgender and gender diverse youth indicating male sex also listed their gender identity as male, transman, or transmasculine, which may be related to a number of factors. The wording of the sex question (ie, “What is your biological sex?”) is problematic for transgender youth, who may have answered this question differently than intended by survey developers. For example, transgender and gender diverse youth may report the option closest to their gender identity as their biological sex, rather than responding with their sex assigned at birth. The inclusion of the term male in the gender identity response option may be problematic for transgender and gender diverse youth, who have likely spent time differentiating sex (eg, male) and gender (eg, cisgender man, transgender man, or transmasculine) terms.²³  It is also possible that youth might have answered yes to being transgender, genderqueer, or genderfluid thinking more about gender presentation than gender identity (eg, a youth assigned male at birth who identifies as a boy or man and has a fluid gender presentation).²⁴  Developmental considerations, including where youth are in their gender identity exploration, may come into play, especially for youth who are still determining the best-fitting descriptors. Cognitive testing with young people is needed, updated from previous foundational work given rapid change in conceptions of sexual and gender identity,^10,11  to understand the ways in which gender diverse youth approach these questions.

Results from this analysis give rise to several question regarding the best way to capture participants who use an identity term that is not among the response options provided. Unexpectedly, 8.4% of youth selected “I don’t describe myself in any of these ways” for sexual orientation, and results demonstrated that youth selecting this option were much more similar in terms of depression and bias-based bullying to straight youth and youth who did not understand the sexual orientation question than they were to any other group of LGBQ+ youth. Current recommendations suggest including this option in surveys of adolescents as a response option for LGBTQ+ youth who use identity descriptors not provided on the survey (eg, asexual or omnisexual for the MSS).^10,16,25  However, the fact that more youth endorsed this response than any other nonheterosexual option in this survey suggests further study is warranted to determine how these youth identify and why they selected this option. These may be youth who are navigating specific cultural identities alongside their sexual and gender identities, who reject sexual and gender identity labels altogether, or who select this option for other reasons.²⁶  They may also be youth who identify as straight but did not select the heterosexual option. Given the percent of the sample that selected this option, it is likely that most or all of these reasons are represented. As such, interpretation of this response category is ambiguous, because of significant heterogeneity in this group.

For gender identity, the option to indicate an identity beyond those listed was only offered to youth who first indicated they identified as transgender, genderqueer, or genderfluid. As a result, youth selecting this option were more similar to transgender or gender diverse youth than they were to cisgender youth on depression and bias-based bullying. A key takeaway from these results is that umbrella response options for youth to indicate that they use a different term than those listed, particularly when the inclusion of an open-ended text field or write-in is not feasible, should be approached with caution. On the basis of this study, we suggest these options only be presented to youth who have indicated some LGBTQ+ identity; however, additional pilot and cognitive testing will ensure robust and accurate data collection.

Finally, rates of depression and bias-based bullying varied by sexual and gender identity with important implications for prevention. For example, positive PHQ-2 depression screens were particularly high among nonbinary and transmasculine youth who indicated their sex as female, which suggests the need for bolstering screening, services, and targeted support for this group of youth. From a prevention perspective, these findings are consistent with established disparities in rates of bias and emotional distress among transgender and gender diverse youth compared to cisgender youth,^27,28  supporting known needs for school- and community-wide interventions to create supportive and inclusive climates.²⁹  In addition, findings point to nuanced prevention needs, such as addressing gender-based bullying of transmasculine and nonbinary youth assigned female at birth. These efforts should tackle conceptions of masculinity and gender in more complex ways than acceptance for transgender and gender diverse youth in general.

The current study has several limitations. The MSS is a school-based survey; given that LGBTQ+ youth are more likely than their straight, cisgender peers to drop out or miss school (eg, because of bullying victimization),³⁰  the results may be an underestimate of true population prevalence. Although this survey included some newer response options, others were not included (eg, asexual), and youth were not able to provide open-ended responses. Further, the one-step gender identity question may be difficult for youth who do not identify as transgender or cisgender. The phrasing of the sex question as biological sex is a limitation because this term is considered offensive or is not preferred by transgender and gender diverse youth.¹²  It is also not clear that all youth interpreted this question similarly. These results should be interpreted with caution and replicated with survey questions specifically asking about sex assigned at birth, as recommended.^9–11  This preliminary exploration of sexual and gender identities did not allow for an in-depth examination of multiple, intersecting socially marginalized identities. Preliminary, descriptive analyses presented here support the need for in-depth future studies of the ways these identities shape lived experiences. Finally, the PHQ-2 is only a screener for depressive symptoms; a more comprehensive assessment was not possible in this large sample.

Evidence from this statewide survey of adolescents indicates the importance of including identities not commonly used in surveys and patient demographic forms. LGBTQ+ youth are a diverse group, and more screening and targeted interventions are needed to adequately address emotional distress and experiences of bias, particularly given emerging evidence that intervention needs may vary by sexual and gender identity.³¹  Clinicians should familiarize themselves with the range of sexual and gender identities used by youth and attend to bias or bullying experiences and emotional distress among all LGBTQ+ youth, but particularly pansexual and queer youth and transmasculine and nonbinary youth who indicate their sex as female. Accurate measurement of sexual orientation and gender identity including diverse response options among adolescents is critical to documenting prevalence, identifying and monitoring health disparities, and ultimately developing interventions to promote health among LGBTQ+ youth.

ANOVA

analysis of variance

LGBTQ+

lesbian, gay, bisexual, transgender, queer, and questioning

MSS

Minnesota Student Survey

PHQ-2

Patient Health Questionnaire 2

TGD

transgender and gender diverse