Johns MM, Lowry R, Andrzejewski J, et al. Transgender Identity and Experiences of Violence Victimization, Substance Use, Suicide Risk, and Sexual Risk Behaviors Among High School Students — 19 States and Large Urban School Districts, 2017. MMWR Morb Mortal Wkly Rep 2019;68:67–71. DOI: http://dx.doi.org/10.15585/mmwr.mm6803a3
Transgender youths (those whose gender identity* does not align with their sex†) experience disparities in violence victimization, substance use, suicide risk, and sexual risk compared with their cisgender peers (those whose gender identity does align with their sex) (1–3). Yet few large-scale assessments of these disparities among high school students exist. The Youth Risk Behavior Survey (YRBS) is conducted biennially among local, state, and nationally representative samples of U.S. high school students in grades 9–12. In 2017, 10 states (Colorado, Delaware, Hawaii, Maine, Maryland, Massachusetts, Michigan, Rhode Island, Vermont, Wisconsin) and nine large urban school districts (Boston, Broward County, Cleveland, Detroit, District of Columbia, Los Angeles, New York City, San Diego, San Francisco) piloted a measure of transgender identity. Using pooled data from these 19 sites, the prevalence of transgender identity was assessed, and relationships between transgender identity and violence victimization, substance use, suicide risk, and sexual risk behaviors were evaluated using logistic regression. Compared with cisgender males and cisgender females, transgender students were more likely to report violence victimization, substance use, and suicide risk, and, although more likely to report some sexual risk behaviors, were also more likely to be tested for human immunodeficiency virus (HIV) infection. These findings indicate a need for intervention efforts to improve health outcomes among transgender youths.
In the 2017 YRBS cycle, states and local urban school districts could pilot a question about transgender identity (Box). This question was developed by CDC survey methodologists with input from external experts in transgender health to create a single-item measure to assess the prevalence of transgender identity among high school students. Ten states and nine large urban school districts piloted this question, and these data were pooled for this analysis (131,901 students). Data were weighted to be representative of public school students attending grades 9–12 in each jurisdiction. Survey procedures protected students’ privacy, participation was anonymous and voluntary, and local procedures were followed to review and approve the YRBS and obtain parental consent.
To produce prevalence estimates for transgender identity, respondents were categorized based on responses to the pilot question into the following four groups: 1) No, I am not transgender; 2) Yes, I am transgender; 3) I am not sure if I am transgender; and 4) I do not know what this question is asking. To examine behavioral comparisons, respondents were categorized based on responses to the pilot question and the question about sex (“What is your sex?”) into the following three groups: 1) cisgender males (male, not transgender); 2) cisgender females (female, not transgender); and 3) transgender students. Because it is unclear whether transgender students’ responses to the sex question reflected their sex or gender identity, this analysis could not further disaggregate transgender students. Students who responded that they were not sure if they were transgender or that they did not know what the question was asking were excluded from behavioral comparisons.
Victimization was assessed by students’ responses to the following items: in the past 12 months 1) threatened or injured with a weapon at school; 2) experienced sexual dating violence; 3) experienced physical dating violence; 4) bullied at school; 5) electronically bullied; 6) in the past 30 days, felt unsafe at or traveling to or from school; or 7) ever forced to have sexual intercourse. Information on lifetime use of cigarettes, alcohol, marijuana, cocaine, heroin, methamphetamines, ecstasy, or inhalants, and prescription opioid misuse was collected. Suicide risk was assessed by responses to questions about whether, in the past 12 months, the student felt sad or hopeless, considered attempting suicide, made a suicide plan, attempted suicide, or had a suicide attempt treated by a doctor or nurse. Sexual risk behaviors were assessed by students’ responses to questions about whether they had ever had sexual intercourse; had first sexual intercourse before age 13 years; had sexual intercourse with four or more persons during their life; had sexual intercourse during the past 3 months (currently sexually active); did not use a condom during last sexual intercourse; did not use any method to prevent pregnancy during last sexual intercourse; drank alcohol or used drugs before last sexual intercourse; and had never been tested for HIV infection.
To examine the prevalence of transgender identity, unadjusted prevalence estimates with 95% confidence intervals (CIs) were calculated using Taylor series linearization for prevalence. To test for differences in behavioral outcomes by gender identity, logistic regression models, controlling for race/ethnicity, grade, and site (school district versus state) produced adjusted prevalence ratios (APRs) with cisgender male students serving as referent group. Post-hoc linear contrast t-tests were used to assess additional between-group differences in outcome prevalence by gender identity. Differences were considered statistically significant if p<0.05 or 95% CIs did not include 1.0.
Across the 19 sites, 94.4% (range = 94.0%–94.8%) of students responded “No, I am not transgender”; 1.8% (range = 1.0%–3.3%) responded “Yes, I am transgender”; 1.6% (range = 0.9%–2.5%) responded “I am not sure if I am transgender”; and 2.1% (range = 1.5%–4.7%) responded “I do not know what this question is asking.” (Table 1)
The reported prevalence of all experiences assessing violence victimization was higher among transgender students than among both cisgender males and cisgender females, including 23.8% reporting ever being forced to have sexual intercourse and 26.4% having experienced physical dating violence (Table 2). A higher percentage of transgender students also reported lifetime use of all substances except marijuana than did cisgender male and cisgender female students; marijuana use was more prevalent among transgender students than among cisgender male students only. A higher proportion of transgender students reported all suicide risk outcomes than did cisgender students.
Transgender students were more likely than cisgender students to report first sexual intercourse before age 13 years, sexual intercourse with four or more persons than were cisgender students, and no method to prevent pregnancy at last sexual intercourse. Transgender students were more likely than were cisgender females to have ever had sex (43.1% versus 33.2%) and to have drunk alcohol or used drugs before their last sexual intercourse (30.0% versus 17.9%). Transgender students were more likely than were cisgender males to report no condom use during their last sexual intercourse (63.8% versus 37.6%). Transgender students were less likely than cisgender males and cisgender females to have not ever been tested for HIV (70.0% versus 87.4% and 86.9%, respectively).