Association between bullying, state-level policy and mental health symptoms in gender diverse youth

ImportanceAs the percentage of young people in the United States identifying as transgender and gender diverse increases, more youth face identity-linked social and structural stigma and discrimination. Little is known about the impact of stigma on psychotic-like experiences in gender diverse youth. ObjectiveTo assess the impact of bullying victimization and state-level policies on psychotic-like experiences among gender diverse youth. DesignIn this prospective cohort study, cross-sectional and longitudinal analyses were conducted using data collected between 2017-2022 across 17 states. SettingThe Adolescent Brain Cognitive Development (ABCD) Study is a U.S. population-based longitudinal study that follows and deeply phenotypes adolescents from the age of 9 to 18. ParticipantsCross-sectional analyses included data from 9,112 participants (mean age=13 {+/-} 0.6) collected between 2019 and 2022. Longitudinal analyses comprised 4,529 participants with data collected across 5 waves between 2017 and 2022. ExposuresSelf-reported frequency of bullying victimization and data on annual state-level policies related to gender identity. Main OutcomesSelf-reported psychotic-like experiences and associated distress, measured by the Prodromal Questionnaire - Brief Child Version. ResultsBased on a dimensional measure of gender, 689 adolescents were identified as most gender diverse (i.e., least congruent with birth-assigned sex) and 8,240 as least gender diverse (i.e., most congruent with birth-assigned sex). Rates of bullying victimization and psychotic-like experiences were significantly elevated in the most vs. least gender diverse group, with bullying partially mediating the difference in psychotic-like experiences (indirect effect = 0.11, p < 2x10-16; direct effect = 0.52, p < 1x10-16). Gender diverse adolescents exhibited greater sensitivity to the effects of bullying on psychotic-like experiences (interaction {beta} = 0.14, 95% CI [0.09, 0.19], p = 8.5x10-08). Moreover, the persistence of unsupportive legislation across 4 years was associated with significantly greater increases in psychotic-like experiences over time in gender diverse youth (interaction {beta} = 0.30, 95% CI [0.20, 0.40], p = 2.2x10-8). ConclusionsThese findings indicate that bullying victimization and unsupportive legislation may explain greater and increasing rates of psychotic-like experiences in gender diverse youth. KEY POINTSO_ST_ABSQuestionC_ST_ABSDo bullying and state-level policy related to gender identity contribute to mental health problems in gender diverse youth in the United States? FindingIn this large U.S.-based sample of adolescents (ages 9-13), gender diverse adolescents reported more frequent experiences of bullying, which partially accounted for increased rates of subclinical psychotic-like experiences (PLEs). Between 2017 and 2022, gender diversity was associated with increasing PLEs only in states with consistently unsupportive policies; in all other states, PLE scores remained stable over time or decreased. MeaningResults suggest that PLEs in the context of gender diversity are partially attributable to the sociopolitical environment and that policy decisions at the state-level have far-reaching impacts on the mental health of youth in the United States.