A recent paper from Southern Oregon University Economics Professor Travis Campbell looks at how crucial family support is for the mental health of transgender youth. JPR鈥檚 Jane Vaughan spoke with Campbell about his research. A warning that this conversation includes mentions of suicide.
Jane Vaughan: Your research focuses on mental health in transgender kids. First, why did you decide to focus on this topic for your research?
Travis Campbell: Well, since 2020, health agencies in England, Denmark, Finland, Norway, Sweden, and Scotland have all restricted access to gender affirming medical care for transgender youth, often citing a lack of evidence about the benefits and concerns about long-term harm. And in the U.S., our policy changes have actually been even more polarized. So since June 2024, [Editor's note: this should be "as of June 2024"], 25 states have actually banned medication and or surgical care for transgender youth, and six states have actually made it a felony to provide gender affirming medical care. And in contrast, we've actually had 15 states plus D.C. that have gone on the opposite direction, creating shield laws that protect access for transgender youth, making it so that they can travel from states where they cannot receive the care to states where it's protected and protect the doctors who are providing the care. So I think in this policy environment, it's really important to create some high quality evidence so that people can carefully weigh the costs and benefits of providing different types of care and other things as well that are important. It's not just medical care.
JV: For sure. Yeah, that's interesting. I had known about some of the bills in the U.S., but I didn't know about that happening in other countries as well. Can you give us sort of a brief overview of how you conducted this research, in layman's terms so we can understand?
TC: The research, it's actually a collection of four different papers that we've published now, using the same dataset and a really similar design. So what we do is, it's actually a survey, it's a really large survey, of 27,000 transgender adults in the United States, called the United States Transgender Survey. That was conducted in 2015. And they're asked retrospective questions, like their age when really important life events occurred, such as the age they first attempted suicide or first ran away from home. And we can use this to estimate the impact that different events have on their mental health, such as developing their gender identity, starting hormone therapy, or conversion therapy even, which would be therapy that tries to change a child's gender identity to match their sex assigned at birth.
JV: The big takeaway that I got from this paper was really the role that family support plays in identity development for these transgender youth. Why is it that family support is so crucial?
TC: In our paper, we look at the impact of four different gender identity milestones on the mental health of transgender youth. So these are things like first feeling that your gender was different, or thinking of yourself as transgender, telling someone else that you're trans, or living full time as your gender identity. And what we find in the paper is that each one of these gender identity milestones associates with increased risk for the child. They become more likely to attempt suicide or run away from home generally. But we find that these risks are mitigated, almost completely even, by supportive family environments. So the changes are really driven by children who live in unsupportive families.
JV: That's interesting, so almost completely mitigated, that higher risk of attempting suicide or running away is almost completely mitigated, if you've got a family that is supportive. If a parent or family is supportive of their trans kids, so uses their correct pronouns or things like that, can you talk about the impact that has on the kid?
TC: Supportive family environments, I think, can help shield children from conversion therapy and can help them access types of gender affirming care that can be beneficial, which we've known. And also, I think, just at a more fundamental level, children need to know that they're unconditionally loved by their parents. And these gender identity milestones are really important events for a lot of transgender kids, and when they undergo them, if their families are supportive, that can mean a lot, but if they're faced with an adverse family, then that can be very damaging.
JV: Okay. You found that if transgender kids have unsupportive families, they are at higher risk of adverse mental health outcomes, like attempting suicide or running away. And I think you said you were measuring their first age at attempting suicide, which sounds like a pretty grim statistic, that they might have attempted suicide multiple times. What do you think it is about the unsupportive families that is making it so difficult?
TC: So we find in the data that supportive family environments tend to have some specific characteristics. Respondents who reported having a supportive family were more likely to say that their family used their correct pronouns, gave them money to help them with their transition, did research on how to support them, stood up for them if other people were not supportive or were averse to them, and helped them change their name or gender on identification documents. In contrast, people who said that their families were not supportive, or were averse to them, were more likely to report having family members stop speaking to them because they were trans or be violent towards them, or be kicked out of the house or not allowing them to wear clothing that matched their gender identity, or even getting sent to conversion therapy, which is again, therapy that tries to change a person's gender identity to match their sex assigned at birth.
JV: And am I right in that, talking about the suicide attempts, did most of these kids attempt suicide multiple times?
TC: So in our data set, we only have information on the age when that first suicide attempt was made. And that's because people are going to have a really good memory a lot of the time of when they first attempted suicide because it's such an important and tragic experience. But we don't have information on subsequent suicide attempts. So we're only looking at the age of first suicide attempts.
JV: Your research is focusing on family support, but I'm wondering what role other supports might play in a kid's life. So friends or classmates, does that support help, too?
TC: Yeah, so that's really important. So in our paper, we find that 42% of children who were in adverse family environments had attempted suicide by the time they were 18, whereas 23% in supportive family environments had attempted suicide by the age of 18. So this is a huge gap and goes a long way in suggesting that family support is really important. But other estimates for the cisgender population suggest that only 5% of cisgender kids would have attempted suicide at least once by the time that they were 18. So even children in supportive family environments, transgender kids are still much more likely to have attempted suicide than cisgender kids. So other things must be really important as well if we want to continue to decrease that disparity. And I think that's because your family cannot shield you from everything that's going on at school or with friends, just like you mentioned.
JV: If we have any parents or family members listening, maybe they have a transgender child, maybe they're struggling with it, they're not sure how to support their kid, how can a parent best support their child? What would you recommend?
TC: I think that their child needs to know that they're unconditionally loved and supported. And they need to speak with their kid about what they need and try to work with them. It could just be using their correct names and pronouns, but it could also be helping their kid socially transition, if they're interested in doing that, exploring their gender with clothing or other ways of dress. And they could also explore using gender affirming medical care as well. So this could be puberty blockers for adolescents that delay the onset of puberty to have more time to consider other forms of medication, like hormone replacement therapy that have some irreversible effects. And they could consider hormone therapy as well if their doctor thinks it's a good idea and they're interested in it. But again, this isn't for everyone. Every kid is different. And they really just need to know that they are loved and supported.
JV: Right. And I imagine it's a conversation with family and doctors as well. For your research, you used information from the 2015 U.S. Transgender Survey. Do you think that your results might have changed at all in recent years? So if you were able to use more recent data up until now, might that change your results?
TC: I'm really interested to see if the results hold using more recent data. So they've actually done another wave of this survey in 2022. The data hasn't been released yet. But the sample size, although it was big before, again, 27,000 respondents, is now much, much larger. So I'd be really interested to see if the results hold or not using the more recent data once it's released, and I will definitely be checking that out.
JV: Are there any concerns with the data that you're working with?
TC: Yes, so it's survey data, and it's not a representative sample, either. The United States Transgender Survey is a really large sample, which is fantastic, but it's a non random online survey. And if you compare who answered the survey to random samples in the U.S., we find that it over represents young and college educated transgender youth. The results may not, while I think are really strong for the sample, they may not be representative of the broader transgender population.
JV: And I'm just curious about this because we cover Oregon and California at JPR, do you have any breakdown by state, or are you looking at a national scale?
TC: All the estimates and these papers that we're discussing are national. We're not doing any breakdown by state. But with the new survey that I mentioned earlier, the 2022 survey that hasn't been released yet, that really large sample size will allow researchers to look at smaller geographic areas and still have a big sample to find interesting stuff.
JV: Yeah, that's interesting, especially just having so many more respondents, I would imagine, maybe there'd be some different results. But we'll have to see. And so that sounds like that's your next step in terms of what you'll be looking at for future research?
TC: Yes, hopefully I'll be able to get access to that data soon. The first step will be trying to replicate these papers again using the new iteration of the survey to make sure that these are strong findings.
JV: I'm interested because you're an economics professor. And it seems like this research could fall under the field of psychology or health care. How is this research an economic issue?
TC: So I consider myself a health economist, so the overlap of economics and health. But I think microeconomics, which is what I do more broadly, is just kind of the study of human decision making. And this is one really important aspect of that. I think we really need credible evidence on both the costs and benefits of different forms of gender care, especially for transgender youth in the U.S.
JV: Your research says, obviously, that family support is really crucial for transgender teenagers. Do you have any recommendations on how to increase that? Now that we've got this result, what do we do now?
TC: Yeah, so this paper is specifically on family support and gender identity milestones. But this is one of a collection of papers that we were working on using a very similar research design from this data. And we really have a couple big findings from the research together. So first, we find that conversion therapy is extremely dangerous. So again, this is therapy that tries to change a transgender child's gender identity to match their sex assigned at birth. And we find large and significant increases in attempting suicide and running away from home when children receive conversion therapy. So the evidence is really clear on that. Next, we find that hormone therapy can be helpful, especially when initiated early into adolescence. By helpful I mean reductions in attempting suicide. And then finally, with this paper, we find that gender identity development for transgender kids does come with risks, meaning increases in the likelihood of attempting suicide or running away from home. But supportive family environments go a long way in protecting children from these risks as their gender identity develops.
JV: What other solutions would you like to see to help address mental health care for transgender kids?
TC: I think it's worth just emphasizing that there's very credible evidence of gender affirming care having important improvements in the mental health of transgender recipients over the first one or two years. So there's clear evidence of these short term improvements in mental health. And there's also very strong evidence that conversion therapy is dangerous. So I think that is important to emphasize.
JV: What about longer term than one to two years? Is there not data for that?
TC: There's very limited evidence on long term effects. So there's survey evidence where people are asked about when they started hormone therapy and then their mental health and other outcomes as adults that suggests long term improvements, but there isn't really strong evidence like there is for the short term effects. So for the short term, there's a really large number of what are called cohort studies. There's actually 21 prospective cohort studies that use clinical data. So these are children who go to gender clinics and receive hormone therapy and then they have data before and after starting it, and they can see whether or not their mental health improves or changes after starting it. We don't have that for long term outcomes. We just have these correlational estimates and survey data.
This interview has been edited for length and clarity.
