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The Importance of Getting the Name Right for Transgender and Other Gender Expansive Youth

      See Related Article on p. 503
      Over the last decade, we have seen a growing number of policies at institutional and local levels that support transgender and other gender-expansive youth in the community, school, mental health, and medical settings. While this progress has been fraught with political controversy and increasing oppression against the transgender community in the form of a military ban, transphobic legislation, and violence, the benefits of protecting transgender youth and affirming their gender identities can be life-saving. These youth are incredibly resilient, but unfortunately, they are still disproportionately affected by negative psychosocial outcomes [
      • Becerra-Culqui TA
      • Liu Y
      • Nash R
      • et al.
      Mental health of transgender and gender nonconforming youth compared with their peers.
      ,
      • Perez-Brumer A
      • Day JK
      • Russell ST
      • Hatzenbuehler ML
      Prevalence and correlates of suicidal ideation among transgender youth in california: findings from a representative, population-based sample of high school students.
      ,
      • Veale JF
      • Watson RJ
      • Peter T
      • Saewyc EM
      Mental health disparities among canadian transgender youth.
      ]. A crucial step in providing gender-affirming support to these youth is consistently using their chosen names and preferred pronouns.
      In this month's issue of the Journal of Adolescent Health, Russell et al. [
      • Russell ST
      • Pollitt AM
      • Li G
      • Grossman AH
      Chosen name use is linked to reduced depressive symptoms, suicidal ideation, and suicidal behavior among transgender youth.
      ] cross-sectional study examined the relationship between use of the chosen name and mental health symptoms for a community clinic cohort of transgender youth whose chosen names differed from their names assigned at birth. The study quantified the number of social contexts—home, school, work, and the company of friends—in which youth were referred to by their chosen names and assessed associations with depressive symptoms and suicidality. The study's primary finding was that for each additional social context in which a youth's chosen name was used, there was a statistically significant decrease in depressive symptoms, suicidal ideation, and suicidal behaviors, after adjusting for degree of social support and demographic variables.
      The study is correlational so causality cannot be assumed, and the sample size was small. Also, access to and treatment with gender-affirming hormones for medical transition were not evaluated. Access to gender-affirming medical treatment may confound the relationship between chosen name use and mental health symptoms. Youth who have started gender-affirming medical treatment have often already socially transitioned to using a chosen name; furthermore, gender-affirming medical treatment is associated with decreased depression and improved psychological functioning [
      • de Vries AL
      • McGuire JK
      • Steensma TD
      • Wagenaar EC
      • Doreleijers TA
      • Cohen-Kettenis PT
      Young adult psychological outcome after puberty suppression and gender reassignment.
      ,
      • de Vries AL
      • Steensma TD
      • Doreleijers TA
      • Cohen-Kettenis PT
      Puberty suppression in adolescents with gender identity disorder: a prospective follow-up study.
      ]. Further studies will be crucial to tease out the mechanism by which the use of the chosen name reduces mental health symptoms.
      Even with this study's limitations, it sheds light on the importance of using chosen names for transgender and other gender-expansive youth. Changing one's name and pronouns are powerful affirmations of self for these young people. Being intentionally or unintentionally misgendered can be a significant source of distress [
      • Gridley SJ
      • Crouch JM
      • Evans Y
      • et al.
      Youth and caregiver perspectives on barriers to gender-affirming health care for transgender youth.
      ]. These youth and their families can experience significant barriers to using chosen names instead of “deadnames,” a term used by some transgender youth to describe a birth-assigned name that is no longer used. For example, families may have to engage with schools to ensure that all teachers and staff address these youth by their chosen names and pronouns, and this may require school-wide training for students, staff, and the parent community. These young people can experience challenges interacting with medical or mental health offices that do not have a system for documenting the chosen name and pronouns in the electronic health record, thereby leading to potential misgendering incidents when they come into contact with front-desk staff, a provider they have not seen before, or ancillary services such as laboratory medicine and radiology. These youth and their families also can be overwhelmed by the state-specific requirements for legally changing the name and gender marker on their birth certificate and state identification card; unfortunately, administrative fees can make this process cost-prohibitive for some families. Of note, only a few states have passed legislation allowing for nonbinary gender markers on state identification and driver's licenses, so youth who are gender nonbinary or gender-fluid may feel pressured to choose a gender marker that does not align with their identity.
      Advocacy at the local, state, and federal levels to address the aforementioned barriers is necessary to support these young people in the use of their chosen names and gender markers. Furthermore, medical systems can and should adhere to recommendations provided by the World Professional Association for Transgender Health to incorporate demographic fields that document chosen name and pronouns even if the patient has not changed their name legally [
      • Deutsch MB
      • Green J
      • Keatley J
      • et al.
      Electronic medical records and the transgender patient: recommendations from the world professional association for transgender health EMR working group.
      ]. Russell et al. [
      • Russell ST
      • Pollitt AM
      • Li G
      • Grossman AH
      Chosen name use is linked to reduced depressive symptoms, suicidal ideation, and suicidal behavior among transgender youth.
      ] uniquely highlight that getting the chosen names right matters for transgender and other gender-expansive youth and their mental health. Moreover, it reminds us why it is important for providers in all social contexts to advocate for these young people to be treated with the dignity they deserve in all of the social facets of their lives.

      References

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        Mental health of transgender and gender nonconforming youth compared with their peers.
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        Prevalence and correlates of suicidal ideation among transgender youth in california: findings from a representative, population-based sample of high school students.
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