Bullying victimization and consistently unsupportive state gender-identity policy environments were associated with higher psychotic-like experience scores among gender-diverse youths in a longitudinal cohort study published in JAMA Network Open.
Researchers analyzed data from the Adolescent Brain Cognitive Development (ABCD) Study, a US population–based longitudinal cohort conducted across 21 sites in 17 states. Cross-sectional analyses included 8,463 youths with a mean age of nearly 13 years, while longitudinal analyses included approximately 4,200 participants with data collected across multiple waves between 2017 and 2022. Researchers noted that participants excluded because of incomplete data differed significantly across several study variables, suggesting the longitudinal subsample may not fully represent the broader cohort.
Gender diversity was measured using a dimensional “felt-gender” scale rather than self-identified transgender status. Participants answered two questions assessing how strongly they felt like a boy or a girl relative to their birth-assigned sex. Based on those responses, 531 youths were categorized as most gender diverse and 6,867 as least gender diverse. The most gender-diverse group was predominantly composed of youths assigned female at birth (83%), a distribution the researchers noted may limit generalizability to youths assigned male at birth and warrants further study.
Psychotic-like experiences were assessed using the Prodromal Questionnaire–Brief Child Version (PQ-BC), a self-report screening instrument measuring subclinical symptoms such as unusual perceptions, suspiciousness, and odd beliefs rather than diagnosed psychotic disorders. Scores were distress weighted on a scale ranging from 0 to 126.
At year 3, the mean psychotic-like experience score was 7.5 among the most gender-diverse youths compared with 2.0 among the least gender-diverse youths. Mean bullying victimization scores were 4.6 vs 2.8, respectively, and broad mental health problem T scores were 58.7 vs 53.3.
In adjusted analyses, the most gender-diverse group scored 0.78 standard deviations higher on psychotic-like experiences than the least gender-diverse group. Bullying victimization partially mediated this association, accounting for 18% of the observed relationship.
Across the overall cohort, greater bullying victimization was associated with higher psychotic-like experience scores. The association appeared stronger among the most gender-diverse youths in primary linear models, although this interaction was attenuated in hurdle-model sensitivity analyses designed to account for the PQ-BC’s zero-inflated distribution.
The study was grounded in the minority stress model, which proposes that chronic exposure to distal stressors such as discrimination, bullying, and structural stigma contributes to adverse mental health outcomes among minoritized groups. The researchers examined both interpersonal stressors and state-level policy environments using annual gender identity–related legislative tallies from the Movement Advancement Project.
Cross-sectional analyses did not identify statistically significant differences in psychotic-like experience scores according to state policy environment at a single time point. However, longitudinal analyses showed that psychotic-like experiences generally declined across adolescence in the overall cohort, while scores increased over time among the most gender-diverse youths living in states with consistently low-support gender-identity policies.
Researchers noted that this longitudinal pattern was specific to psychotic-like experiences and was not observed for broader psychopathology measures, suggesting a potentially more specific association with hypervigilance- or paranoia-related symptom domains.
The findings may have implications for psychosis-risk assessment in gender-diverse youths. Prior research has linked psychotic-like experiences with increased risk for later psychotic disorders, suicidal behavior, and poor functional outcomes. Researchers also noted that school anti-bullying interventions have demonstrated mental health benefits and cost-effectiveness in previous studies.
The researchers cautioned that the observational study design precludes causal conclusions. The policy metric reflected overall legislative climate rather than the effects of individual laws, participant residence was inferred from study site rather than home address, and youths may have differed in their awareness of state-level policies.
“Our findings highlight the importance of considering both the immediate social environment and broader sociopolitical milieu when delivering care to gender-diverse youths and implementing interventions,” wrote lead study author Dylan E. Hughes, MA, of the University of California, Los Angeles, and colleagues. The researchers additionally noted that clinicians assessing psychosis risk in gender-diverse youths should consider the potential contribution of gender minority stress to avoid misattribution of symptoms.
Disclosures: The ABCD Study was supported by the National Institutes of Health and other federal partners. Hughes was supported by the National Institutes of Health. Sarah E. Chang, PhD, Carlos Cardenas-Iniguez, PhD, and Carrie E. Bearden, PhD, reported grant funding outside or during the submitted work. No other disclosures were reported.
Source: JAMA Network Open
