Abstract: Gender Dysphoria, Affirming Care, and Self-Injurious Thoughts and Behaviors Among Transgender and Nonbinary Adults: Evidence from a Community-Based Sample (Society for Social Work and Research 31st Annual Conference)

Schedule:

Friday, January 22, 2027

Union Station 19 (Hilton San Francisco Union Square)

* noted as presenting author

Ankur Srivastava, PhD, Assistant Professor, University of North Carolina at Chapel Hill

William J. Hall, PhD, Associate Professor, University of North Carolina at Chapel Hill

Adam Bryant Miller, PhD, Associate Professor, University of North Carolina at Chapel Hill

Pin-Chen Chiang, MSW, Social Work Doctoral Student, University of North Carolina at Chapel Hill, Chapel Hill, NC

Sonyia Richardson, PhD, Assistant Professor, University of North Carolina at Chapel Hill, Chapel Hill, NC

Hannah Burgess, BA, MSW Student, University of North Carolina at Chapel Hill

Cayson Tiedge, MSW, Research Assistant, University of North Carolina at Chapel Hill, NC

Denise Williams, PhD, Research Assistant, University of North Carolina at Chapel Hill, Chapel Hill, NC

Dicky Baruah, MSW, Doctoral Student, University of North Carolina at Chapel Hill, Chapel Hill, NC

Jake Leite, MSW, Social Work Doctoral Student, University of North Carolina at Chapel Hill, Chapel Hill, NC

Adam Englert, MSW, Social Work Doctoral Student, University of North Carolina at Chapel Hill, Chapel Hill, NC

CasSandra Cailin, MSW, Doctoral Student, University of North Carolina at Chapel Hill, NC

Juliana Wilson, MSW, Research Associate, University of North Carolina at Chapel Hill, Chapel Hill, NC

Introduction. Transgender and nonbinary (TGNB) adults experience elevated rates of self-injurious thoughts and behaviors (SITBs), including suicidal ideation, suicide attempts, and non-suicidal self-injury (NSSI), often linked to minority stress processes such as stigma, discrimination, and barriers to affirming care. Gender dysphoria, i.e., distress due to incongruence between gender identity and sex assigned at birth, functions as a proximal stressor and is associated with elevated SITBs risk. Gender-affirming care (GAC) is protective, yet structural barriers including cost, lack of insurance, and restrictive policies limit access, particularly in the Southern US. Prior research has centered binary transgender experiences, leaving nonbinary populations underexamined. This study examines prevalence, group differences, and associations between gender dysphoria, barriers to GAC, and SITBs among TGNB adults.

Methods. Data were drawn from a cross-sectional survey administered at 36 LGBTQ+ Pride events across North Carolina. The analytic sample comprised 1,109 TGNB adults aged 18 and older. Gender dysphoria, affirming care status, and barriers to GAC were assessed via self-report. SITBs included past-12-month suicidal ideation, suicide attempts, and NSSI. Multivariate logistic regression examined associations in the full sample and stratified by gender identity, adjusting for sex assigned at birth, sexual orientation, age, and race/ethnicity.

Results. The sample was predominantly nonbinary (69.3%), with 30.6% identifying as transgender, and a mean age of 28.1 years (SD = 9.6). The sample was largely non-Hispanic White (71.2%), followed by Black (9.7%), Latinx (9.0%), and multiracial or another identity (10.1%). Overall, 32.0% reported past-12-month suicidal ideation, 5.4% a suicide attempt, and 16.4% NSSI; rates did not differ significantly between transgender and nonbinary participants. Gender dysphoria was reported by 62.2% of the total sample, with significantly higher prevalence among transgender (88.0%) than nonbinary (49.8%) adults. In fully adjusted models, gender dysphoria was associated with higher odds of suicidal ideation, suicide attempts, and NSSI. Stratified analyses revealed critical within-group differences: among transgender adults, dysphoria was significantly associated only with suicidal ideation, while among nonbinary adults it was associated with suicidal ideation, suicide attempts, and NSSI, reflecting a broader SITBs risk profile in this group. Regarding GAC, 75.0% of transgender adults reported having received or currently receiving affirming care, compared to only 20.7% of nonbinary adults. Commonly reported barriers were cost of care (38.3%), insurance not covering GAC (27.3%), and not knowing how to find care (27.0%). In the total sample, lack of health insurance was associated with significantly higher odds of suicide attempts. Subgroup analyses showed that lack of insurance was associated with elevated odds of suicidal ideation and suicide attempts among transgender adults, and with higher odds of suicide attempt among nonbinary adults. No other barriers were significant independent predictors of SITBs.

Conclusion. Gender dysphoria and structural barriers to GAC, particularly lack of health insurance, are significant and independent contributors to SITBs among TGNB adults. Risk patterns differed meaningfully by gender identity, reinforcing the need to disaggregate these populations in research, care and practice. Findings call for sustained policy advocacy to protect access to affirming care, and expanded insurance coverage for GAC in restrictive political environments.