Beyond Societal Binaries: A Call to Eliminate Mental Health Inequities Among Liminal Youth

Executive order Defending Women from Gender Ideology Extremism and Restoring Biological Truth to the Federal Government1 mandates that the US government recognize a person’s sex assigned at birth and not their gender identity, reflecting a shift toward using rigid biological frameworks to dismiss the fact that gender is a social as well as biological construct, and reject the lived realities of individuals who do not conform to societal binaries. Analogous US precedents include the “One Drop” rule, a legal principle that asserted that anyone with at least 1 ancestor with African ancestry be considered Black,2,3 and the Defense of Marriage Act, a federal law that defined marriage as between a man and woman.4These policies and related societal norms represent sources of structural stigma,5 placing in the periphery liminal individuals—whose bodies, identities, behaviors, and/or experiences challenge traditional definitions of gender, sexual orientation, race, and ethnicity as social constructs—with implications for mental health. We draw from anthropology,6,7 defining liminality not solely as a transitional state, but as having an identity or identities that exist outside of binary, foundational societal categories of male/female, straight/gay, white/Black. Liminal individuals include those with transgender, gender nonbinary, bisexual, pansexual, asexual, multiracial, and/or multiethnic identities. Although the concept of liminality is not new, liminality as a risk for mental health inequities has not, to our knowledge, ever been considered.8,9 We argue that national surveillance data8,9 fit into a larger trend of loneliness and related mental health challenges among liminal adults,10 outline US trends of liminality, and provide multilevel recommendations for families, health care systems, and policies to eliminate mental health inequities among liminal youth.Liminal populations are reported on in national surveillance efforts but are viewed by society as belonging to separate gender identity, sexual orientation, racial, and ethnic categories. One exception is from intersectionality frameworks, rooted in Black feminism, which argue for examining interlocking systems of oppression.11,12 Although intersectionality, at least as it was originally conceptualized, examines the experience of having multiple oppressed identities,11,12 intersectionality does not explain what it means for an individual to be told that their identity does not exist (ie, liminality). Although not mutually exclusive (ie, some intersectional youth are also liminal), liminality is a separate, complementary framework for understanding youth mental health inequities.Unlike intersectional youth, liminal youth exist outside societal binaries in a space of inclusion, exclusion, and ambiguity, being among the most likely to be miscategorized by their peers13–15 during a period in which establishing a coherent identity is a primary developmental task. Not only do liminal youth exist between societal categories, they often must decide whether or not to disclose their liminal identity and struggle to “fit in” with those in a dominant category.16–19 For example, bisexual youth may be viewed as heterosexual until they decide to disclose their bisexuality.16,20 The same may be true for biracial (white/Black) youth who are “white passing.” Choice of disclosure can result in rejection but also invalidation of their identity—accusations of inauthenticity13—and suggestions that their liminal identities represent a transient stage (eg, bi erasure)20,21 and that they thus choose an aspect of their identity.14 Although liminal youth share the experience of existing outside societal binaries, it is important to recognize that the forms of stigma they encounter—ranging from hypervisibility to erasure—are distinct and require tailored supports. Liminality can result in exposure to discrimination based on their (liminal) identity,21 as well as a lack of belonging with other youth13—each a critical risk and protective factor, respectively, for negative mental health outcomes.22–24Liminal youth face among the highest rates of suicidal ideation and behavior compared with their peers.8,9 According to Youth Risk Behavior Surveillance (YRBS) data, multiracial, high school–aged youth had among the highest rates of seriously considering suicide and attempting suicide in the past year in 2023.8 Bisexual and transgender youth had the highest rates of active suicidal ideation and suicide attempts, higher than all other sexual and gender identities (see Figure 1A).8 Similarly, Trevor Project data indicate that among youth aged 13 to 24 years, more than 2 of every 5 transgender male, transgender female, and gender nonbinary youth considered suicide and more than 1 in 10 attempted suicide in the past year, higher than their cisgender male and female counterparts (see Figure 1B).9Mental health inequities among liminal individuals likely have long-term implications for adulthood. Indeed, based on a 2024 Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report, similar to YRBS and Trevor Project data, loneliness and related mental health concerns during adulthood were highest among transgender female respondents, transgender male respondents, gender nonbinary respondents, bisexual respondents, and multiracial adults (see Figure 1C).10 Although the samples differ across these data sources, the consistency across findings is striking.The high prevalence of negative mental health outcomes among liminal individuals occurs at a time of rapid sociodemographic shifts in which adolescents are increasingly liminal. US Census data indicate that 1 in 20 adolescents identify as multiracial, accounting for more than one-fifth (23%) of all multiracial individuals.25 Likewise, 1 in 12 male individuals (7%) and 1 in 5 female individuals (21%) in Generation Z identify as bisexual, with each subsequent generation seeing an increase of individuals who identify as transgender or gender nonbinary.26 Taken together, the elevated prevalence of suicidality/mental health challenges, changing sociodemographic trends, and rapidly emerging federal efforts (eg, executive orders) to use rigid biological frameworks to erase the existence of individuals who live outside of societal binaries warrant prioritization of liminal youth as a target population for mental health promotion efforts.There are existing, evidence-based approaches that work, even if they are rarely tailored specifically for liminal youth. For example, access to LGBTQIA+-affirming care27–29 is associated with reductions in negative mental health outcomes for youth, including for liminal adolescents. The 2024 Ending Unequal Treatment report from the National Academies of Sciences, Engineering, and Medicine30 further underscores that culturally and linguistically appropriate care—particularly when delivered by clinicians who share racial, ethnic, or linguistic backgrounds with patients—is linked to improved clinical outcomes such as symptom reduction and greater adherence to treatment.31–33 Additionally, parental affirmation of an adolescent’s sexual and gender identity (eg, bisexuality, gender nonconformity)34–36 and familial engagement in racial-ethnic socialization and support of multiracial, multiethnic experiences37,38 are associated with a reduced likelihood of negative mental health outcomes. Finally, a growing body of evidence indicates that exposure to structural stigma, including anti-LGBTQIA+ legislation and racially and ethnically discriminatory policies, is correlated with worsened mental health outcomes among liminal youth,39–43 making the reduction of such exposures a critical leverage point.Table 1 draws upon the bioecological model,48 to provide actions at the family, institution, and policy levels to eliminate mental health inequities experienced by liminal youth. We call for advocacy for and scale-up of LGBTQIA+ affirming care, culturally and linguistically appropriate care by racially, ethnically, and linguistically concordant providers, implementation of programs and practices developed in collaboration with liminal youth that validate liminal identities (eg, family acceptance programs)49 in clinics and schools, and policies that treat liminal youth equitably and which affirm liminal identities.