Bullying, State Policy, and Mental Health Symptoms in Gender-Diverse Youths

Importance: As the percentage of young people in the US identifying as transgender and gender-diverse increases, more youths face identity-linked social and structural stigma and discrimination. Little is known about the impact of stigma on psychotic-like experiences in gender-diverse youths. Objective: To assess the association of being bullied and state policies with psychotic-like experiences among gender-diverse youths. Design, Setting, and Participants: In this prospective cohort study, cross-sectional and longitudinal analyses were conducted between 2023 and 2025 using data collected between January 1, 2017, and December 31, 2022, across 17 states. The Adolescent Brain Cognitive Development (ABCD) Study is a US population-based, longitudinal study that follows and deeply phenotypes youths from the age of 9 to 18 years. Cross-sectional analyses included data from 8463 participants collected between January 1, 2019, and December 31, 2022. Longitudinal analyses included 4200 participants with data collected across 5 waves between January 1, 2017, and December 31, 2022. Statistical analysis was performed from January 1, 2023, to December 31, 2025. Exposures: Self-reported frequency of being bullied and data on annual state policies related to gender identity. Main Outcomes and Measures: Self-reported PLEs and associated distress, measured by the Prodromal Questionnaire-Brief Child Version. Results: The study sample included 8463 youths (mean [SD] age, 12.9 [0.6] years; 4490 [53.1%] assigned male at birth). Based on a dimensional measure of gender, 531 youths (6.3%) were identified as most gender diverse (ie, least congruent with birth-assigned sex) and 6867 (81.1%) as least gender diverse (ie, most congruent with birth-assigned sex). Rates of being bullied and PLEs were significantly elevated in the most vs least gender-diverse group, with bullying partially mediating the difference in PLEs (indirect association = 0.15, P < .001; direct association = 0.63, P < .001). Moreover, the persistence of unsupportive legislation across 4 years was associated with significantly greater increases in PLEs over time in gender-diverse youth (interaction β = 0.31; 95% CI, 0.21-0.42; P < .001). Conclusions and Relevance: In this cohort study, being bullied and unsupportive legislation were associated with greater and increasing rates of PLEs in gender-diverse youths. This study's findings suggest that mental health in gender-diverse youths could benefit from supportive environments and policies that reduce bullying and avoid perpetuating stigma.