- Email: [email protected]
Transgender Adolescents' Uses of Social Media for Social Support
Journal of Adolescent Health xxx (2019) 1e6
www.jahonline.org Original article
Transgender Adolescents' Uses of Social Media for Social Support Ellen Selkie, M.D., M.P.H. a, *, Victoria Adkins, M.S.W. b, Ellie Masters c, Anita Bajpai, M.D. d, and Daniel Shumer, M.D. e a
Division of Adolescent Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan University of Michigan, Ann Arbor, Michigan Oakland University William Beaumont School of Medicine, Oakland University, Auburn Hills, Michigan d Oberlin College, Oberlin, Ohio e Division of Pediatric Endocrinology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan b c
Article history: Received May 28, 2019; Accepted August 23, 2019 Keywords: Qualitative; Transgender; FTM; MTF; Social support; Mental health; Well-being; Social media; Adolescent; Youth; Internet
A B S T R A C T
Purpose: Transgender adolescents are at higher risk for negative mental health outcomes, such as depression, anxiety, and suicidality, compared with cisgender adolescents. Social media may be an effective venue for addressing these health disparities because most adolescents have access to online information and socialization. This study used qualitative inquiry to explore transgender adolescents' uses of social media for social support. Methods: Transgender adolescents between the ages of 15 and 18 years with a social media profile were recruited from a pediatric gender clinic in the Midwestern U.S. A 30- to 60-minute semistructured interview assessed ways participants used social media to access transgender-related support. Thematic analysis was used to develop categories and code the transcripts. Coding discrepancies were resolved by two researchers following initial coding. Results: Results represent data from 25 interviews comprising 13 transmasculine, 11 transfeminine, and one nonbinary participant(s), with 68% of the sample identifying as white, nonHispanic. Categories emerged regarding forms of support participants received from transgender-related online communities including emotional support through peers and role models, appraisal support for validating their experiences, and informational support for navigating health decisions and educating family and friends. Participants also referenced negative experiences, including harassment and exclusionary behavior online. Conclusions: Social media platforms represent hubs of community for transgender adolescents. These communities provide emotional, appraisal, and informational support that transgender youth may not otherwise be able to access. Future research should use the affordances of social media to identify approaches to addressing health disparities and improving the well-being of transgender adolescents. Ó 2019 Published by Elsevier Inc. on behalf of Society for Adolescent Health and Medicine.
Conflicts of interest: The authors have no conflicts of interest to disclose. Data statement: The data generated during this study are not publicly available because of the identifiable nature of interview data. * Address correspondence to: Ellen Selkie, M.D., M.P.H., University of Michigan, 300 N. Ingalls St., Ann Arbor, MI 48109. E-mail address: [email protected] (E. Selkie).
IMPLICATIONS AND CONTRIBUTION
This study identifies the types of support transgender youth find on social media and how that contributes to their wellbeing. This study also provides practical information to health care providers serving this population to better understand what information and support transgender youth need and are exposed to online.
Transgender youth are three times more likely to experience depression, anxiety, and suicidality and have higher prevalence of eating disorders compared with the general population [1,2]. Gender dysphoria, family and peer rejection, and stigma put transgender youth at risk for such mental health challenges, and
1054-139X/Ó 2019 Published by Elsevier Inc. on behalf of Society for Adolescent Health and Medicine. https://doi.org/10.1016/j.jadohealth.2019.08.011
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internalized transphobia is associated with depression and anxiety [3,4]. Psychological health concerns are compounded by the decreased likelihood of transgender people to seek treatment because of discrimination and inadequate provider training [5,6]. Transgender youth, in particular, often lack access to supportive medical or mental health care [7]. However, social support may serve as a protective factor for youth encountering these challenges [8e10]. Social support has been found to impact the well-being and self-esteem of transgender individuals in the face of stigma [11e13]. Emotional support refers to support in the form of caring, trust, and empathy. Appraisal support refers to statements that validate the words or actions of others. Informational support comes in the form of information to aid in decision-making [8e10]. The “buffering hypothesis” posits that social support in the face of stressors can decrease perceived threats and improve coping, which can be protective for mental health. The most effective social supports match the needs of the individualdin minority populations, this can include support from others who have shared experiences such as marginalization and discrimination [14]. In stigmatized communities, researchers theorize that reappraisal and comparison can be moderators for stress and empowerment. Individuals can evaluate themselves more positively when comparing themselves to other individuals within that community, rather than viewing themselves in prejudiced or stereotypical frameworks [15,16]. Such support may be particularly relevant to transgender youth, as connections with peers in the lesbian, gay, bisexual, and transgender (LGBT) community have been linked to greater reported resilience in transgender adults [17]. In order for minority communities to collectively cope, members need access to each other. Even with strong personal coping skills, individuals are still at risk for adverse health effects without the resources that social support can offer [16]. For example, one study of LGBT youth found that participants desired more contact with LGBT peers and role models [18]. For transgender youth in particular, awareness of and interaction with other transgender individuals before and early in gender identity development may also decrease suicidality and fear and increase general comfort levels [19]. One way that these communities often access each other is through social media. According to a Pew Research study of LGBT Americans, nearly 80% of LGBT adults use Facebook or Twitter, and more than half the members in the community found new friends via social media [20]. Furthermore, transgender individuals report using the Internet to limit isolation and maintain anonymity [21e23]. Social media can also provide information on sensitive topics such as sexual health and gender identity [24]. Use of social media for support may expose adolescents to both benefits and risks. In one meta-analysis, social media use was associated with identity experimentation, higher selfesteem, and increased perceptions of social support and capital. However, significant negative experiences also included cyberbullying, depression, and social isolation [25]. Other studies have found social media to be more beneficial for young adults who have low self-esteem or report low life satisfaction [26] or those with low in-person social support [27]. Active engagement with an online community may be a protective factor against depressive symptoms, although the same cannot be said for passive engagement (i.e., “lurking”) in which depressive symptoms can increase [28]. For transgender youth specifically, one study found that Twitter posts were more than twice as
frequently reported to provide positive social stimuli (55%) for transgender youth compared with negative stimuli (26%) [21]. Given previous research on social media support, social media may also be a resource for transgender youth in their search for community and affirmational health care [29e31]. However, previous literature has not explored the perspectives of these youth regarding social media specific to being transgender. As such, the purpose of this qualitative study was to understand how transgender adolescents use social media to find social support. Methods Participants Participants for this study were recruited from a pediatric gender services clinic in the Midwestern U.S. Eligible patients were at least aged 15 years, spoke English, and had at least one social media account. Eligible patients were recruited through phone call or in clinic. Parental consent and adolescent assent were obtained at the time of interview. Interviews occurred before or after the patient's appointment or were conducted via Skype, and participants received a gift card for participating. This study was approved by the University of Michigan Institutional Review Board. Interviews Demographic data were collected on gender identity, age, race/ethnicity, and income status. Semistructured interviews were conducted privately with a trained interviewer and lasted 30e60 minutes. The interview questions were developed as part of a larger qualitative study and were initially based on previous clinical knowledge and experiences of two of the authors, E.S. and D.S., both practicing physicians caring for transgender youth. Interview questions explored the participant's knowledge, beliefs, and perspectives regarding transgender-related social media content (Appendix A). Interviews were audio recorded, and a study team member transcribed each interview verbatim in Microsoft Word. Audible but nonverbal aspects of the interview (e.g., laughing and pauses) and spoken words were recorded as text [32]. The transcriber attempted to adhere as faithfully to the recorded audio as possible by relistening to segments while reading the transcript and did not “standardize” the dialog to conform to their own conceptions of formal English grammar [33]. Analysis All thematic coding was performed using NVivo (QSR International). Codes were primarily developed using an inductive approach and repeated assessment by the authors, who have clinical and research experience with the health of transgender youth. Throughout initial coding of the first 10 transcripts, four research team members (E.S., E.M., D.S., and V.A.) independently used the codebook, suggested additional concepts, and eliminated unused codes. Research team members met regularly to adjust the codebook and reconcile discrepancies. The remainder of the transcripts were double coded by two team members (V.A and E.M.), and discrepancies were reconciled by another team member (D.S.). After reconciliation, percent agreement was calculated in NVivo and reflected an overall 95% agreement
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between coders. The final codebook contained 12 coding categories and 45 subcodes (Appendices B and C). Results Demographics A total of 25 individuals aged 15e18 years (average: 16 years) participated; no participants were excluded from analysis. Of those 25 participants, 11 identified as transfeminine, 13 as transmasculine, and 1 as nonbinary; and 20 identified as white, non-Hispanic; 1 as African American; 2 as American Indian; and 2 as Asian. Interviews averaged 28 minutes. Participants reported accessing the following social media platforms for transgenderspecific content: YouTube (80% of participants), Instagram (72%), Facebook (48%), Twitter (48%), and Tumblr (44%). Categories Emotional support. Participants described social media as a place where they could find other transgender people to interact with. This was especially important to participants who did not feel that people they knew offline would understand what they were going through, whether due to scarcity of other transgender youth in their area, personal fears of being “out” offline, or lack of understanding from cisgender peers. Social media were described as helpful in decreasing feelings of isolation. One participant explained, “Being transgender gets really lonely, even though there are people that support you [.] it still does get very, very lonely. And then you see other people who also feel lonely, and that it’s not just you who feels lonely. And that, if you're not physically there with them, you can still feel a little bit lonely together, and/or less lonely.” Another participant noted, “I feel like it's hard to meet trans people and learn things about trans people even if you are trans, just in day-to-day interaction because one, there aren’t that many and two, a lot of trans people don’t really want you to know that they're trans, and that makes it hard to start a conversation, and I can't blame them because I'm in that boat. But social media because there's more anonymity there really, more people are open to talking about their experiences as trans people and helps you understand it more.” Participants also noted the utility of social media in dealing with offline concerns. This was pronounced during the experience of coming out as transgender online, which was often intimately tied to the experience of coming out offline. As one participant put it, “I came out online first and then to friends in school including teachers. But I felt.I felt like I could. It's.it's really contradictory online because it's so impersonal yet personal at the same time. But it felt like I was seen on as a male online, and if I can do that here then I can do that in school and in my home and in other places where that impacts my life.” Other participants described that interacting with other transgender people online gave them hope for the future. Participants described having difficulty with dysphoria before medical transition but receiving support from online peers. One participant described that before beginning testosterone, “I was in a really deep depression and I found all these people who were post-op and post-T, um I, I was like, that's a future that I could have if I stick around a little bit longer and get to see that happen for me too.” For youth undergoing medical treatment, seeing others' experiences online was a way of coping with frustrations they may have during their own transition. As one participant said, “It
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makes me confident for the most part, um, and hopeful, I guess is the other word I would use to describe it, cause like, I'm about a year in, I feel like I have a lot longer to go, and sort of shows me an optimistic end point that I might reach.” Appraisal support. Participants described feeling validated by transgender-related social media content, particularly when the person posting the content was a public figure. As one participant said, “not a lot of people talk about it and so when somebody, like more well known, I guess in a way, talks about it, it just normalizes it and it just makes me feel that it’s okay to be this way.” Other participants described having feelings that they did not know were normal or acceptable, even among the transgender community, but then having these feelings validated by social media content: “I see a lot of stuff on the internet, positivity wise, specifically around like lesbian trans people and I guess that's the-the thing that, you know, I feel like I get the most support out of right now, because that's um-that's a part of my identity that's still a bit harder for me to grapple with, um, just because like I don’t feel valid a lot of the time in that part of who I am and seeing positivity on the internet is helpful.” Another participant noted, “[Transgender YouTuber] really showcases the whole thing like how it's okay to have bad days and it's okay to be weak and feel all those emotions and he also talks about these things that a lot of trans people don’t talk about.” Participants described affirmational support from others being as simple as a “like” or a positive comment on one of their posts. In particular, participants reported receiving and appreciating compliments on personal appearance and “passing” in their gender presentation. As one participant noted, “I would have to say a good amount of trans women and men probably don’t feel as comfortable as they could feel, and I feel like the reason that I've come to the point in my life where I feel like I am very comfortable, is probably due to social media. Because like I said, the amount of love that I get, people constantly telling me, ‘oh my god you look so pretty! You're prettier than me! I would have never thought you were a boy!’ Like just those simple remarks.” Informational support. Most participants commented on the ability to get information from other transgender people about gender affirming therapy as a helpful aspect of social media. As a participant described, “With trans people having access to the internet and tips for bodies pre-T and bodies after T written by actual trans people and articles about dysphoria and how to go about getting hormones has really been helpful and probably led me to getting T now, 11 months ago. Because if I had to go about this all on my own I would have no idea.” Participants also found social media helpful to educate their families: “I think it helped my parents more, cause I would like show them videos of how it affected other people and other people explaining it, like their stories, and doctors. that helped them to allow me to go to a doctor.” In addition to learning about the logistics of obtaining treatment, participants also cited social media as a source for learning about safely accessing hormones. For example, a participant said, “I've seen posts advising against getting testosterone or estrogen without a doctor, as in you don’t know what kind of dosage you need, or not properly sterilized needles and as a trans person who does not have great healthcare, it's really hard to not think about not doing those things. And when you are in a deep depression because of dysphoria and you're getting misgendered
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87 times a day it's pretty hard to go about life and be validated as the gender that you are. But it's nice to know that people are trying to stop that even if it is just through a post advising against it.”
community users having “a lot more patience with previous transphobic people who are willing to learn and educate themselves instead of bashing them for their past mistakes.” Discussion
Negative social media experiences. Although social media were seen as an overall positive tool for support among participants, negative aspects of social media were also identified. All participants talked about seeing hurtful comments or content pertaining to transgender people, and some considered it to be normative. More than one in four participants mentioned instances of personal harassment. Participants spoke of openly expressed transphobia, both outside and inside of online transgender community spaces: “[Transphobic people] have access to the internet and can also share their opinions. And knowing that they're actual people out in the world that have-share those opinions. And you can see it with all the likes and reblogs that they do have those opinions. And social media also as well-it gives me a platform but it also gives them a platform. And that's a little unnerving.” Another participant explained, “It's public. Which is both a blessing and a curse because you can connect with all these people but also you are open to a lot of hate.” Even when participants had not experienced direct harassment, the experience of seeing someone else victimized could be distressing: “people go out of their way to hate on certain people and even if it's not targeted at me, it makes me feel bad for the people it's targeted at.” Within the transgender social media community, participants noted that victimization and exclusion also occur. Participants noted posts about the “right” way to be transgender, which could be invalidating, especially for people who identify as gender expansive or nonbinary. As one participant explained, “There's a lot of gatekeeping, especially with people who are gender nonconforming or gender variant, it's like yeah you're trans, but you're not trans enough for this community to accept you so we're not gonna do that. Or it's.there's not a lot of praise for people who don’t use medication or choose not to transition at all, just like you, yeah you might be trans but you're not trans enough.” Conversely, other participants noted shaming of those who posted about the “right” way to be transgender: “A lot of times people say things like oh you don’t need to pass to be trans and like that's true, but that ideology sometimes makes it hard to find resources about like how to help you pass better and stuff like that if that's what you actually want to do because it's sort of drowned out by the sentiment that you don’t have to.” When witnessing negative behavior, participants had several mechanisms of approaching the content. A common conceptualization was that transphobia was due to “ignorance” or being “uneducated,” which participants felt made it easier to ignore the content: “The negative people I guess that are uneducated about LGBT people and who just do not know and they are just horrible like in that sense and they really degrade people so that's like the bad part but I stay away from people like that.” Others saw this as an opportunity to combat transphobia through education. When speaking of a particular YouTube celebrity addressing transphobic viewer comments, a participant said, “He responds articulately and well-written and smartly. Um, which is, it's nice to see, ‘cause I'm-I'm not a very patient person when it comes to that.’ It's nice to see someone be willing to wait and educate instead of be very quick to anger.” Another participant noted online transgender
This qualitative study explored how social media platforms are used by transgender adolescents to access social support. Participants received emotional support from peers they had connected with online but also were able to augment this online support with support in offline contexts. Seeing the narratives of other transgender people provided affirmational support for participants' own feelings, contributing to a sense of hope about the future. Use of social media for informational support regarding medical care logistics and expectations was helpful in empowering participants to take next steps in their affirmation and treatment of gender dysphoria. Participants also noted encounters with negative, antitrans content on social media and described ways they cope with this content. These findings add to the growing body of literature on transgender adolescents' support seeking behaviors. Although transgender youth may be at risk for poor social support in their homes and communities, our study participants reported finding support online. In online environments, transgender adolescents may feel they are able to express ideas that they would not be able to express offline because of stigma and bias [34]. They may receive active appraisal support through positive feedback and validation from others, which has shown to be associated with increased self-esteem [35]. In addition, passive appraisal support, such as seeing positive comments on another transgender person's posts, can be important in adolescents, given the developmental tendency to compare oneself to peers. This is consistent with other qualitative findings that youth who recognize themselves in transgender peers led to improved navigation and acceptance of identity [12]. Further research should explore the extent to which transgender youth get social support online versus offline. It is important to recognize the potential social media risks for transgender youth. LGBT adolescents are at higher risk for online victimization and its detrimental effectsdfor example, poor academic performance, low self-esteem, depression, and suicidalitydcompared with heterosexual, cisgender peers. [36] Furthermore, although transgender youth may benefit from the ability to explore identity online, they may not be able to fully control their online representation (“digital footprint”), which could put them at risk for unwanted privacy invasion in the future [37]. Given these risks, transgender youth must be guided to be cautious in their use of social media while exploring online support. Our study had several limitations, many of which can be further investigated in future studies. We did not collect demographic data on participants' home locations; this may be relevant, for example, in determining trends in social media support in rural versus urban transgender youth [38]. Similarly, we did not collect sexual orientation data, which may have added another dimension to findings. However, our interviews were developed with a specific focus on gender identity in keeping with the growing trend of separating gender identity from sexual orientation in research [39]. Our clinic requires that the patient present with at least one parent to their initial visit. Therefore, our study recruitment strategy missed patients whose parents are not supportive of their gender identity
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and arguably may be the population most in need of social support. As such, future work must also explore the use of social media for support in nonclinical populations. As with all qualitative research, we attempted to incorporate reflexivity into our study design [40]. The research team comprised individuals of multiple gender identities, as well as health care providers who work directly with gender diverse youth. We recognize that each individual's preconceptions impact study development and analysis, and that participants do not speak for all transgender youth. However, we felt that the study team's combined expertise and experiences allowed us to address such preconceptions to the best of our ability. Despite these limitations, our study has important implications for professionals who work with transgender youth. Awareness of social media use can present opportunities for further discussion with youth regarding support needs. Our study findings may also help foster greater understanding of the lived experiences of transgender youth online. Finally, this study establishes a starting point for future investigation regarding the impact of social media support on well-being in transgender youth. Acknowledgments Our team would like to acknowledge Lynn Metz, Sara Wiener, Lindsay Gray, Sara Kahn, and all the Medical Staff that helped make this study possible. A poster presentation of this study was presented at The Society for Adolescent Health and Medicine (SAHM), Annual Meeting, in March 2018. Funding Source This work was supported by the Children's Health Research Award, an Intramural Research Funding Program through the Department of Pediatrics and Communicable Diseases at the University of Michigan, Ann Arbor, MI, in 2016. Supplementary Data Supplementary data related to this article can be found at http://doi.org/10.1016/j.jadohealth.2019.08.011. References [1] Reisner SL, Vetters R, Leclerc M, et al. Mental health of transgender youth in care at an adolescent urban community health center: A matched retrospective cohort study. J Adolesc Health 2015;56:274e9. [2] Connolly MD, Zervos M, Barone CJ II, et al. The mental health of transgender youth: Advances in understanding. J Adolesc Health 2016;29:189e 495. [3] White Hughto JM, Reisner SL, Pachankis JE. Transgender stigma and health: A critical review of stigma determinants, mechanisms, and interventions. Soc Sci Med 2015;147:222e31. [4] Chodzen G, Hidalgo MA, Chen D, Garofalo R. Minority stress factors associated with depression and anxiety among transgender and gender-nonconforming youth. J Adolesc Health 2019;64:467e71. [5] Obedin-Maliver J, Goldsmith E, Stewart L, et al. Lesbian, gay, bisexual, and transgendererelated content in undergraduate medical education. JAMA 2011;306:971e7. [6] Guss C, Shumer D, Katz-Wise S. Transgender and gender nonconforming adolescent care: Psychosocial and medical considerations. Curr Opin Pediatr 2015;27:421e6. [7] Von Vogelsang A-C, Milton C, Ericcson I, Stromberg L. “Wouldn”t it be easier if you continued to be a guy?’ e a qualitative interview study of transsexual persons’ experiences of encounters with healthcare professionals. J Clin Nurs 2016;25:3577e88.
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Adolescents' views regarding uses of social networking websites and text messaging for adolescent sexual health education. Am J Health Educ 2011;42:205e12. [25] Best P, Manktelow R, Taylor B. Online communication, social media and adolescent wellbeing: A systematic narrative review. Child Youth Serv Rev 2014;41:27e36. [26] Ellison NB, Steinfield C, Lampe C. The benefits of Facebook “friends:” Social capital and college students’ use of online social network sites. J Computer Mediated Commun 2007;12:1143e68. [27] Bessière K, Kiesler S, Kraut R, Boneva BS. Effects of internet use and social resources on changes in depression. Inf Commun Soc 2008;11:47e70. [28] Escobar-Viera CG, Shensa A, Bowman ND, et al. Passive and active social media use and depressive symptoms among United States adults. Cyberpsychol Behav Soc Netw 2018;21:437e43. [29] Kosenko KA, Bond BJ, Hurley RJ. An exploration into the uses and gratifications of media for transgender individuals. 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www.jahonline.org Original article
Transgender Adolescents' Uses of Social Media for Social Support Ellen Selkie, M.D., M.P.H. a, *, Victoria Adkins, M.S.W. b, Ellie Masters c, Anita Bajpai, M.D. d, and Daniel Shumer, M.D. e a
Division of Adolescent Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan University of Michigan, Ann Arbor, Michigan Oakland University William Beaumont School of Medicine, Oakland University, Auburn Hills, Michigan d Oberlin College, Oberlin, Ohio e Division of Pediatric Endocrinology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan b c
Article history: Received May 28, 2019; Accepted August 23, 2019 Keywords: Qualitative; Transgender; FTM; MTF; Social support; Mental health; Well-being; Social media; Adolescent; Youth; Internet
A B S T R A C T
Purpose: Transgender adolescents are at higher risk for negative mental health outcomes, such as depression, anxiety, and suicidality, compared with cisgender adolescents. Social media may be an effective venue for addressing these health disparities because most adolescents have access to online information and socialization. This study used qualitative inquiry to explore transgender adolescents' uses of social media for social support. Methods: Transgender adolescents between the ages of 15 and 18 years with a social media profile were recruited from a pediatric gender clinic in the Midwestern U.S. A 30- to 60-minute semistructured interview assessed ways participants used social media to access transgender-related support. Thematic analysis was used to develop categories and code the transcripts. Coding discrepancies were resolved by two researchers following initial coding. Results: Results represent data from 25 interviews comprising 13 transmasculine, 11 transfeminine, and one nonbinary participant(s), with 68% of the sample identifying as white, nonHispanic. Categories emerged regarding forms of support participants received from transgender-related online communities including emotional support through peers and role models, appraisal support for validating their experiences, and informational support for navigating health decisions and educating family and friends. Participants also referenced negative experiences, including harassment and exclusionary behavior online. Conclusions: Social media platforms represent hubs of community for transgender adolescents. These communities provide emotional, appraisal, and informational support that transgender youth may not otherwise be able to access. Future research should use the affordances of social media to identify approaches to addressing health disparities and improving the well-being of transgender adolescents. Ó 2019 Published by Elsevier Inc. on behalf of Society for Adolescent Health and Medicine.
Conflicts of interest: The authors have no conflicts of interest to disclose. Data statement: The data generated during this study are not publicly available because of the identifiable nature of interview data. * Address correspondence to: Ellen Selkie, M.D., M.P.H., University of Michigan, 300 N. Ingalls St., Ann Arbor, MI 48109. E-mail address: [email protected] (E. Selkie).
IMPLICATIONS AND CONTRIBUTION
This study identifies the types of support transgender youth find on social media and how that contributes to their wellbeing. This study also provides practical information to health care providers serving this population to better understand what information and support transgender youth need and are exposed to online.
Transgender youth are three times more likely to experience depression, anxiety, and suicidality and have higher prevalence of eating disorders compared with the general population [1,2]. Gender dysphoria, family and peer rejection, and stigma put transgender youth at risk for such mental health challenges, and
1054-139X/Ó 2019 Published by Elsevier Inc. on behalf of Society for Adolescent Health and Medicine. https://doi.org/10.1016/j.jadohealth.2019.08.011
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internalized transphobia is associated with depression and anxiety [3,4]. Psychological health concerns are compounded by the decreased likelihood of transgender people to seek treatment because of discrimination and inadequate provider training [5,6]. Transgender youth, in particular, often lack access to supportive medical or mental health care [7]. However, social support may serve as a protective factor for youth encountering these challenges [8e10]. Social support has been found to impact the well-being and self-esteem of transgender individuals in the face of stigma [11e13]. Emotional support refers to support in the form of caring, trust, and empathy. Appraisal support refers to statements that validate the words or actions of others. Informational support comes in the form of information to aid in decision-making [8e10]. The “buffering hypothesis” posits that social support in the face of stressors can decrease perceived threats and improve coping, which can be protective for mental health. The most effective social supports match the needs of the individualdin minority populations, this can include support from others who have shared experiences such as marginalization and discrimination [14]. In stigmatized communities, researchers theorize that reappraisal and comparison can be moderators for stress and empowerment. Individuals can evaluate themselves more positively when comparing themselves to other individuals within that community, rather than viewing themselves in prejudiced or stereotypical frameworks [15,16]. Such support may be particularly relevant to transgender youth, as connections with peers in the lesbian, gay, bisexual, and transgender (LGBT) community have been linked to greater reported resilience in transgender adults [17]. In order for minority communities to collectively cope, members need access to each other. Even with strong personal coping skills, individuals are still at risk for adverse health effects without the resources that social support can offer [16]. For example, one study of LGBT youth found that participants desired more contact with LGBT peers and role models [18]. For transgender youth in particular, awareness of and interaction with other transgender individuals before and early in gender identity development may also decrease suicidality and fear and increase general comfort levels [19]. One way that these communities often access each other is through social media. According to a Pew Research study of LGBT Americans, nearly 80% of LGBT adults use Facebook or Twitter, and more than half the members in the community found new friends via social media [20]. Furthermore, transgender individuals report using the Internet to limit isolation and maintain anonymity [21e23]. Social media can also provide information on sensitive topics such as sexual health and gender identity [24]. Use of social media for support may expose adolescents to both benefits and risks. In one meta-analysis, social media use was associated with identity experimentation, higher selfesteem, and increased perceptions of social support and capital. However, significant negative experiences also included cyberbullying, depression, and social isolation [25]. Other studies have found social media to be more beneficial for young adults who have low self-esteem or report low life satisfaction [26] or those with low in-person social support [27]. Active engagement with an online community may be a protective factor against depressive symptoms, although the same cannot be said for passive engagement (i.e., “lurking”) in which depressive symptoms can increase [28]. For transgender youth specifically, one study found that Twitter posts were more than twice as
frequently reported to provide positive social stimuli (55%) for transgender youth compared with negative stimuli (26%) [21]. Given previous research on social media support, social media may also be a resource for transgender youth in their search for community and affirmational health care [29e31]. However, previous literature has not explored the perspectives of these youth regarding social media specific to being transgender. As such, the purpose of this qualitative study was to understand how transgender adolescents use social media to find social support. Methods Participants Participants for this study were recruited from a pediatric gender services clinic in the Midwestern U.S. Eligible patients were at least aged 15 years, spoke English, and had at least one social media account. Eligible patients were recruited through phone call or in clinic. Parental consent and adolescent assent were obtained at the time of interview. Interviews occurred before or after the patient's appointment or were conducted via Skype, and participants received a gift card for participating. This study was approved by the University of Michigan Institutional Review Board. Interviews Demographic data were collected on gender identity, age, race/ethnicity, and income status. Semistructured interviews were conducted privately with a trained interviewer and lasted 30e60 minutes. The interview questions were developed as part of a larger qualitative study and were initially based on previous clinical knowledge and experiences of two of the authors, E.S. and D.S., both practicing physicians caring for transgender youth. Interview questions explored the participant's knowledge, beliefs, and perspectives regarding transgender-related social media content (Appendix A). Interviews were audio recorded, and a study team member transcribed each interview verbatim in Microsoft Word. Audible but nonverbal aspects of the interview (e.g., laughing and pauses) and spoken words were recorded as text [32]. The transcriber attempted to adhere as faithfully to the recorded audio as possible by relistening to segments while reading the transcript and did not “standardize” the dialog to conform to their own conceptions of formal English grammar [33]. Analysis All thematic coding was performed using NVivo (QSR International). Codes were primarily developed using an inductive approach and repeated assessment by the authors, who have clinical and research experience with the health of transgender youth. Throughout initial coding of the first 10 transcripts, four research team members (E.S., E.M., D.S., and V.A.) independently used the codebook, suggested additional concepts, and eliminated unused codes. Research team members met regularly to adjust the codebook and reconcile discrepancies. The remainder of the transcripts were double coded by two team members (V.A and E.M.), and discrepancies were reconciled by another team member (D.S.). After reconciliation, percent agreement was calculated in NVivo and reflected an overall 95% agreement
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between coders. The final codebook contained 12 coding categories and 45 subcodes (Appendices B and C). Results Demographics A total of 25 individuals aged 15e18 years (average: 16 years) participated; no participants were excluded from analysis. Of those 25 participants, 11 identified as transfeminine, 13 as transmasculine, and 1 as nonbinary; and 20 identified as white, non-Hispanic; 1 as African American; 2 as American Indian; and 2 as Asian. Interviews averaged 28 minutes. Participants reported accessing the following social media platforms for transgenderspecific content: YouTube (80% of participants), Instagram (72%), Facebook (48%), Twitter (48%), and Tumblr (44%). Categories Emotional support. Participants described social media as a place where they could find other transgender people to interact with. This was especially important to participants who did not feel that people they knew offline would understand what they were going through, whether due to scarcity of other transgender youth in their area, personal fears of being “out” offline, or lack of understanding from cisgender peers. Social media were described as helpful in decreasing feelings of isolation. One participant explained, “Being transgender gets really lonely, even though there are people that support you [.] it still does get very, very lonely. And then you see other people who also feel lonely, and that it’s not just you who feels lonely. And that, if you're not physically there with them, you can still feel a little bit lonely together, and/or less lonely.” Another participant noted, “I feel like it's hard to meet trans people and learn things about trans people even if you are trans, just in day-to-day interaction because one, there aren’t that many and two, a lot of trans people don’t really want you to know that they're trans, and that makes it hard to start a conversation, and I can't blame them because I'm in that boat. But social media because there's more anonymity there really, more people are open to talking about their experiences as trans people and helps you understand it more.” Participants also noted the utility of social media in dealing with offline concerns. This was pronounced during the experience of coming out as transgender online, which was often intimately tied to the experience of coming out offline. As one participant put it, “I came out online first and then to friends in school including teachers. But I felt.I felt like I could. It's.it's really contradictory online because it's so impersonal yet personal at the same time. But it felt like I was seen on as a male online, and if I can do that here then I can do that in school and in my home and in other places where that impacts my life.” Other participants described that interacting with other transgender people online gave them hope for the future. Participants described having difficulty with dysphoria before medical transition but receiving support from online peers. One participant described that before beginning testosterone, “I was in a really deep depression and I found all these people who were post-op and post-T, um I, I was like, that's a future that I could have if I stick around a little bit longer and get to see that happen for me too.” For youth undergoing medical treatment, seeing others' experiences online was a way of coping with frustrations they may have during their own transition. As one participant said, “It
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makes me confident for the most part, um, and hopeful, I guess is the other word I would use to describe it, cause like, I'm about a year in, I feel like I have a lot longer to go, and sort of shows me an optimistic end point that I might reach.” Appraisal support. Participants described feeling validated by transgender-related social media content, particularly when the person posting the content was a public figure. As one participant said, “not a lot of people talk about it and so when somebody, like more well known, I guess in a way, talks about it, it just normalizes it and it just makes me feel that it’s okay to be this way.” Other participants described having feelings that they did not know were normal or acceptable, even among the transgender community, but then having these feelings validated by social media content: “I see a lot of stuff on the internet, positivity wise, specifically around like lesbian trans people and I guess that's the-the thing that, you know, I feel like I get the most support out of right now, because that's um-that's a part of my identity that's still a bit harder for me to grapple with, um, just because like I don’t feel valid a lot of the time in that part of who I am and seeing positivity on the internet is helpful.” Another participant noted, “[Transgender YouTuber] really showcases the whole thing like how it's okay to have bad days and it's okay to be weak and feel all those emotions and he also talks about these things that a lot of trans people don’t talk about.” Participants described affirmational support from others being as simple as a “like” or a positive comment on one of their posts. In particular, participants reported receiving and appreciating compliments on personal appearance and “passing” in their gender presentation. As one participant noted, “I would have to say a good amount of trans women and men probably don’t feel as comfortable as they could feel, and I feel like the reason that I've come to the point in my life where I feel like I am very comfortable, is probably due to social media. Because like I said, the amount of love that I get, people constantly telling me, ‘oh my god you look so pretty! You're prettier than me! I would have never thought you were a boy!’ Like just those simple remarks.” Informational support. Most participants commented on the ability to get information from other transgender people about gender affirming therapy as a helpful aspect of social media. As a participant described, “With trans people having access to the internet and tips for bodies pre-T and bodies after T written by actual trans people and articles about dysphoria and how to go about getting hormones has really been helpful and probably led me to getting T now, 11 months ago. Because if I had to go about this all on my own I would have no idea.” Participants also found social media helpful to educate their families: “I think it helped my parents more, cause I would like show them videos of how it affected other people and other people explaining it, like their stories, and doctors. that helped them to allow me to go to a doctor.” In addition to learning about the logistics of obtaining treatment, participants also cited social media as a source for learning about safely accessing hormones. For example, a participant said, “I've seen posts advising against getting testosterone or estrogen without a doctor, as in you don’t know what kind of dosage you need, or not properly sterilized needles and as a trans person who does not have great healthcare, it's really hard to not think about not doing those things. And when you are in a deep depression because of dysphoria and you're getting misgendered
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87 times a day it's pretty hard to go about life and be validated as the gender that you are. But it's nice to know that people are trying to stop that even if it is just through a post advising against it.”
community users having “a lot more patience with previous transphobic people who are willing to learn and educate themselves instead of bashing them for their past mistakes.” Discussion
Negative social media experiences. Although social media were seen as an overall positive tool for support among participants, negative aspects of social media were also identified. All participants talked about seeing hurtful comments or content pertaining to transgender people, and some considered it to be normative. More than one in four participants mentioned instances of personal harassment. Participants spoke of openly expressed transphobia, both outside and inside of online transgender community spaces: “[Transphobic people] have access to the internet and can also share their opinions. And knowing that they're actual people out in the world that have-share those opinions. And you can see it with all the likes and reblogs that they do have those opinions. And social media also as well-it gives me a platform but it also gives them a platform. And that's a little unnerving.” Another participant explained, “It's public. Which is both a blessing and a curse because you can connect with all these people but also you are open to a lot of hate.” Even when participants had not experienced direct harassment, the experience of seeing someone else victimized could be distressing: “people go out of their way to hate on certain people and even if it's not targeted at me, it makes me feel bad for the people it's targeted at.” Within the transgender social media community, participants noted that victimization and exclusion also occur. Participants noted posts about the “right” way to be transgender, which could be invalidating, especially for people who identify as gender expansive or nonbinary. As one participant explained, “There's a lot of gatekeeping, especially with people who are gender nonconforming or gender variant, it's like yeah you're trans, but you're not trans enough for this community to accept you so we're not gonna do that. Or it's.there's not a lot of praise for people who don’t use medication or choose not to transition at all, just like you, yeah you might be trans but you're not trans enough.” Conversely, other participants noted shaming of those who posted about the “right” way to be transgender: “A lot of times people say things like oh you don’t need to pass to be trans and like that's true, but that ideology sometimes makes it hard to find resources about like how to help you pass better and stuff like that if that's what you actually want to do because it's sort of drowned out by the sentiment that you don’t have to.” When witnessing negative behavior, participants had several mechanisms of approaching the content. A common conceptualization was that transphobia was due to “ignorance” or being “uneducated,” which participants felt made it easier to ignore the content: “The negative people I guess that are uneducated about LGBT people and who just do not know and they are just horrible like in that sense and they really degrade people so that's like the bad part but I stay away from people like that.” Others saw this as an opportunity to combat transphobia through education. When speaking of a particular YouTube celebrity addressing transphobic viewer comments, a participant said, “He responds articulately and well-written and smartly. Um, which is, it's nice to see, ‘cause I'm-I'm not a very patient person when it comes to that.’ It's nice to see someone be willing to wait and educate instead of be very quick to anger.” Another participant noted online transgender
This qualitative study explored how social media platforms are used by transgender adolescents to access social support. Participants received emotional support from peers they had connected with online but also were able to augment this online support with support in offline contexts. Seeing the narratives of other transgender people provided affirmational support for participants' own feelings, contributing to a sense of hope about the future. Use of social media for informational support regarding medical care logistics and expectations was helpful in empowering participants to take next steps in their affirmation and treatment of gender dysphoria. Participants also noted encounters with negative, antitrans content on social media and described ways they cope with this content. These findings add to the growing body of literature on transgender adolescents' support seeking behaviors. Although transgender youth may be at risk for poor social support in their homes and communities, our study participants reported finding support online. In online environments, transgender adolescents may feel they are able to express ideas that they would not be able to express offline because of stigma and bias [34]. They may receive active appraisal support through positive feedback and validation from others, which has shown to be associated with increased self-esteem [35]. In addition, passive appraisal support, such as seeing positive comments on another transgender person's posts, can be important in adolescents, given the developmental tendency to compare oneself to peers. This is consistent with other qualitative findings that youth who recognize themselves in transgender peers led to improved navigation and acceptance of identity [12]. Further research should explore the extent to which transgender youth get social support online versus offline. It is important to recognize the potential social media risks for transgender youth. LGBT adolescents are at higher risk for online victimization and its detrimental effectsdfor example, poor academic performance, low self-esteem, depression, and suicidalitydcompared with heterosexual, cisgender peers. [36] Furthermore, although transgender youth may benefit from the ability to explore identity online, they may not be able to fully control their online representation (“digital footprint”), which could put them at risk for unwanted privacy invasion in the future [37]. Given these risks, transgender youth must be guided to be cautious in their use of social media while exploring online support. Our study had several limitations, many of which can be further investigated in future studies. We did not collect demographic data on participants' home locations; this may be relevant, for example, in determining trends in social media support in rural versus urban transgender youth [38]. Similarly, we did not collect sexual orientation data, which may have added another dimension to findings. However, our interviews were developed with a specific focus on gender identity in keeping with the growing trend of separating gender identity from sexual orientation in research [39]. Our clinic requires that the patient present with at least one parent to their initial visit. Therefore, our study recruitment strategy missed patients whose parents are not supportive of their gender identity
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and arguably may be the population most in need of social support. As such, future work must also explore the use of social media for support in nonclinical populations. As with all qualitative research, we attempted to incorporate reflexivity into our study design [40]. The research team comprised individuals of multiple gender identities, as well as health care providers who work directly with gender diverse youth. We recognize that each individual's preconceptions impact study development and analysis, and that participants do not speak for all transgender youth. However, we felt that the study team's combined expertise and experiences allowed us to address such preconceptions to the best of our ability. Despite these limitations, our study has important implications for professionals who work with transgender youth. Awareness of social media use can present opportunities for further discussion with youth regarding support needs. Our study findings may also help foster greater understanding of the lived experiences of transgender youth online. Finally, this study establishes a starting point for future investigation regarding the impact of social media support on well-being in transgender youth. Acknowledgments Our team would like to acknowledge Lynn Metz, Sara Wiener, Lindsay Gray, Sara Kahn, and all the Medical Staff that helped make this study possible. A poster presentation of this study was presented at The Society for Adolescent Health and Medicine (SAHM), Annual Meeting, in March 2018. Funding Source This work was supported by the Children's Health Research Award, an Intramural Research Funding Program through the Department of Pediatrics and Communicable Diseases at the University of Michigan, Ann Arbor, MI, in 2016. Supplementary Data Supplementary data related to this article can be found at http://doi.org/10.1016/j.jadohealth.2019.08.011. References [1] Reisner SL, Vetters R, Leclerc M, et al. Mental health of transgender youth in care at an adolescent urban community health center: A matched retrospective cohort study. J Adolesc Health 2015;56:274e9. [2] Connolly MD, Zervos M, Barone CJ II, et al. The mental health of transgender youth: Advances in understanding. J Adolesc Health 2016;29:189e 495. [3] White Hughto JM, Reisner SL, Pachankis JE. Transgender stigma and health: A critical review of stigma determinants, mechanisms, and interventions. Soc Sci Med 2015;147:222e31. [4] Chodzen G, Hidalgo MA, Chen D, Garofalo R. Minority stress factors associated with depression and anxiety among transgender and gender-nonconforming youth. J Adolesc Health 2019;64:467e71. [5] Obedin-Maliver J, Goldsmith E, Stewart L, et al. Lesbian, gay, bisexual, and transgendererelated content in undergraduate medical education. JAMA 2011;306:971e7. [6] Guss C, Shumer D, Katz-Wise S. Transgender and gender nonconforming adolescent care: Psychosocial and medical considerations. Curr Opin Pediatr 2015;27:421e6. [7] Von Vogelsang A-C, Milton C, Ericcson I, Stromberg L. “Wouldn”t it be easier if you continued to be a guy?’ e a qualitative interview study of transsexual persons’ experiences of encounters with healthcare professionals. J Clin Nurs 2016;25:3577e88.
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