On the basis of the data from a national student survey for higher education in Norway (the SHoT2018 study), we compared life satisfaction, loneliness, mental health, and suicidal behavior among transgender students (N = 96) with cisgender students (N = 49,836). Many transgender students reported experiences in the same range as their cisgender peers, but on average, they scored in the direction of psychosocial hardship. Compared to cisgender students, transgender students more often reported psychosocial burdens regarding satisfaction with life, loneliness, mental health problems and disorders, and suicide-related measures. There were no significant differences in any of the measures between the binary and non-binary transgender students. These findings are in line with studies among transgender youth in other countries [7, 9,10,11,12, 30], indicating a vulnerable gender minority population group in need of special attention in Norway as well.
The costs of violating gender normativity
We believe that the increased burdens reported by transgender students in Norway are associated with violating existing gender norms—not only the norms for appropriate behaviors for men and women but also the cisnormative notion that only two reciprocally exclusive gender categories of men and women exist. In Norway and most other industrialized countries, these norms permeate all aspects of society, including people’s identities and behaviors, and are taken for granted by lay persons, health professionals, and educators . Each young transgender person faces the personal challenges and costs of violating these norms. They run the continuous risk of being discriminated against and ridiculed.
Identity theory and life course studies see this period as crucial with regard to, for example, intimacy and sexuality, personal identity and taste, group belonging, and dealing with new types of interpersonal relationships and professional standards [32, 33]. For many transgender persons, gender-identity concerns arise during the formative years of adolescence and young adulthood, corresponding to the age period of higher education. Transgender students face unique challenges related to the defining nature of their identities, appropriating their personal way of behaving and presenting themselves in line with their gender identity, and learning to deal with possible body changes and medical treatment, as well as the demanding work of coming out and responding to possible prejudice stigmatization. They have to face issues such as: “What is my gender identity and how do I manage and navigate in this field?” and “Should I tell friends and relatives?” In this more challenging and complex landscape of personal and interpersonal concerns, the young transgender student must navigate and find solutions.
In Norway, the last decade has seen signs of more differentiated gender conceptualizations. For example, transgender persons are more visible in the media, there are public and academic discussions about diagnoses such as gender dysphoria and treatment options, activist organizations include various transgender groups, and the Norwegian government now utilizes the “LGBTQI” phrase (Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex) in official documents . In addition, public attitudes in Norway are gradually becoming less negative toward transgender persons, as revealed by population-based surveys in 2008, 2013, and 2017 . Even so, transgender persons in Norway report experiences in school (e.g., a lack of information about different gender identities) and the health system (e.g., a lack of adequate counseling for transgender patients) indicating the need for improvements .
Gender incongruence vs gender dysphoria
The psychosocial burdens of many transgender students represent a complex mixture of external social attitudes to gender non-conformity and internal emotional reactions to gender non-congruence, which are probably differently distributed within the sample. For some transgender persons the aspect of gender dysphoria may be most prominent, leading to serious bodily dissatisfaction and a subsequent strong wish for medical gender affirmation. Identifying and being recognized as a patient in need of medical treatment may enhance emotional coping, whereas being dismissed by the health care system may represent a major existential threat to identity. However, not all transgender individuals desire or need medical gender affirmation. Distress arises when the need for is greater than access to gender affirmation. For those binary transgender persons who are not visibly transgender, negative social responses to gender incongruence may be reduced because public attitudes are less negative toward binary transgender persons than toward non-binary transgender persons .
For other transgender persons, gender dysphoria may possibly be more associated with social role than with bodily attributes. By not aspiring to pass as a cisgender male or female, the non-binary transgender person may appear more provocative to cultural cis-normativity, given the finding noted above that more Norwegians hold negative attitudes toward gender-fluid persons than toward persons who have received gender-confirming medical treatment , increasing the risk of social sanctions. Importantly, many transgender persons manage well, as documented in a recent survey in Belgium , suggesting that there are important resilience factors that need to be explored in future studies.
The need for health-promoting efforts for transgender students
The present findings imply that a range of health-promoting efforts for transgender students is needed. Strategies for societal changes in the direction of greater acceptance of gender diversity are vital. Here, we want to point to the specific situation for various transgender students in higher education. A qualitative study from the US identified four factors relating to the well-being and safety of transgender students: 1) coming out as transgender in the classroom, 2) interactions with fellow students and interactions with instructors, 3) course context (e.g., online or not; in online courses, one may have less control over exposure as a transperson due to university policies regarding legal names and email), and 4) campus experiences . On the basis of these arenas for possible interventions, the current findings and those of other studies (e.g., Swanbrow Becker et al.) , and our knowledge of higher institutions, we advise higher education institutions in Norway to establish a learning climate that is more inclusive for gender minorities at the policy and practical levels. For example, the institutions can emphasize the responsibility of instructors to create safe environments in which students can openly express gender diversity, that instructors should respect students’ chosen name, and that instructors should always behave as if gender diversity exists in student groups. In addition, the institutions can follow a policy of non-tolerance of harassment. A visible sign of institutional support to transgender students can be to introduce non-gendered bathroom facilities all over campus.
Another field relates to course content. At the very least, transgender students should be mentioned in diversity programs. We also advise that students and health and social welfare institutions—such as general practitioners, student health services, and student welfare organizations—be routinely advised that many gender minority students face important psychosocial challenges and that opportunities for receiving help exist. Counseling services should be aware of heightened risk of trauma history with harassment and victimization among transgender students. After implementing transgender-promoting interventions, varying from attitude changes among students and instructors to institutional policies, a well-functioning institution would also, as a routine, evaluate interventions.
Strengths and limitations
An important strength of this study is the population-based nationwide sample with an acceptable response rate and thus, the sample provides data with the potential for generalizability. Generalizations from the transgender sample should still be made with caution, however, because we have no information with regard to how many among these groups decided not to participate in the study or how well the gender questions differentiated between relevant groups. An additional strength is that responses from transgender participants were directly comparable to those from other students, since recruitment and information given about the survey was identical for all students.
One limitation is that we did not ask for measures of gender dysphoria or medical gender affirmation. Furthermore, we did not ask about sex assigned at birth, and may therefore not have identified all students who identify as other than the gender they were assigned at birth. Nonetheless, we were able to compare binary and non-binary respondents within the transgender group through the analyses. Although no significant differences were identified in these analyses, we call attention to samples and analyses even more attentive to subgroups among transgender youth that may be specifically vulnerable or resilient. A final limitation is the small sample size of the transgender students included, which is reflected by the wide confidence intervals. The small group sizes also mean that we had insufficient statistical power to detect potential differences between binary and non-binary transgender persons.