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Restroom, locker room restrictions foster abuse of transgender teens

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Don’t let fear drive policy

The study findings “make a compelling case for what we as gender specialist providers witness every day in our work: failure to support transgender and gender-expansive youth in being able to fully live in their affirmed gender puts them at physical as well as psychological risk,” wrote Diane Ehrensaft, PhD, and Stephen M. Rosenthal, MD, in an accompanying editorial.

What can reduce the risk of these youth experiencing abuse and assault, according to the editorialists, is putting policies in place that support them. Dr. Ehrensaft and Dr. Rosenthal cited the state of California’s 2013 decision to allow all students in public schools, from kindergarten through 12th grade “the right to use the bathroom and locker room consistent with their affirmed gender identity” as an example of something pediatricians should be advocating for in other states.

Restrictions on bathroom use to their assigned birth identity may cause transgender youth to be at increased risk for verbal and physical harassment and abuse, they said. It may also lead some to avoid restroom use and increase their risk for urinary tract infections, impacted stool, and school avoidance, the editorialists noted. They added that “[such] policies are often fear based, with nontransgender students thought to be the ones at risk for sexual assault by transgender intruders, by anyone whose genitalia does not match the one associated with the sign on the door, or by predators posing as transgender students.” The editorialists noted that these attitudes can come from school personnel or parents and that pediatricians should be aware of “the high prevalence of sexual assault” on transgender and gender nonbinary youth” (Pediatrics. 2019 May 6. doi: 10.1542/peds.2019-0554).

Dr. Ehrensaft and Dr. Rosenthal are affiliated with the Benioff Children’s Hospital at the University of California, San Francisco. They had no financial conflicts to disclose.



Transgender youth with restricted restroom and locker room use at school were significantly more likely to experience sexual assault at school than those without such restrictions, based on surveys from more than 3,000 teens in the United States who identified as transgender or nonbinary.

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“Little is known about risk factors for sexual assault in gender minority adolescents, but school policies and practices play an important role in other forms of victimization,” including restricting transgender students from using restrooms or locker rooms that match their gender identities, wrote Gabriel R. Murchison, MPH, of Harvard University, Boston, Mass., and colleagues in Pediatrics (2019 May 6. doi:

To examine the relationship between school restroom/locker room policies and sexual assault on transgender teens, the researchers reviewed data from the Lesbian, Gay, Bisexual, Transgender, and Queer or Questioning (LGBTQ) Teen Study, an anonymous web-based survey of U.S. adolescents aged 13 to 17 years who could read and write in English. Participants were assigned to one of four gender groups: trans male, trans female, nonbinary who were assigned male at birth (AMAB), or nonbinary who were assigned female at birth (AFAB) based on the survey questions asking their sex assigned at birth and current gender identity. The final study population of 3,673 individuals included 1,359 boys and 1,947 nonbinary youth AFAB and 158 transgender girls and 209 nonbinary youth AMAB. The results were published in Pediatrics.

Overall, sexual assault was significantly more likely for transgender teens with restroom and locker room restrictions at school compared to those without such restrictions, with risk ratios of 1.26 for transgender boys and 2.49 for transgender girls, and 1.42 for nonbinary AFAB youth. Restroom/locker room restrictions were not significantly associated with sexual abuse in nonbinary AMAB youth.

The 12-month prevalence of sexual assault was highest among nonbinary youth AFAB (27%), followed by 26.5% among transgender boys, 18.5% among transgender girls, and 17.6% among nonbinary youth AMAB.

Sexual assault was determined based on participants’ response to the question, “During the past 12 months, how many times did anyone force you to do sexual things that you did not want to do? (Count such things as kissing, touching, or being physically forced to have sexual intercourse.)” The researchers adjusted for multiple factors associated with adolescent sexual assault including alcohol use, family connectedness, and educational attainment of caregivers; as well as variables including exposure to antitransgender stigma and perception of teacher support at school.

The researchers also identified four mediating variables: sexual harassment, feeling safe in restrooms and locker rooms, feeling safe in other locations at school, and classmates’ knowledge of gender status.

“Significant indirect effects were present for all 4 mediating variables,” which included feel safe in restrooms and locker rooms, feel safe elsewhere in school, classmates know gender minority status, and sexual harassment. The fourth mediating variable mentioned fully explains “the association between restroom and locker room restrictions and sexual assault victimization,” the researchers wrote.

The findings were limited by several factors including the lack of racial diversity and the reliance on cross-sectional, nonprobability data, the researchers said.

However, the results are strengthened by the large sample size and suggest that avoiding restrictive policies at school can make a difference in reducing abuse of transgender teens, they wrote.

“From a prevention perspective, pediatricians are key advocates for transgender and nonbinary patients, and their role may include educating school officials and submitting letters confirming the patient’s need to express their gender identity,” that emphasize the importance of “safe, identity-congruent restrooms and locker rooms,” the researchers concluded.

The study was supported in part by the Office of Vice President for Research at the University of Connecticut, and the Human Rights Campaign Foundation provided in-kind support for the LGBTQ Teen Study. Mr. Murchison disclosed participation in survey development and data collection for the LGBTQ Teen Study as an employee of the Human Rights Campaign Foundation.

SOURCE: Murchison G et al. Pediatrics . 2019 May 6. doi: .

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