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The North Carolina bathroom bill could trigger a health crisis among transgender youth, research shows

Two protesters hold up signs against passage of North Carolina legislation limiting the bathroom options for transgender people during a rally in Charlotte on March 31. (AP Photos/Skip Foreman)
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In 2014, Blake Brockington was celebrated as the homecoming king of East Mecklenburg High School in Charlotte, N.C. When interviewed about this achievement, he noted that what was the “single-handedly hardest part of [his] trans journey” was that “really hateful things were said on the Internet. … I saw how narrow-minded the world really is. … I’ve had a hard time coming out to my family, I had a hard time coming out to my friends at school, but I did it. I’ve lost a lot of friends but I want other trans youth to understand that they’re not alone, and that this is a large community.”

Less than a year later, Brockington committed suicide.

Like many other transgender youth, Brockington had been rejected by his parents as a child and sent into the foster care system. Transgender youth whose parents reject their gender identity are 13 times more likely to attempt suicide than transgender kids who are supported by their parents. The climate for transgender kids can be as unwelcoming in society writ large as it sometimes is in their family.

Currently, six U.S. states — Illinois, Kansas, Mississippi, North Carolina, South Carolina and Tennessee — are considering, or have recently passed, “bathroom bills” that make it illegal for transgender Americans to use the bathroom of the gender they identify with. Republicans have promoted these bills in the hope of energizing their conservative voting base in the November elections, as we discuss in detail below.

What is the potential public health impact of these bathroom bills?

According to previous studies, the public health impact of passing these bills may be severe. We already know that bathrooms and locker rooms may not be safe for transgender and gender-nonconforming people, regardless of these bathroom bills. Results from GLSEN’s 2013 National School Climate Survey of LGBT middle and high school students found that over 63 percent of transgender youth avoided bathrooms at school because they felt unsafe, and 52 percent avoided locker rooms, compared with fewer than 40 percent of their cisgendered peers.

This is what Americans think about transgender students in locker rooms

And it’s easy to see why: One survey of 93 transgender/gender non-conforming adults in D.C. found that 68 percent had been verbally harassed and 9 percent had experienced physical assault or violence in a gender-segregated restroom, and 54 percent of the sample had experienced some sort of health problem (such as a urinary tract or kidney infection) as a result of trying to avoid a public gender-segregated restroom.

But even if these bills are ultimately ruled unconstitutional and overturned, they may still affect public health. Policies and people, like disparities and discrimination, do not exist in a vacuum but are part of encompassing institutions, structures and environments. Anti-LGBT legislation has serious and enduring consequences, not just in overt actions but also the messages sent to LGBT people. These bills send negative signals and stir up a frenzy of negative attention. That risks increasing suicide and self-harm among already fragile transgender adolescents.

In recent medical studies, Mark Hatzenbuehler and Katherine Keyes and Kristie Seelman find a clear relationship between stigmatizing laws and psychological harm. Anti-LGBT legislation legitimizes the message that you are not welcome here, your safety is not paramount, and you may not choose how to identify or express that identity. Adolescents receive these negative messages just as they are starting to form identities and gain independence. The emphatic social rejection triggers depression, low self-esteem, hopelessness and, often, suicidal thoughts.

The Williams Institute at UCLA estimates that approximately 1.7 percent of adolescents aged 13-19 are transgender or gender non-conforming. That translates into approximately 63,300 transgender adolescents in the six states considering bills. That number may surprise you. More than two-thirds of all transgender Americans say they hide their gender or gender transition to avoid discrimination. This is understandable given the vast majority of transgender people say they’ve been harassed at work; nearly half say they were not hired because of their gender identity; and one-quarter say they were fired because of who they were.

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Among adolescents, the consequences of being openly transgender/gender non-conforming may be even more severe. More than 78 percent of transgender adults said they were verbally harassed during K-12th grade, and 12 percent were sexually assaulted in school. For transgender/gender non-conforming people of color, those rates are substantially higher. Moreover, 9 percent of transgender adults who do not have a high school diploma say they left school because of harassment. Transgender students are two to four times as likely as all other LGB youth — a population already at higher risk — to be verbally harassed, physically harassed or physically assaulted because of gender and gender expression.

A greater proportion of Americans (18 percent) claim to have seen a ghost than say they have met a transgender person (16 percent). That may be holding back acceptance. When heterosexual Americans know and interact with lesbians and gay men, they are more likely to accept and embrace them. Recent research suggests that having a conversation with a transgender person appears to reduce rejection. But if transgender Americans cannot safely express their gender identities, that destigmatization cannot happen.

How do you soften attitudes about transgender people? This new study explains

Discrimination against transgender people has resulted in a public health epidemic. The largest study found that 41 percent of transgender Americans attempt suicide at some point in their lives — compared to 1.6 percent of the general population. Young transgender Americans were even more likely to attempt to kill themselves, with some estimates putting the suicide attempt rate among transgender youth at 57 percent.

Promoting laws that stigmatize LGBT people will compound the catastrophic health outcomes among an already vulnerable population. In 2009, the American Journal of Public Health presented data on the effects of state “Defense of Marriage Acts,” restricting marriage to different-sex couples. In states that legislated bans on marriage equality, mood disorders within the LGBT population increased by 37 percent and generalized anxiety by 248 percent. In 2010 the National Center for Transgender Equality found that after increased bullying, harassment, assault or rejection, reports of suicide attempts rose from 41 to 51 percent overall.

Calculating the impact for transgender youth

To some, which bathroom you get to use may seem trivial. For transgender Americans it speaks to your place in the world. Research published this month by Kristie Seelman found that 60 percent of transgender youth who had been denied access to school bathrooms had attempted suicide, compared to 43 percent among those who had not been denied.

Drawing on all the available evidence, we can make some pretty disturbing calculations. As of 2014 (the most recent year for which data are available), an estimated 3,725,590 adolescents between the ages of 13 and 19 lived in the six states with recently passed or on-the-books bills regarding transgender bathroom use (North Carolina, South Carolina, Tennessee, Mississippi, Kansas and Illinois).

Given that the Williams Institute estimates that 1.7 percent of youth aged 13-19 are transgender, approximately 63,335 transgender youth reside in these states. Studies have explored the effect of moderately inclusive versus non-inclusive school polices for LGBT students and on being denied access to preferred bathrooms at work or school.

In inclusive schools, or schools where youth may choose their bathrooms, between 19.1 percent and 43 percent of LGBT youth or adults attempt suicide. When schools are not inclusive, or when transgender adults are denied access to bathrooms, between 31 percent and 67 percent of LGBT youth or adults attempt suicide.

This one graph shows the biggest threat to LGBT rights in Malawi

Extrapolating from these numbers, we can predict that should these bills all pass, we can expect between 7,600 and 17,101 more youth suicide attempts in these six states. Among youth aged 15-24, between 1 in 100 and 1 in 200 who attempt suicide die as a result.

If these bills pass, we can expect between 38 and 86 additional suicides. That is, almost three classrooms of American children will die from the hostile climate.

And that’s just the most extreme outcome. In addition, of course, trans and gender-nonconforming people will suffer increased anxiety, depression, self-harm, and incomplete suicide attempts.

What can be done?

How can we counter the epidemic? One simple and effective solution is to accept people for who they are — and be kind. A study in the journal Pediatrics found that transgender youth who are accepted by their communities do not suffer such disproportionately high rates of mental health issues. If their gender is accepted, transgender kids averaged an anxiety score of 50.1 on a NIH scale — almost the same as the national norm of 50.

Respected role models help as well, reassuring young people that they are heard and can aspire to be leaders rather than victims. Ever since Harvey Milk, role modeling has had an enormously positive effect among the LGBT community. However, today there are only four transgender Americans in elected office nationwide. Five of the six states hosting anti-LGBT bills have no LGBT state legislators of any stripe.

Why the bathroom backlash?

Can state governments argue that they are merely responding to constituent pressure? Hardly. In 2015, the support for transgender inclusion in non-discrimination policies for LGBT people ranged from 66 percent in Oklahoma to 84 percent in Washington state, in the states where transphobic bills are being debated. So why would GOP leaders take aim at transgender youth?

This map shows the 31 countries where transgender and gender-variant candidates have run for office since 1977

No one has yet found evidence that transgender people assault cisgendered people in bathrooms, as these campaigns claim. We conclude that these laws were aimed at mobilizing certain voters. As a former North Carolina legislator told the journalist D.G. Martin, “Don’t be fooled. They knew exactly what they were doing. This new law will mobilize their base and add 2 percent to their voter turnout in the fall — maybe just enough to win the governor’s race for them.”

Shoshana Goldberg is a doctoral candidate in the Gillings School of Global Public Health at the University of North Carolina at Chapel Hill.

Andrew Reynolds is a professor of political science and the director of the LGBTQ Representation and Rights Research Initiative at the University of North Carolina at Chapel Hill.