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European Child & Adolescent Psychiatry (2024) 33:3503–3516
https://doi.org/10.1007/s00787-024-02396-9
ORIGINAL CONTRIBUTION
How social issocial media fortransgender andgender‑diverse youth?
Association ofonline social experiences withinternalizing mental
health problems
LenaHerrmann1· ClausBarkmann1· CarolaBindt1· SarahHohmann1· SaskiaFahrenkrug1· IngaBecker‑Hebly1
Received: 13 August 2023 / Accepted: 11 February 2024 / Published online: 17 March 2024
© The Author(s) 2024
Abstract
Adolescents spend a critical amount of their free time on the Internet and social media. Transgender and gender-diverse
(TGD) adolescents, who report elevated rates of mental health issues, especially internalizing problems, have both positive
and negative online social experiences (e.g., support and cyberbullying). This can have both beneficial and/or harmful effects
on their mental health. Given the lack of research, the present study examined TGD adolescents’ online (social) experiences
and the association of positive and negative online social experiences with internalizing problems. The sample consisted
of n = 165 TGD adolescents (11–18years) diagnosed with gender dysphoria who attended a Gender Identity Service for
children and adolescents (Hamburg GIS) in Germany between January 2020 and December 2022 during the COVID-19
pandemic. Positive (use of online support networks) and negative online social experiences (cyberbullying or other adverse
online interactions) were assessed using study-specific items and internalizing problems using the Youth Self-Report. Fre-
quencies of various online (social) experiences were analyzed, and a multiple linear regression analysis was performed to
test their association with internalizing problems. In total, 42% of participants reported positive online social experiences
(use of online support networks) and 51% of participants reported negative online social experiences (cyberbullying or other
adverse online interactions). There was no significant association between negative online social experiences and internal-
izing problems but between positive online social experiences and more internalizing problems (adjusted R2 = .01). TGD
adolescents may seek online support, especially when struggling with mental health problems. Therefore, it is crucial to
support youth navigating these online spaces more safely and positively and to empower them to buffer against potentially
harmful experiences. Furthermore, strengthening offline relations with peers and family members is pivotal, given their
importance for TGD adolescents’ mental health.
Keywords Transgender· Gender-diverse· Social media· Internet· Mental health
Introduction
The Internet and social media have fundamentally changed
social interactions and experiences, especially among ado-
lescents. Transgender and gender-diverse (TGD) adolescents
have both positive (e.g., seeking and/or receiving support)
and negative experiences (e.g., cyberbullying) online with
potentially beneficial versus harmful effects on their mental
health [1]. While the impact of offline social experiences
(e.g., peer problems or family support) on the mental health
of TGD adolescents is well-documented [2, 3], there is little
knowledge about how various online social experiences are
associated with psychological problems in TGD adolescents.
Several studies document that TGD adolescents (i.e.,
who do not or not entirely identifywith their birth-assigned
sex) report significantly more behavioral and emotional
problems, especially internalizing ones, and elevated rates
of depression, suicidality, self-harm, and eating disorders
in comparison to their cisgender peers (i.e., who identify
with their birth-assigned sex) [3–6]. According to the
minority stress model, these mental health disparities can
be caused by experiencing stigma, prejudice, and discrimi-
nation because of one’s minority status [7, 8]. The effect of
* Lena Herrmann
le.herrmann@uke.de
1 Department ofChild andAdolescent Psychiatry,
Psychotherapy andPsychosomatics, University Medical
Centre Hamburg-Eppendorf, Hamburg, Germany
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3504 European Child & Adolescent Psychiatry (2024) 33:3503–3516
these so-called minority stressors can be buffered against
by coping mechanisms and social support, for example, by
the lesbian, gay, bisexual, transgender, and queer (LGBTQ)
community [9]. Consistent with the minority stress model,
studies indicate that difficulties in social interactions with
peers or so-called poor peer relations have a significant and
negative impact on the psychological functioning of young
TGD individuals [2, 3, 10, 11]. Additionally, family support
and general family functioning (or the lack thereof) appear
to contribute to better (or worse) psychological outcomes
in TGD children and adolescents [3, 10, 12]. In summary,
research has demonstrated the importance of offline social
experiences and interactions in affecting the mental health of
TGD youth. Similarly, positive versus negative online social
experiences could have either positive or negative effects on
the mental health of TGD youth.
The Internet and social media have substantially changed
social relationships, interactions, and experiences. Social
media is a communication format where one can produce
and share content, create profiles, interact with others, and
build social networks [13, 14]. Nearly all adolescents in the
USA use at least one social media platform (95% use You-
Tube) and as many as 97% are online daily [15]. In Germany,
where the present study took place, 88% of adolescents are
online daily and spend, on average, 4h on the Internet [16].
These numbers from the general population are similar to
those of a recent German clinical study on TGD adolescents
who were, on average, online for 4.2h daily [17]. Of impor-
tance for the present study, which was conducted during the
COVID-19 pandemic, is that adolescents from the German
general population spent, on average, more time online at the
beginning of the COVID-19 pandemic than before and that
these numbers decreased in 2021 but were still elevated in
comparison to the pre-pandemic levels [16, 18, 19].
In meta-analyses, adolescent social media use is associ-
ated with both worse mental health outcomes and higher
levels of well-being, highlighting the complexity of the asso-
ciation and the need to address other risk and protective
factors and to identify for whom social media use has which
effect [20]. Among LGBTQ youth specifically, the associa-
tion between social media use and mental health outcomes
may be different and even more complex than among non-
LGBTQ youth [21], given the multiple benefits (e.g., easy
and anonymous access to identity-related information) and
risks (e.g., being exposed to homophobic and transphobic
content) of the Internet and social media for LGBTQ youth
[22]. While most studies are drawn from broaderLGBTQ
samples (which are, therefore, also described in the follow-
ing summary), there is a need to recognize and examine the
unique experiences of TGD youth that may differ from other
groups under the LGBTQ umbrella. For instance, in a recent
study examining a clinical sample similar to the present one,
60% of TGD adolescents experimented with their gender
identity online, about 30% came out online first, and 90%
had socially transitioned online. About half of TGD adoles-
cents each had sought online support for LGBTQ or TGD
people and reported negative online social experiences [17].
Social support through connecting online to other like-
minded peers and the LGBTQ community can help minor-
ity youth feel less alone, isolated, or depressed [22–24].
LGBTQ youth may also feel safer and more supported
participating in online than in offline LGBTQ communities
[25]. In a recent qualitative study, socially isolated LGBTQ
youth living in rural areas of the USA frequently sought
support in online communities and groups when they were
not feeling emotionally well or had problems. By connect-
ing to like-minded peers in online groups, they described
feeling a sense of belonging [26]. For TGD youth, it may
be especially difficult to find like-minded peers and other
TGD youth offline (because of their minority status). Thus,
meeting other TGD individuals online can be an important
source of support and make them feel less lonely [27]. In
an Australian community-based study called “Trans Path-
ways,” three-quarters of TGD youth used social media to
help themselves feel better, for example, by meeting other
TGD people online who told them how life could be better
[28]. The Internet and social media can also be a source of
support when dealing with specific mental health problems.
For instance, in an Australian quantitative study conducted
during pandemic-related social isolation, 82% of TGD youth
had used social media to seek support for suicidal thoughts
or self-harm [29].
However, the Internet and social media can also bear risks
and negative experiences. One potentially harmful experi-
ence is cyberbullying. Cyberbullying can be defined as com-
municating aggression or causing harm to others with the
help of digital media, for example, by spreading rumors or
threatening messages online [30]. Compared to their het-
erosexual and cisgender counterparts, LGBTQ youth are
significantly more likely to experience cyberbullying, with
25 to 40% of LGBTQ youth and up to 50% of TGD youth
reporting cyberbullying [17, 27, 31, 32].
Cyberbullying and other negative online social
experiences contribute to the psychological distress of
LGBTQ youth and young adults and are associated with
higher levels of suicidality and depression [30, 31, 33,
34]. Compared to offline bullying, perpetrators may feel
more confident online because of the anonymity, making
cyberbullying and transphobic behavior more likely and
“easy” to carry out [24, 35]. As online information is easy to
access and share and because of its’ persistence, adolescents
seem to perceive cyberbullying as worse than offline bullying
[33, 36]. However, when comparing the effect of both forms
on LGBTQ youths’ mental health problems, cyberbullying
seems to have a similarly large effect as offline bullying.
Furthermore, experiencing both forms of victimization at
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3505European Child & Adolescent Psychiatry (2024) 33:3503–3516
the same time might increase the risk of depression and
suicidality even more [30, 31, 33].
Current study
Although there are several, mainly US American, studies on
the associations of positive online social experiences (use of
online support networks) and negative online social experi-
ences (cyberbullying or other adverse online interactions)
with especially internalizing problems in LGBTQ youth, the
experiences of TGD youth are not assessed or not differen-
tiated from those of sexual minority youth in most studies.
Thus, quantitative studies focusing on these associations in
TGD youth specifically and studies from Europe are cur-
rently lacking. Therefore, the present study focused on sev-
eral specific (social) experiences TGD adolescents may have
on the Internet and social media and how these are associ-
ated with internalizing problems. We aimed to answer the
following research questions:
1) Which experiences (experimenting with and expressing
gender identity online, positive vs. negative online social
experiences) do TGD adolescents have on the Internet
and social media?
2) How are positive (use of online support networks) vs.
negative online social experiences (cyberbullying or
other adverse online interactions) associated with inter-
nalizing problems in TGD adolescents? Is there an inter-
action effect?
We hypothesized that positive online social experiences
(use of online support networks) would be associated with
fewer and negative online social experiences (cyberbullying
or other adverse online interactions) with more internalizing
problems in TGD adolescents.
Methods
Study design
Data came from a cross-sectional study assessing a
clinical cohort of TGD adolescents with psychometric
self-report questionnaires. The data collection took place
at the Hamburg Gender Identity Service for children and
adolescents (Hamburg GIS) between January 2020 and
December 2022. Thus, the study period fell within the
time of the COVID-19 pandemic. The Hamburg GIS at the
University Medical Center Hamburg-Eppendorf in Germany
offers specialized diagnostics, counseling, and gender-
affirming treatment to TGD youth and to youth who have
questions about their gender or sexual identity. All families
attending the Hamburg GIS are invited to participate in the
study at their first appointment, thus before undergoing any
form of counseling or treatment.
As part of a research project on “Gender- and Neurodi-
versity in Childhood and Adolescence” ongoing since 2020,
the present study evaluated various updated questionnaires
on the psychological health and the life experiences of
TGD youth. The local ethics committee approved the study
(12/2019-PTK-HH). Participation is voluntary, i.e., coun-
seling or treatment is offered regardless of participation or
nonparticipation in the study. All participants completed an
informed consent form for their voluntary participation.
Participants
The wider study population included children (aged
5–10years) and adolescents (aged 11years and above)
who attended the clinic between January 2020 and Decem-
ber 2022. In this period, 415 families had presented to the
Hamburg GIS (79% assigned female at birth [AFAB], 21%
assigned male at birth [AMAB]; Fig.1). Incomplete data-
sets, children, youth without a diagnosis of gender dyspho-
ria, and other cases (for various reasons) were excluded from
the analyses (see Fig.1). The final sample comprised 165
TGD adolescents aged 11 to 18years (87% AFAB, 13%
AMAB) with a clinical diagnosis of gender dysphoria.
Variables andinstruments
Sociodemographic aswell aspsychosocial characteristics
andtime spent online
The following sociodemographic characteristics were evalu-
ated: birth-assigned sex, age at assessment (upon clinical
entry), current gender identity, citizenship, parental socio-
economic status, and parental marital status and living situ-
ation. For detailed descriptions of the sociodemographic
variables, see Levitan etal. [3] and Herrmann etal. [17].
In addition, we evaluated the following psychosocial
characteristics to control for two predominately offline social
experiences, which are well-documented risk and protec-
tive factors for internalizing problems in TGD youth (see
Introduction): general family functioning and poor peer rela-
tions. The McMaster Family Assessment Device (FAD) was
used to assess general family functioning [37]. The FAD
has been used in previous studies on TGD youth [3, 10,
38]. For the present study, we used only the FAD subscale
on general family functioning, which consists of 12 items,
such as feeling accepted and understood (e.g., “Individuals
are accepted for what they are”), supporting each other (“In
time of crisis we can turn to each other for support”) and
expressing feelings to each other (“We can express feelings
to each other”). The adolescents rate the items on a 4-point
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3506 European Child & Adolescent Psychiatry (2024) 33:3503–3516
scale (from 1 = “strongly agree” to 4 = “strongly disagree”).
An average general family functioning score is created by
adding the items and dividing the sum by the total number
of items, resulting in a range from 1 to 4, with higher scores
indicating lower levels of family functioning. For categorical
analyses (problematic or unhealthy family functioning), the
cutoff is 2.17 [39]. The internal consistency of the scale was
good in the present study (Cronbach’s
𝛼
= .89).
Poor peer relations were assessed with the German 1991
version of the Youth Self-Report (YSR) [40, 41]. The YSR
includes 119 items that adolescents rate on a 3-point scale
ranging from 0 (“not true”) to 2 (“very true or often true”)
concerning the past six months. An index for poor peer rela-
tions was created based on the following items: Item 25 (“I
don’t get along with other kids”), Item 38 (“I get teased a
lot”), and Item 48 (“I am not liked by other kids”). The poor
peer relation index has been used in several clinical studies
to assess problematic social interactions of TGD children
and adolescents with peers [2, 3, 10]. The index can range
from 0 to 6. Higher scores reflect poorer peer relations. In
the present study, the internal consistency of the index was
acceptable to questionable (Cronbach’s
𝛼
= .66).
To control for the quantity of Internet use, time spent
online was measured with an item of the Trans Youth Social
Media Questionnaire (TYSMQ). The TYSMQ is a self-
constructed self-report questionnaire on TGD adolescents’
online activities and experiences. For its construction, we
used and adapted items from two representative German
studies on adolescents’ free time and media activities [19,
32]. We also added items to reflect the unique experiences
of TGD adolescents. The questionnaire has already been
used in another clinical study on TGD adolescents [17]. For
time spent online, adolescents rated an item (“How many
hours do you spend online/on the Internet daily?”) on an
8-point scale ranging from “none” to “7 or more hours.”
Later, answers were dichotomized (0 = up to 5h daily and
1 = more than 5h daily) for analysis purposes.
Online (social) experiences
Various online (social) experiences were measured with the
TYSMQ and with single items. The following online (social)
experiences were evaluated in the present study: experiment-
ing with gender identity online (“Did you experiment with
your gender identity on the Internet/social media before
you did in everyday life?”), coming out online first (“Did
you come out on the Internet/social media before you told
your friends/parents?”), gender role online (“In which role
or gender do you live on the Internet/social media?”), feel-
ing understood and accepted in different life domains (e.g.,
“Do you feel understood and accepted on the Internet/social
media for who you are?”), positive online social experiences
(use of online support networks), and negative online social
experiences (cyberbullying or other adverse online interac-
tions). For more details on these items and the TYSMQ,
please refer to Herrmann etal. [17].
For positive online social experiences (use of online
support networks), adolescents were asked: “Do you visit
online (Facebook) groups/forums or platforms that focus
on networking, support, or treatment of transgender or
LGBTQ people?” The item could be rated on a 4-point
scale ranging from 0 (“never”) to 3 (“yes, often”). For the
analysis, answers were divided into two categories: 0 = no
(never) and 1 = yes (rarely too often).
Fig. 1 Participants and sex
ratios at the Hamburg GIS for
children and adolescents
BASELINE
DATA COLLECTION
n = 165 data sets
eligible for analysis
Clinical entry (Jan. 2020 – Dec. 2022):
N = 415 families (children & adolescents)
n = 226 complete data files
incl. informed consent
(children & adolescents)
Excluded cases:
- n = 22 children younger than 11 (no
self-report)
- n = 22 with prior consultations (“second
look”) and/or prior hormonal treatment
(GnRHa and GAH)
- n = 3 no gender dysphoria diagnosis
- n = 3 with severe psychiatric problems
- n = 11 diagnosis could not be assessed
for various reason (e.g. only one
a
pp
ointment
)
Drop-out:
- n = 154 no participation
- n = 35 missing data (missing
informed consent or incomplete
questionnaire sets)
Sex ratio upon clinical entry:
79% birth-assigned females
21% birth-assigned males
Sex ratio (n = 226 children &
adolescents):
81% birth-assigned females
18% birth-assigned males
Sex ratio (n = 165
adolescents, analysis
sample):
87% birth-assigned females
13% birth-assigned males
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3507European Child & Adolescent Psychiatry (2024) 33:3503–3516
For negative online social experiences (cyberbully-
ing or other adverse online interactions), adolescents
were asked whether they had ever had negative experi-
ences online or experienced cyberbullying online or on
social media. The item was rated on a 4-point scale from
0 (“never”) to 3 (“yes, often”). Similar to the positive
online social experiences, two categories for negative
online social experiences (0 = no and 1 = yes) were built.
In addition, adolescents were able to indicate whether
the negative online social experiences had been related
to their gender identity or sexual orientation and whether
they had been victim, perpetrator, or both victim and per-
petrator of this behavior.
Internalizing problems
Internalizing problems were assessed with the YSR [40,
41]. Using the German population-based, age-specific, and
sex-specific norm scores by Döpfner etal. [40], T scores
for the three YSR scales (total problem score, internaliz-
ing, and externalizing problems) were computed to deter-
mine whether the scores of the present study were within
the normal range of the German population. Furthermore,
clinical range scores (> 90th percentile; T score > 63) were
calculated. In the present study, the internal consistency of
the internalizing scale was excellent (Cronbach’s
𝛼
= .92).
For exploratory purposes and to evaluate psychologi-
cal functioning more comprehensively, YSR scores for
externalizing and total problems (sum of all problems)
were additionally calculated, and an index for suicidality
was created. As suggested by the YSR manual [40] and to
avoid artificial conflation, we excluded the following items
for the calculation of the total problem score: asthma (Item
2), allergies (Item 4), socially desirable items (16 items),
and cross-gender identification (Item 5 and Item 110). As
described in previous studies [2, 42], Items 84 and 85 were
set to zero if the free-text answers were gender-related.
The internal consistencies of the externalizing scale (Cron-
bach’s
𝛼
= .86) and the total problem scale (Cronbach’s
𝛼
= .95) were good to excellent. In addition, two items from
the YSR were used to create an index for suicidality, as
in other clinical studies on TGD adolescents [4, 6, 43]:
Item 18 on self-harming behavior and suicide attempt (“I
deliberately try to hurt or kill myself”) and Item 91 on
suicidal ideation (“I think about killing myself”). The sum
score of the index ranges from 0 to 4, with higher scores
indicating higher levels of suicidality. In the present study,
the internal consistency of the index was acceptable to
questionable (Cronbach’s
𝛼
= .67).
Statistical analyses
T-tests and chi-square tests (or Fisher’s exact tests) were
conducted to explore possible sex differences (AFAB vs.
AMAB) in the sociodemographic and psychosocial char-
acteristics and the time spent online and various online
(social) experiences. Paired t-tests were performed to com-
pare the degree of feeling understood and accepted online
with different offline life domains. Standardized effect
sizes (d and odds ratios, OR) were calculated to quantify
the magnitude of the effect.
For a descriptive evaluation of internalizing problems,
the raw scores, T scores, and clinical ranges (> 90th per-
centile; T scores > 63) for the YSR internalizing scale were
used. In addition, we calculated 95% confidence intervals
to compare the present sample with age- and sex-equiva-
lent population-based German norms [40]. A significant
deviation from the reference group can be assumed if the
confidence intervals are not within the range of the T dis-
tribution (M = 50, SD = 10). Vice versa, whenever confi-
dence intervals overlap, there is no significant difference
[44]. For exploratory purposes, the externalizing scale,
the total problem score, and the suicidality index were
evaluated similarly.
For testing our hypotheses, a multiple linear regression
analysis was performed. The raw scores of the YSR inter-
nalizing scale were used as an outcome variable. Predic-
tors were entered in a block-wise manner. In the first step,
the birth-assigned sex, age, general family functioning,
and poor peer relations were entered as control variables.
In the second step, positive online social experiences (use
of online support networks) were added. In the third step,
negative online social experiences (cyberbullying or other
adverse online interactions) were introduced to the regres-
sion analysis. In the fourth step, the interaction between
positive and negative online social experiences was added.
An a priori power analysis (using G*Power) demonstrated
that in a multiple linear regression analysis with 165 cases
and seven predictors, a medium effect (f = 0.15) can be
tested with a power of 95%. For exploratory purposes,
similar analyses were conducted with externalizing prob-
lems, the total problem score, and the suicidality index
as outcomes. As in other similar studies [3, 10], three
items on poor peer relations (Items 25, 38, and 48) were
excluded from the total problem score when exploring its
association with online social experiences because the
poor peer relation index was already a predictor in the
model.
Single missing values were imputed with the expecta-
tion–maximization algorithm [45] and the mean values.
SPSS 27 was used for all statistical analyses.
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3508 European Child & Adolescent Psychiatry (2024) 33:3503–3516
Results
Sociodemographic aswell aspsychosocial
characteristics andtime spent online
See Table1 for all results on sociodemographic and psy-
chosocial characteristics and time spent online. TGD ado-
lescents were, on average, 15 and a half years old when
presenting to the Hamburg GIS. The vast majority of TGD
adolescents (82%) identified as binary (e.g., trans man/boy
or male) and 18% as nonbinary or were gender questioning
at their initial presentation to the Hamburg GIS. Most ado-
lescents were German citizens and had a medium (53%)
or high (39%) (parental) socioeconomic background. The
(parental) socioeconomic status of AMAB adolescents was
significantly higher than that of AFAB adolescents. There
were no other sex differences for any characteristics pre-
sented in Table1.
In about half of the cases, both parents lived together
or were married. The reported family interactions (gen-
eral family functioning) were, on average, unproblematic
(below the cutoff). In total, 41% of adolescents described
problematic family functioning (above the cutoff), and
72% had encountered at least one peer-related problem in
the past six months. Most adolescents reported spending
up to 5h on the Internet each day, whereas one-third
reported spending more than 5h online daily.
Online (social) experiences
See Table2 for all results on online (social) experiences.
Two-thirds of TGD adolescents had experimented with their
gender identity online first (then offline), and one-third had
come out online first before telling their friends or parents.
Additionally, 89% presented themselves not as their birth-
assigned sex online but in another gender (role). On the
Internet and social media, TGD adolescents felt, on aver-
age, rather understood and accepted for who they are. TGD
adolescents felt significantly more understood and accepted
online than by their parents, classmates/peers, and teachers
but significantly less understood and accepted online than
by their friends. AMAB adolescents reported to feel sig-
nificantly less understood and accepted by their peers than
AFAB adolescents (t(163) = 2.09, p = 0.038, d = 0.48). There
were no other sex differences for any of these variables in
our study, meaning that AFAB and AMAB adolescents
reported similar online (social) experiencesin the present
study.
Regarding positive online social experiences, 42% of
TGD adolescents had used online support networks for TGD
or LGBTQ individuals (16% rarely, 14% occasionally, and
Table 1 Sociodemographic and psychosocial characteristics and time spent online among adolescents assigned female vs. assigned male at birth
* p < .05, AFAB/AMAB assigned female/male at birth, FAD McMaster Family Assessment Device, FT Fisher’s exact test, YSR Youth Self-Report
AFAB AMAB Total Group comparisons
(n = 143) (n = 22) (n = 165)
n%n%n%Χ2/FT df p OR
Current gender identity
Binary 116 81.1 20 90.9 136 82.4
Nonbinary or gender questioning 27 18.9 2 9.1 29 17.6 – – .372 0.43
Citizenship
German 140 97.9 21 95.5 161 97.6
Other 3 2.1 1 4.5 4 2.4 – – .439 2.22
Parents’ marital status and living situation
Both parents living together/married 67 46.9 13 59.1 80 48.5
Other 76 53.1 9 40.9 85 51.5 1.14 1 .285 0.61
Time spent online
Up to 5h daily 98 68.5 14 63.6 112 67.9
More than 5h daily 45 31.5 8 36.4 53 32.1 0.21 1 .647 1.24
M SD M SD M SD t df p d
Age at assessment (in years) 15.43 1.34 16.02 1.46 15.51 1.37 −1.90 163 .059 − 0.44
Parental socioeconomic status (Winkler Index) 6.75 1.54 7.45 1.44 6.84 1.54 −2.02 163 .045 − 0.46*
General family functioning (FAD) 2.01 0.60 2.01 0.46 2.01 0.58 −0.02 163 .988 − 0.00
Poor peer relations (YSR) 1.55 1.43 2.00 1.72 1.61 1.47 −1.33 163 .185 − 0.31
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3509European Child & Adolescent Psychiatry (2024) 33:3503–3516
12% often). AMAB adolescents tended to use online sup-
port networks more often than AFAB adolescents, but the
difference was statistically nonsignificant. Negative online
social experiences were similarly common: Half of TGD
adolescents reported cyberbullying or other adverse online
social experiences (31% rarely, 13% rarely, and 7% often).
Negative online social experiences were in 67% of the cases
related to the TGD adolescents’ gender identity (35%), their
sexual orientation (2%), or both (30%). Among TGD ado-
lescents who reported negative online social experiences,
the majority (55%) had been the target of cyberbullying;
5%, perpetrators; and 19%, both. Another 21% had neither
been victims nor perpetrators of cyberbullying and reported
other adverse online interactions instead (e.g., “It happened
in groups that I wasn't in myself. Friends told me about it”).
Internalizing problems
Table3 shows the results for internalizing problems. Com-
pared to adolescents from the German norm population,
TGD adolescents had, on average, significantly higher T
scores (95% CI not including M = 50), which were elevated
by almost 2 SD. In total, 62% of TGD adolescents scored
within the clinical range of internalizing problems (> 90th
percentile; T scores > 63). There were no significant sex dif-
ferences (overlapping 95% CIs).
Association ofpositive vs. negative online social
experiences withinternalizing problems
For the results on the association of positive vs. negative
online social experiences with internalizing problems, see
Table4. In the final model of the multiple linear regression
analysis, female birth-assigned sex, lower levels of gen-
eral family functioning, poorer peer relations, and positive
online social experiences (use of online support networks)
were significantly associated with reporting more internal-
izing problems. Neither negative online social experiences
(cyberbullying or other adverse online interactions) nor
the interaction between positive and negative online social
experiences were significant predictors for internalizing
problems. The final model explained 44% of the variance in
Table 2 Online (social) experiences of adolescents assigned female vs. assigned male at birth
* p < .05, ***p < .001, AFAB/AMAB assigned female/male at birth, FT Fisher’s exact test
AFAB AMAB Total Group comparisons
(n = 143) (n = 22) (n = 165)
n%n%n%Χ2/FT df p OR
Experimenting with gender identity online
No, experimented in everyday life first 49 34.3 7 31.8 56 33.9
Yes, experimented online first 94 65.7 15 68.2 109 66.1 0.05 1 .821 1.12
Coming out online first
No, came out with friends/parents first 96 67.1 13 59.1 109 66.1
Yes, came out online first 47 32.9 9 40.9 56 33.9 0.55 1 .458 1.41
Gender role online
Gender role of their birth-assigned sex 16 11.2 3 13.6 19 11.5
Gender role of another gender 127 88.8 19 86.4 146 88.5 – – .722 0.80
Positive online social experiences (use of online support networks)
No (never) 86 60.1 9 40.9 95 57.6
Yes (rarely, occasionally, or often) 57 39.9 13 59.1 70 42.4 2.89 1 .089 2.18
Negative online social experiences (cyberbullying or other adverse online interactions)
No (never) 70 49.0 11 50.0 81 49.1
Yes (rarely, occasionally, or often) 73 51.0 11 50.0 84 50.9 0.01 1 .927 0.96
M SD M SD M SD t df p d
Feeling understood and accepted in different life domains
Internet/social media 3.34 0.75 3.05 1.13 3.30 0.81 Comparison to other domains
Parents 2.64 1.17 2.77 1.02 2.66 1.15 6.25 164 < .001 0.49***
Friends 3.50 0.75 3.45 0.74 3.49 0.75 −2.52 164 .013 −0.20*
Classmates/peers 2.34 1.16 1.77 1.31 2.26 1.19 10.23 164 < .001 0.80***
Teachers 2.66 1.11 2.27 1.42 2.61 1.16 7.03 164 < .001 0.55***
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
3510 European Child & Adolescent Psychiatry (2024) 33:3503–3516
internalizing problems, while all control variables together
explained 42%, positive online social experiences (use of
online support networks) 1%, negative online social experi-
ences (cyberbullying or other adverse online interactions)
0.2%, and the interaction between positive and negative
online social experiences 0.3%.
Exploratory data analyses
In addition to the hypothesis testing, exploratory analyses
were performed (see Table5, 6, 7, 8). In comparison to inter-
nalizing, externalizing problems were less common but still
elevated in TGD adolescents (T scores 0.6 SD above M = 50;
Table5). In total, 12% of TGD adolescents scored within
the clinical range of externalizing problems. On the total
problem score, TGD adolescents scored 1.5 SD higher than
the norm population, and 53% scored within the clinical
range. Concerning suicidality, more than half of TGD ado-
lescents reported that they sometimes (30%) or often (24%)
tried to hurt or kill themselves (YSR Item 18). In addition,
43% thought sometimes (33%) or often (10%) about killing
themselves (YSR Item 91). There were no significant sex
differences for any of the scores.
In summary, three exploratory multiple linear regres-
sion analyses were conducted. First, lower levels of family
functioning and negative online social experiences (cyberbul-
lying or other adverse online interactions) were significantly
associated with more externalizing problems, whereas posi-
tive online social experiences (use of online support networks)
and the interaction (positive x negative online social experi-
ences) were not (Table6). The final model explained 22%
of the variance, of which negative online social experiences
(cyberbullying or other adverse online interactions) explained
8%.
Second, significant predictors for the total problem score
were female birth-assigned sex, lower levels of family func-
tioning, poorer peer relations, and negative online social
experiences (cyberbullying or other adverse online interac-
tions) (Table7). Neither positive online social experiences
(use of online support networks) nor the interaction (positive
x negative online social experiences) were significant predic-
tors. In total, 44% of the variance was explained. Reporting
negative online social experiences (cyberbullying or other
adverse online interactions) explained 4% of the variance in
the total problem score.
Third, female birth-assigned sex, lower levels of family
functioning, and poorer peer relations were significantly asso-
ciated with a higher suicidality index (Table8). There were
no significant associations between positive or negative online
social experiences nor the interaction (positive x negative
Table 3 Internalizing problems
according to the birth-assigned
sex and compared to German
norm scores
Note. Age and birth-assigned sex-equivalent German norm YSR T scores with M = 50 and SD = 10 were
derived from Döpfner etal. (1998)
TGD transgender and gender diverse, YSR Youth Self-Report
Raw scores T scores (TGD adolescents
with reference to the norm)
Clinical range
(T scores > 63)
M SD 95% CI M SD 95% CI n%
YSR internalizing scale
Assigned female at birth 24.31 12.00 [22.32; 26.29] 68.08 12.12 [66.08; 70.09] 86 60.1
Assigned male at birth 22.14 10.08 [17.67; 26.60] 70.18 10.80 [65.39; 74.97] 17 77.3
Total 24.02 11.76 [22.21; 25.83] 68.36 11.94 [66.53; 70.20] 103 62.4
Table 4 Association of positive
(use of online support networks)
vs. negative online social
experiences (cyberbullying or
other adverse online interaction)
with internalizing problems
(YSR raw scores)
Results of the final model of the multiple linear regression analysis: F (7, 157) = 19.10, adjusted R2 = .44,
p < .001
* p < .05, ***p < .001, FAD McMasters’ Family Assessment Device, YSR Youth Self-Report
b SE b ß p
Intercept 3.44 7.99 .668
Birth-assigned sex (0 = female, 1 = male) − 4.12* 2.08 − .12 .049
Age in years − 0.17 0.53 − .02 0.754
General family functioning (FAD) 7.80*** 1.28 .38 < .001
Poor peer relations (YSR) 3.38*** 0.51 .42 < .001
Positive online social experiences (0 = no, 1 = yes) 4.42* 2.10 .19 .037
Negative online social experiences (0 = no, 1 = yes) 3.38 1.87 .14 .073
Interaction (positive x negative social online experiences) − 3.95 2.84 − .15 .166
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
3511European Child & Adolescent Psychiatry (2024) 33:3503–3516
online social experiences) and the suicidality index. The final
model explained 30% of the variance in the suicidality index.
Discussion
The present study, which took place during the COVID-19
pandemic, aimed to examine the online (social) experiences
of TGD adolescents and the associations of positive (use of
online support networks) and negative online social experi-
ences (cyberbullying or other adverse online interactions)
with internalizing problems.
Many TGD adolescents had used the Internet and social
media to experiment with and express their gender identity.
Most TGD adolescents had experimented with their gen-
der identity online first, 34% had come out online first, and
nearly 90% presented themselves in another gender (role)
online. In addition, they felt significantly more understood
and accepted online than in most offline domains. These
findings are in line with other studies [17, 31] and highlight
the advantages of the Internet and social media for the iden-
tity development of TGD adolescents.
About 40% of TGD adolescents had visited online groups
or platforms focusing on networking, support, or treatment
of TGD or LGBTQ people, underscoring the importance
of online support networks for TGD youth, probably espe-
cially during special circumstances such as the COVID-19
pandemic. Another study from the Hamburg GIS suggests
that TGD adolescents primarily use easily accessible social
media and smartphone apps such as WhatsApp, Instagram,
and Reddit as online support networks [17]. We hypothe-
sized that using online support networks (as opposed to not
using them) would be associated with fewer internalizing
problems. However, using online support networks was, in
Table 5 Exploratory analyses of externalizing problems, total problem score, and suicidality index according to the birth-assigned sex and com-
pared to German norm scores
Raw scores T scores (TGD adolescents with reference to the
norm)
Clinical range
(T scores > 63)
M SD 95% CI M SD 95% CI n%
YSR externalizing scale
Assigned female at birth 13.07 7.61 [11.81; 14.33] 56.19 8.92 [54.71; 57.66] 19 13.3
Assigned male at birth 11.64 7.01 [8.53; 14.74] 53.50 7.64 [50.11; 56.89] 1 4.5
Total 12.88 7.53 [11.72; 14.04] 55.83 8.79 [54.48; 57.18] 20 12.1
YSR total problem score
Assigned female at birth 59.79 26.21 [55.46; 64.12] 64.99 10.21 [63.31; 66.68] 77 53.8
Assigned male at birth 53.27 20.19 [44.32; 62.22] 63.82 7.77 [60.37; 67.26] 11 50.0
Total 58.92 25.53 [55.00; 62.85] 64.84 9.91 [63.31; 66.36] 88 53.3
YSR suicidality index
Assigned female at birth 1.38 1.30 [1.17; 1.60] – – – – –
Assigned male at birth 0.82 1.14 [0.31; 1.32] – – – – –
Total 1.31 1.29 [1.11; 1.51] – – – – –
Table 6 Exploratory analysis
for the association of positive
(use of online support networks)
vs. negative online social
experiences (cyberbullying or
other adverse online interaction)
with externalizing problems
(YSR raw scores)
Results of the final model of the multiple linear regression analysis: F(7, 157) = 7.52, adjusted R2 = .22,
p < .001
*** p < .001, FAD McMasters’ Family Assessment Device, YSR Youth Self-Report
b SE b ß p
Intercept 3.18 6.03 .598
Birth-assigned sex (0 = female, 1 = male) − 1.40 1.57 − .06 .371
Age in years − 0.09 0.40 − .02 .817
General family functioning (FAD) 4.45*** 0.97 .34 < .001
Poor peer relations (YSR) − 0.29 0.39 − .06 .455
Positive online social experiences (0 = no, 1 = yes) 1.13 1.58 .07 .477
Negative online social experiences (0 = no, 1 = yes) 4.79*** 1.41 .32 < .001
Interaction (positive x negative online social experiences) − 0.31 2.14 − .02 .886
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
3512 European Child & Adolescent Psychiatry (2024) 33:3503–3516
the present study, associated with reporting more internal-
izing problems. This result contrasts also previous studies
indicating that online support, for example, by connecting
to peers or the LGBTQ community, helps TGD youth to
feel better, less alone, or lessdepressed [22, 23, 26, 28].
As a result, the association might be more ambiguous than
previously assumed because TGD youth might seek online
support, especially when they are already struggling with
emotional problems. However, since we only asked TGD
adolescents if (and how often) they had visited/used online
support networks, we do not know how they used these and
whether their experiences were always positive or support-
ive. Thus, more studies are needed that consider the per-
ceived quality of such online social experiences [46].
Half of TGD adolescents reported negative online social
experiences including cyberbullying and other adverse
online interactions. These numbers resemble other previ-
ous studies [17, 27, 32] and emphasize that the Internet and
social media have both advantages and disadvantages for
TGD youth. In contrast to other broader studies on LGBTQ
youth [30, 31, 33, 34] and our second hypothesis, negative
online social experiences (cyberbullying or other adverse
online interactions) were not associated with more internal-
izing problems in TGD youth.
However, different results were found in our exploratory
analyses: Here, negative online social experiences (cyber-
bullying or other adverse online interactions) but not positive
online social experiences (use of online support networks)
were significant predictors for reporting more externalizing
problems and emotional and behavioral problems, in general
(total problem score). These results underline the possible
impact of negative online social experiences (cyberbully-
ing or other adverse online interactions) on TGD youths’
mental health outcomes. However, for suicidal ideation and
behavior (YSR suicidality index), which were similarly com-
mon as in other studies [4, 6], neither positive nor negative
online social experiences were significant predictors. Hence,
further research is needed to disentangle the complex asso-
ciations between positive vs. negative online social experi-
ences and mental health outcomes in TGD youth. For future
studies, it would also be interesting if media literacy skills,
the level of moderation on online platforms, or belonging to
a subgroup within TGD youth (e.g., nonbinary youth) influ-
ence the associations.
Table 7 Exploratory analysis
for the association of positive
(use of online support networks)
vs. negative online social
experiences (cyberbullying or
other adverse online interaction)
with the total problem score
(YSR raw scores)
Results of the final model of the multiple linear regression analysis: F(7, 157) = 19.12, adjusted R2 = .44,
p < .001
* p < .05, **p < .01, ***p < .001, FAD McMasters’ Family Assessment Device, YSR Youth Self-Report
b SE b ß p
Intercept 11.49 16.86 .497
Birth-assigned sex (0 = female, 1 = male) − 10.02* 4.38 − .14 .023
Age in years − 0.29 1.11 − .02 .796
General family functioning (FAD) 17.50*** 2.70 .41 < .001
Poor peer relations (YSR) 5.10*** 1.08 .30 < .001
Positive online social experiences (0 = no, 1 = yes) 7.73 4.42 .15 .082
Negative online social experiences (0 = no, 1 = yes) 12.75** 3.95 .26 .002
Interaction (positive x negative online social experiences) − 6.04 5.99 − .11 .314
Table 8 Exploratory analysis
for the association of positive
(use of online support networks)
vs. negative online social
experiences (cyberbullying or
other adverse online interaction)
with the suicidality index (YSR
raw scores)
Results of the final model of the multiple linear regression analysis: F(7, 157) = 11.22, adjusted R2 = .30,
p < .001
* p < .05, **p < .01, ***p < .001, FAD McMasters’ Family Assessment Device, YSR Youth Self-Report
b SE b ß p
Intercept 0.76 0.98 .438
Birth-assigned sex (0 = female, 1 = male) − 0.67** 0.25 −.18 .009
Age in years − 0.10 0.06 − .11 .107
General family functioning (FAD) 0.76*** 0.16 .34 < .001
Poor peer relations (YSR) 0.21** 0.06 .24 .001
Positive online social experiences (0 = no, 1 = yes) 0.41 0.26 .16 .109
Negative online social experiences (0 = no, 1 = yes) 0.45 0.23 .18 .050
Interaction (positive x negative online social experiences) − 0.02 0.35 − .01 .947
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3513European Child & Adolescent Psychiatry (2024) 33:3503–3516
In summary, the present findings are only partly in
line with the minority stress model [7, 8]: For example,
in contrast to the proposed “buffering” effect of support,
positive online social experiences were not associated
with less, but more internalizing problems. However, in
line with the minority stress model and previous stud-
ies [3, 10, 12], offline social experiences such as fam-
ily functioning and poor peer relations were among the
strongest predictors for the psychological functioning of
TGD youth, highlighting their crucial role in the mental
health of TGD adolescents once again. Therefore, these
results call for further studies to test the applicability of
the minority stress model to online contexts and to clar-
ify if online vs. offline social experiences have different
meanings for psychological problems in TGD youth.
Strengths andlimitations
Whereas there are many studies on the associations
between positive and negative offline social experiences
(e.g., family functioning and poor peer relations) and the
psychological functioning of TGD youth [2, 3, 10], the
associations with various online social experiences are
still not well documented. Therefore, the present study
contributes novel findings to adolescent TGD health
research by highlighting an important (online) life domain
where young people spend most of their free time.
Along with the research gap, validated questionnaires
for assessing online (social) experiences specifically in
TGD youth are missing, which is why we used self-con-
structed and adapted items (for more details, see Her-
rmann etal. [17]). However, for other variables, such as
internalizing problems, common and validated question-
naires were used (e.g., YSR). As internalizing problems
were self-reported, just like most other variables (exclud-
ing the socioeconomic status and the nationality), these
do not represent clinical diagnoses.
Moreover, the study was conducted during the COVID-
19 pandemic, which might have impacted our results
given that adolescents spent more time online during the
pandemic [18]. Therefore, the impact of online social
experiences might be different or smaller after the pan-
demic, when adolescents spend less time online and
more time in real life/offline again. Furthermore, with
the cross-sectional design of our study, only associations
and not causal relationships could be evaluated, calling
for longitudinal research. In addition, the generalizability
is limited because the present clinical sample is not rep-
resentative of TGD adolescents in the general population.
Furthermore, we focused on the use of online support
networks as positive online social experiences—which
might lack specificity as already mentioned (use vs. qual-
ity)—and cyberbullying and “other” adverse interactions
as negative online social experiences. There are probably
more positive and negative online experiences (includ-
ing social experiences, but not restricted to them) not
examined in the study, which could be crucial for TGD
adolescents’ mental health, e.g., building and maintain-
ing friendships online, especially for youth who would
otherwise feel isolated [22, 23, 26].
Implications
Since many TGD adolescents, especially those who
reported high levels of internalizing problems, used online
support networks, interventions that focus on increasing
positive online (social) experiences may be helpful: For
example, creating TGD-specific platforms with strong
community guidelines [34] or providing mental health
support or TGD-specific and accurate information in an
interactive but professional way may contribute to more
positive experiences.
Additionally, interventions that empower TGD adoles-
cents to buffer against negative online social experiences
or even prevent these before happening are needed. For
example, educational interventions for improving social
media account management (e.g., use of privacy settings)
and peer-driven educational programs against cyberbully-
ing could be beneficial [30, 34]. Moreover, media literacy
programs aimed at parents could improve their understand-
ing of potential risks and dangers their children may face
online and support them in teaching healthy media con-
sumption habits.
Sensitizing clinicians working with TGD youth to help
them navigate social media and the internet, for example, by
providing helpful online resources or educating them about
the potential positive and negative effects of the Internet/
social media, may additionally be beneficial. At least, clini-
cians need to be aware of the side effects the Internet may
have on their patients’ mental health.
Finally, given the importance of the relationships and
interactions with peers and family members for the men-
tal health of TGD youthin this and similar studies [3,
10, 12], one should not lose sight of their offline social
experiences.
Conclusion
In the present study, positive online social experiences
(using online support networks) of TGD adolescents were
associated with more internalizing problems, but negative
online social experiences (cyberbullying or other adverse
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3514 European Child & Adolescent Psychiatry (2024) 33:3503–3516
interactions) were not. We suggest that TGD adolescents
who are already struggling with internalizing problems
more often seek online support, but further (longitudi-
nal) research is needed to understand the mechanisms and
causal relationships better. Given that TGD youth are at
risk for lower levels of psychological functioning and that
the Internet and social media are unlikely to disappear
but possibly become increasingly indispensable, especially
for marginalized groups such as TGD youth, interventions
that focus on more positive or safer use of the Internet and
social media and equip youth to manage the possible risks
are critical.
Author contributions Data collection was done by LH, IBH, and SF.
The principal investigator of the study was IBH. Conceptualization of
the present study was done by LH, CaB, SH, and IBH. Material prepa-
ration and data analysis were performed by IBH, ClB, and LH. The
first draft of the manuscript was written by LH. All authors reviewed
the manuscript for important intellectual content.
Funding Open Access funding enabled and organized by Projekt
DEAL. The first author received a scholarship for her PhD (nonprofit
foundation: FAZIT-Stiftung), of which the present study was part.
Data availability The data are not publicly available.
Declarations
Competing interests The authors declare that they have no competing
interests.
Ethical approval This study was performed in line with the principles
of the Declaration of Helsinki. The local ethics committee granted
ethical approval for the study.
Consent to participate and consent to publish All participants gave
their written consent to participate in the study and to the use and
publication of their anonymized data.
Open Access This article is licensed under a Creative Commons
Attribution 4.0 International License, which permits use, sharing,
adaptation, distribution and reproduction in any medium or format,
as long as you give appropriate credit to the original author(s) and the
source, provide a link to the Creative Commons licence, and indicate
if changes were made. The images or other third party material in this
article are included in the article’s Creative Commons licence, unless
indicated otherwise in a credit line to the material. If material is not
included in the article’s Creative Commons licence and your intended
use is not permitted by statutory regulation or exceeds the permitted
use, you will need to obtain permission directly from the copyright
holder. To view a copy of this licence, visit http://creativecommons.
org/licenses/by/4.0/.
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