The relationship between gender identity and depressive symptoms in adolescents: A moderated mediation model of self-efficacy and family functioning

doi:10.21203/rs.3.rs-4949530/v1

【Background】 Gender identity is associated with adolescent depression, but the relationship remains unclear. To further clarify the relationship between gender identity and mental health, this study targets adolescents with significant fluctuations in gender identity, constructs a moderated mediation effect model, examines the relationship between gender identity and depression, and explores the mediating role of self-efficacy and the moderating role of family functioning, to provide scientific references for proposing effective psychological interventions for different gender identity groups.

【Methods】Using whole group convenience sampling method, 2340 students from a school in Changsha, Hunan Province, were selected for the survey, and the Patient Health Questionnaire-9 items (PHQ-9), the Family Care Index Scale(APGAR), the General Self-Efficacy Scale-Schwarzer (GSES), and gender identity-related questions were used for the assessment of mental health.

【Results】The prevalence of depression was 40.5% among transgender adolescents, which was significantly higher than that of cisgender adolescents (15.6%). At the same time, gender identity, self-efficacy, family functioning, and depression constituted a moderated mediation model, with family functioning moderating the posterior path of this mediation process. Specifically, self-efficacy was progressively less predictive of depression as family functioning increased.

【Conclusion】Transgender adolescents showed significantly poorer mental health than cisgender adolescents. There was a partial mediating effect of self-efficacy between gender identity and adolescent depression, with family functioning moderating the latter half of this mediation effect. This study advances our understanding of the relationship between depression and self-efficacy or family functioning in adolescents of different gender identities.

Gender identity

depression

self-efficacy

family functioning

The close relationship between Gender identity and mental health has attracted increasing attention. Gender identity refers to an individual's self-perceived gender based on personal experiences, including sensations and perceptions of their physiological characteristics and outward manifestations^[1]. This identity may align with the sex assigned at birth (i.e., cisgender) or differ from it (i.e., transgender). Data indicated that the global transgender population is approximately 25 million, with about 4 million in China, representing 0.3–0.5% of the total population. Among adolescents, the proportion of transgender individuals reaches 1.3%^{[3, 4]}. It is worth noting that recent research has demonstrated increased rates of depression, suicidality and self-harm, and psychiatric morbidity among transgender youth when compared with their peers. However, further research is needed to explore the relationship between gender identity and mental health status as well as its mechanisms of influence.

Studies consistently document a high prevalence of mental health distress in transgender people.Previous studies have demonstrated that depressive symptoms are significantly more prevalent among transgender individuals compared to their cisgender counterparts, with findings reported in Australia^[3], New Zealand^[4], and the United States^[5]. In China, a web-based survey by the Beijing Lesbian, Gay, Bisexual,Transgender(LGBT) Center showed that 61.5% of the 2060 transgender survey respondents had symptoms of depression^[2]. According to Meyer's model hypothesis^[3], people from minority groups will experience some additional stressors, namely minority stress, and this discrimination and stigmatization will affect their mental health. In the adolescent group, as they are in an important period of physical and mental development, the development of secondary sexual characteristics gives them a deeper identification or aversion to their biological self-gender, and gender identity is mostly formed at this stage, their mental health is more vulnerable ^[4–8]. Adolescent transgender groups also have higher depressive symptoms^[9]. Depression, as a negative emotion, can lead to a series of adverse consequences, such as comorbid anxiety disorders and insomnia, leading to lower performance and reduced social functioning in adolescent students ^[10–13]; It can even raise the risk of self-harm and suicide^[14–16]. Therefore, it is crucial to explore the intrinsic influence mechanism of gender identity on depression in order to promote the physical and mental development of adolescents and decrease the concurrent emotional symptoms.

Despite numerous studies highlighting the severity of depressive symptoms in the transgender community, current research primarily focuses on advocacy and hormone therapy-related issues^[17–19]. There is a notable gap in exploring the factors influencing depressive symptoms, especially within the transgender adolescent community. Timely screening, diagnosis, and targeted interventions for transgender adolescents at high risk of depression are essential to reducing the risk of self-harm and suicide, yet these areas remain underexplored.

Self-efficacy has been identified as a significant negative predictor of depression in various populations^[23]. Self-efficacy refers to the confidence in one's ability to achieve specific goals. High self-efficacy enables adolescents to perceive themselves as competent in facing challenges, enhancing self-motivation and coping strategies^[24] For adolescents in pubertal development, the primary distress caused by inconsistency between gender identity and biological sex reduces their self-efficacy and prevents them from rationally dealing with difficult situations^{[20, 21]}, leading to an increase in self-negative evaluations and a consequent high prevalence of depressive symptoms.

Self-efficacy, which is the confidence in one's ability to achieve specific goals, has been found to be a strong predictor of lower levels of depression in various populations^[23]. High self-efficacy helps adolescents perceive themselves as competent in facing challenges, enhancing their self-motivation and coping strategies ^[24]. However, adolescents in pubertal development may experience distress due to incongruence between their gender identity and biological sex, which can lower their self-efficacy and hinder their ability to deal with difficult situations rationally ^{[25, 26]}. This can lead to an increase in self-negative evaluations and a higher prevalence of depressive symptoms. BOWLING J et al. argue that the psychological resilience of minorities is primarily rooted in their sense of identity ^[27], and increased self-efficacy is crucial for coping with internalized transphobia and negative expectations. Unfortunately, societal and other pressures have led to transgender individuals developing negative feelings, including self-hatred ^{[28, 29]}. Additionally, INZLICHT M et al ^[30] hypothesized that coping with stigma, such as ego depletion, diminishes the ability to control and regulate a person's behavior in areas unrelated to stigma, making them more susceptible to depression and anxiety ^[31]. It can be postulated that adolescents' self-efficacy may play a mediating role in the relationship between gender identity and depression.

Family functioning reflects the structural and organizational characteristics of a family group, as well as the patterns of interaction between its members ^[18]. Family Systems Theory (FST) has been used to examine how family dynamics affect adolescent health^[22–24], and research has shown that healthy family relationships can help prevent risky behaviors and improve mental well-being^[25]. It can be speculated that family functioning in the transgender community may be a moderator of their depression. Additionally, well-functioning family functioning can help prevent adolescents from stress-induced psychosis-like experiences ^[26]. For transgender individuals, low perceived family care may hinder them from receiving effective family support when facing external stress and internalized stigmas. As a result, they may lack an accurate perception of their coping abilities, leading to low self-efficacy, increased negative thoughts, and a higher likelihood of depressive symptoms. Therefore, in the current study, we hypothesize that family functioning moderates the relationship between self-efficacy and adolescent depression, i.e., family functioning moderates the second half of the mediating role of self-efficacy.

In summary, self-efficacy, as a protective factor, likely plays a crucial role in the relationship between gender identity and adolescent depression, while family functioning may significantly influence the impact of self-efficacy on depression. Therefore, this study targets adolescents, constructing a moderated mediation model (Fig. 1) to examine the relationship between gender identity and depression. Using independent samples t-tests, Pearson's correlation, stepwise regression, and Model 14 of the PROCESS procedure, this study explores the mediating role of self-efficacy and the moderating role of family functioning. These findings aim to provide scientific references for proposing effective mental health promotion methods for different gender identity groups.

2.1 Subjects

Using a whole group convenience sampling method, students from the first and second years of both middle school and high school at a private school in Changsha, Hunan Province, were sampled in May 2021. The survey was conducted class by class. All students aged between 10 and 19, who had no serious physical ailments and had signed the informed consent form, were included. Group tests were administered in class-based groups by highly trained teachers with backgrounds in psychiatry and psychology. The questionnaires were filled out anonymously and collected on the spot after completion. Participants who met one or more of the following criteria were excluded: (1) previously diagnosed with a severe mental illness; (2) currently suffering from a serious physical illness; (3) impaired cognitive functioning, preventing them from completing the assessment. A total of 2,340 students completed the questionnaire series, with 1,951 valid questionnaires collected.

This study was approved by the Research Ethics Committee of Second Xiangya Hospital of Central South University .

2.2 Tools.（Clinical Assessment）

2.2.1 The Patient Health Questionnaire-9 (PHQ-9) PHQ-9 was used to assess subjects' depression over the past week^[37]. Responses were recorded on a 4-point scale. A higher total score indicates a more severe level of depression. In this study, a total score of ≥10 was used as a threshold for possible depression, with scores of 15 and above indicating major depression^[27]. The Chinese version of the PHQ-9 has high internal consistency with a Cronbach's alpha coefficient of 0.859 in studies of adolescent populations^[28].

2.2.2 Family Functioning The Family Care Index Scale (Adaptation-Partnership-Growth-Affection-Resolve) (APGAR) was used to evaluate the subjective and quantitative functioning of the subject's family, reflecting their satisfaction with family functioning ^[29]. The Family APGAR questionnaire consists of five items: (1) Adaptation; (2) Partnership; (3) Growth; (4) Affection; and (5) Intimacy (Resolve) ^{[30, 31]}. Responses were recorded on a 3-point scale, with total scores categorized as follows: 7-10 indicating good family functioning, 4-6 indicating moderate family dysfunction, and 0-3 indicating severe family dysfunction. Chinese version shows evidence of reliability and construct validity in previous researchers. The Cronbach's α coefficient for this scale in this study was 0.850.

2.2.3 Self-efficacy The General Self-Efficacy Scale-Schwarzer (GSES) was used to measure subjects' ability to control or dominate their actions^[32]. The Chinese version of the GSES consists of 10 items covering five aspects: sense of effort, natural ability, sense of environment, sense of goal attainment, and self-expectation. The GSES has good applicability in Chinese populations^[33], with a Cronbach's α coefficient of 0.895 in this study.

2.2.4 Gender Identity Gender identity was assessed using the following questions: ① What was your biological sex at birth? (male/female) ② What do you think your gender is? (male/female/neither/undecided). The grouping criteria were as follows: ① Cisgender group: biological sex is male and the subject identifies as male, or biological sex is female and the subject identifies as female. ② Transgender group: biological sex is male and the subject identifies as female; or biological sex is female and the subject identifies as male; or biological sex is either male or female and the subject identifies as neither male nor female; or biological sex is either male or female and the subject is unsure of their gender.

2.3 Analysis steps and statistical methods

Statistical analyses were conducted using IBM SPSS 26.0. First, subjects who had ever been diagnosed with severe psychosis, had serious physical illnesses or impaired cognitive functioning were excluded. To improve the reliability of the questionnaire, three validation questions were included (e.g., 'Please choose A/B/C directly for this question') at the beginning, middle, and end of the questionnaire. Data from subjects who did not correctly answer all three validation questions were excluded. Additionally, questionnaires with more than 10% missing values were removed. The remaining data were subjected to multiple imputations, selecting the result with the highest Cronbach's α among the five imputed datasets.

After processing the questionnaire data, the Harman one-way test was used to analyze common method bias. The maximum factor variance explained was 21.48% (less than 40%), indicating no significant common method bias. Independent samples t-tests were used to compare the mental health status of different adolescent gender identity groups, and Pearson correlation analysis was used to correlate self-efficacy with the mental health status of adolescent students.

Finally, the mediating effect of self-efficacy between gender identity and depression was validated using Model 4 of the PROCESS macro for SPSS, prepared by Hayes, with a Bootstrapping test (5000 resamples) and bias correction to calculate the Confidence Interval (CI)^[34]. The moderating effect of family functioning on the mediating effect of self-efficacy was also explored using Model 14^[35], with standardization and centering of all continuous variables.

3.1 Common method bias test

To protect the privacy of adolescents, the survey was conducted anonymously, reducing the potential influence of common method bias on the data. The Harman one-way test was used for analysis, revealing seven factors with eigenvalues greater than 1. The maximum factor variance explained accounted for 21.48% (less than 40%), indicating that common method bias is not significant in this study.

3.2 Basic demographic information

Among the 1951 students who completed valid questionnaires, 1,840 (94.3%) were cisgender and 111 (5.7%) were transgender. Within the transgender group, 40 individuals (36.0%) identified as transgender females, and 71 individuals (64.0%) identified as transgender males. The basic demographic information is detailed in Table 1.

Table 1 Basic demographic information on adolescent students
	Total (%)/Mean (standard deviation)	Cisgender (N=1840)	Transgender (N=111)
Age	13.19±1.243	13.18±1.242	13.26±1.256
Sex at birth
Male	1030	990(96.1)	40(3.9)
Women	921	850(92.3)	71(7.7)
Grade
First year of junior middle school	634	600(94.6)	34(5.4)
Second year in junior middle school	893	844(94.5)	49(5.5)
First year in senior high school	274	253(92.3)	21(7.7)
Second year in senior high school	150	143(95.3)	7(4.7)
Ethnic Group
Han	1837	1734(94.4)	103(5.6)
Others	114	106(93.0)	8(7.0)

3.3 Comparison of the mental health status of different adolescent students' gender identity groups

This study found significant differences in depression, family functioning, and self-efficacy among different gender identity groups (see Table 2 for details). In the cisgender group, 287 subjects (15.6%) were detected with depression, whereas in the transgender group, 45 subjects (40.5%) were detected with depression. Additionally, family functioning and self-efficacy levels were significantly lower in the transgender group compared to the cisgender. Overall, the transgender group exhibited significantly poorer mental health, particularly with higher levels of depression, compared to the cisgender group.

Table 2 Comparison of the mental health status of different adolescent students' gender identity groups
Variant	t	p	Cisgender (N=1840)	Transgender (N=111)
(mean ± standard deviation)	t	p	Cisgender (N=1840)	Transgender (N=111)
Depression	-6.724	0.000	5.11±4.89	9.03±6.03
Family functioning	5.139	0.000	6.30±2.72	4.93±2.70
Self-efficacy	3.527	0.000	24.62±6.31	22.44±6.32

3.4 Correlation analysis between self-efficacy and mental health status of adolescent students

Pearson correlation analysis was conducted, and the results (see Table 3 for details) present the correlation matrix of the variables observed in this study. It was concluded that in both cisgender and transgender groups, (1) depression was significantly negatively correlated with family functioning and self-efficacy (p < 0.05), and (2) self-efficacy was significantly positively correlated with family functioning (p < 0.01).

Table 3 Correlation analysis between self-efficacy and depression, family functioning
variant	cisgender			transgender
variant	1	2	3	1	2	3
1. Depression	1			1
2. Family functioning	-0.427^***	1		-0.284^**	1
3. Self-efficacy	-0.225^***	0.278^***	1	-0.190^*	0.272^**	1
Notes:p＜0.05，p＜0.01，**p＜0.001

3.5 Test of mediating effects of self-efficacy

To further investigate the potential mechanisms by which gender identity affects mental health, firstly, this project standardized and centered all continuous variables, The mediation effect analysis of categorical variables, proposed by Wen Zhonglin's team^[35], was employed, using the cisgender group as the base reference. Stepwise regression analysis was conducted to determine the mediating effect of self-efficacy in the transgender group while controlling for age. The results showed that relative to the cisgender group, the transgender group had a significant positive predictive effect on depression. When the mediator variable (self-efficacy) was included, the positive predictive effect of the transgender group on depression remained significant. Gender identity was a significant negative predictor of the mediator variable self-efficacy, and self-efficacy was also a significant negative predictor of depression. Therefore, gender identity not only directly predicts depression, but also predicts depression through the mediating role of self-efficacy, indicating that self-efficacy partially mediates the relationship between gender identity and depression^[36]. (See Table 4 for details)

In addition, the mediating effect of self-efficacy between adolescents' gender identity and depression was validated by the Bootstrapping test (5000 resamples) with Model 4 of PROCESS for SPSS, prepared by Hayes^{[37, 38]}. The results showed that the Bootstrap confidence intervals for both the direct effect on depression and the mediating effect of self-efficacy did not include "0"^[49], indicating that the mediating effect of self-efficacy was significant. The direct effect (3.515) and the mediating effect (0.364) accounted for 90.62% and 9.38%, respectively, of the total effect (3.879). (See Table 5 for details)

Table 4 Mediation effect test for self-efficacy
regression equation		fitness index			Significance of coefficients
Outcome variable	Predictor variable	R	R²	F	B	t
Depression		0.223	0.05	50.864^***
	Age				0.532	5.934^***
	Gender identity				3.879	8.067^***
Self-efficacy		0.098	0.01	9.454^***
	Age				-0.291	-2.537^*
	Gender identity				-2.153	-3.494^***
Depression		0.307	0.094	67.551^***
	Age				0.483	5.504^***
	Gender identity				3.515	7.463^***
	Self-efficacy				-0.169	-9.796^***

Notes:*p＜0.05，**p＜0.01，***p＜0.001

Table 5 Breakdown of total, direct, and mediating effects
	efficiency value	SE	Boot LLCI	Boot ULCI	relative affect value
Aggregate effect	3.879	0.481	2.936	4.823
Direct effect	3.515	0.471	2.592	4.439	90.62%
Mediating effects of Self-efficacy	0.364	0.116	0.142	0.598	9.38%

3.6 Moderating effects of family functioning on the mediating effects of self-efficacy

Model 14 (the second half of the moderated mediation model, consistent with the theoretical framework of this study) in the Process program developed by Hayes was used to standardize and center all continuous variables, and a moderated mediation effect test was conducted on the transgender group, controlling for age. The analysis results indicated (see Table 6 for details) that, compared to the cisgender group, transgender identity significantly positively predicted depression and significantly negatively predicted self-efficacy, which in turn significantly and negatively predicted depression. With the inclusion of family functioning as a moderator variable, the interaction term of self-efficacy and family functioning significantly moderated depression. As shown in Table 7, there was a significant negative moderating effect of family functioning on depression in the transgender group relative to the cisgender group. This indicates that gender identity, self-efficacy, family functioning, and depression constitute a moderated mediation model, moderating the latter paths of the mediation process.

Further simple slope analyses(see Figure 3 for details) showed that self-efficacy negatively predicted depression in subjects with both lower levels of family functioning (M-1SD) and higher levels of family functioning (M+1SD). However, the predictive effect of self-efficacy on depression progressively decreased as family functioning increased. This suggests that as family functioning improves, transgender individuals are less likely to experience depression through diminished self-efficacy compared to cisgender individuals.

Table 6 Moderated mediated effects analysis for transgender
Outcome variable	Predictor variable	Overall fit index			Significance of regression coefficients
Outcome variable	Predictor variable	R	R²	F	β	t
Self-efficacy		0.0980	0.0096	9.4536^***
	Age				-0.2915	-2.5368^*
	Transgender				-2.1534	-3.4937^***
Depression		0.4761	0.2267	114.0495 ^***
	Age				0.4237	5.2190^***
	Transgender				2.7009	6.1689^***
	Self-efficacy				-0.0934	-5.5899^***
	Family functioning				-0.6875	-17.8529^***
	Self-efficacy* Family functioning				0.0177	3.2903^**

Notes:*p＜0.05，**p＜0.01，***p＜0.001

Table 7 Analysis of moderating effects of family functioning
Outcome variable	Moderating effects of family functioning					Index of moderated mediation
Outcome variable		Effect	SE	Boot LLCI	Boot ULCI	Index	SE	Boot LLCI	Boot ULCI
Depression Score	M-1SD	0.3105	0.1133	0.1163	0.5540	-0.0365	0.0182	-0.0762	-0.0065
	M	0.2105	0.0745	0.0807	0.3712
	M+1SD	0.1105	0.1105	0.0175	0.2406

The purpose of this study was to examine the relationship between gender identity and depression, exploring the mediating role of self-efficacy and the moderating role of family functioning. The results found that transgender adolescents had significantly poorer mental health than cisgender adolescents. Additionally, self-efficacy partially mediated the relationship between gender identity and adolescent depression, with family functioning moderating the latter part of this mediating effect.

4.1 Transgender adolescents are at higher risk of depression than cisgender adolescents

Gender identity has been reported to be associated with depressive symptoms ^[39]. Our study showed that the transgender adolescent group had significantly lower levels of family functioning and self-efficacy compared to cisgender adolescents, as well as more severe mental health problems. Other studies have reported higher rates of suicidality^[40], poor health status ^[41], the prevalence of HIV ^[42], and use of cigarettes alcohol, and illicit drugs ^[8]among transgender adolescents compared to their cisgender counterparts. These issues may be associated with a lack of social support, lack of parental approval, and gender identity-based violence^{[43, 44]}. Consistent with previous findings our study indicates that transgender adolescents are at higher risk of depression than cisgender adolescents^{[45, 46]}.

4.2 Gender Identity Influences Depression Symptoms through Self-Efficacy

Self-efficacy, defined as the ability to implement self-motivation and improve coping strategies in the face of adversity, impacts depression symptoms ^[47]Studies by Riaz Ahmad Z et al.^[59] and Yang X et al.^[60] found that depression is negatively correlated with self-efficacy, indicating that higher self-efficacy is associated with a lower risk of depression symptoms^[48]. This relationship has also been observed in adolescent populations^[49]. To further explore the relationship between gender identity and depression, we focused on whether self-efficacy mediated the association between gender identity and depressive symptoms.

Our results showed that the direct and mediated effects of gender identity on depression accounted for 90.62% and 9.38% of the total effect, respectively, reflecting that high self-efficacy helps reduce depression. Gender identity was a significant negative predictor of self-efficacy, and self-efficacy was a significant negative predictor of depression. Thus, self-efficacy partially mediated the relationship between gender identity and depression. These findings support the minority stress model, which categorizes minority stress into distal and proximal stress^[50]. Good self-efficacy among transgender adolescents reduces proximal stress, leading to more positive psychological outcomes and fewer depressive symptoms in the face of situations such as stigmatization. YANG X et al. ^[51] also demonstrated this in a cross-sectional study of transgender females.

In summary, gender identity influences depressive symptoms through self-efficacy, suggesting an explanatory mechanism behind depression in transgender adolescents.

4.3 Indirect moderating role of family functioning in gender identity and depression symptoms

As previous studies have shown, parents are the main source of external support for sexual minorities ^{[52, 53]}, and transgender individuals receive less family support than cisgender individuals ^[54]. Family functioning plays an important role in the association between transgender adolescents and depression. A supportive family environment provides transgender adolescents with greater self-esteem and support and reduces the development of unhealthy psychological symptoms such as depression and anxiety^[55]. In addition, our findings suggest that family functioning moderates the second half of this mediating effect. As family functioning improves, transgender individuals are less likely to experience depression through diminished self-efficacy compared to the cisgender group, highlighting the significant role of the family in the depression process of transgender adolescents. In the clinical treatment of depression in transgender adolescents, more emphasis may need to be placed on improving family relationships. Hazell P. found that in the short term, family therapy may have a slight advantage over individual psychotherapy in treating adolescent depression ^[56].

Depression was significantly negatively correlated with both family functioning and self-efficacy, and self-efficacy was significantly positively correlated with family functioning, Sitek E J et al.'s study found that adolescents diagnosed with depression generally assessed poorer family functioning^[57]. HE K et al. showed that adolescents from poorer family backgrounds were more prone to low self-efficacy ^[58], consistent with our findings. However, another study did not find a correlation between self-efficacy and depression^[59], probably due to the specific context of the study, which was conducted during the COVID-19 pandemic.

4.4 Implications and limitations

The current findings have important implications for improving depression symptoms in transgender adolescents. Our finding that family functioning plays an important moderating role in this pathway of self-efficacy and depressive symptoms may suggest that family functioning is a noteworthy predictor for identifying transgender adolescents at risk of depressive symptoms due to low self-efficacy.

A possible limitation of this study is that our assessment was based on adolescent self-reported questionnaires, which may be subject to bias in adolescents' perceptions of themselves. Additionally, there may be other factors besides self-efficacy and family functioning, such as interpersonal interactions, internet dependence, and academic performance may interact with depression symptoms in transgender adolescents and should be considered when interpreting the results of the study. These considerations could be beneficial for further research. Although the significant moderating mediating effects found in this study provide a mechanistic explanation, gender identity, self-efficacy, family functioning, and depressive symptoms were measured concurrently, so causal inferences cannot be made. For example, it is possible that depressive symptoms or low family functioning may also contribute to low self-efficacy.

Finally, the study's limitation includes the fact that the survey was conducted in a single school and did not involve a large-scale questionnaire administration, which should be considered when interpreting the results.

Overall, transgender adolescents are at a higher risk of developing psychological problems. In clinical treatment, distinguishing whether an adolescent's gender identity is transgender or cisgender is crucial and may lead to more positive treatment outcomes. Based on the findings of this study, in the treatment of depression in transgender adolescents, more attention should be paid to the role of self-efficacy and family functioning.

Patient Health Questionnaire-9 items (PHQ-9)

General Self-Efficacy Scale-Schwarzer (GSES)

Family Care Index Scale(Adaptation-Partnership-Growth-Affection-Resolve) (APGAR)

Lesbian, Gay, Bisexual, Transgender(LGBT)

Family Systems Theory (FST)

Confidence Interval (CI)

Standard error(SE)

Mean(M)

Statistical Package for the Social Sciences（SPSS）

Ethical approval and consent to participate:

Not applicable

Consent for publication:

Not applicable

Availability of supporting data and materials:

The datasets used and/or analyzed in the current study are available from corresponding authors on reasonable request.

Competing interests:

The authors declare that they have no conflicts of interest related to this study. This manuscript has been read and approved by all the authors and has not been submitted to or is not under consideration for publication elsewhere.

Funding:

This work was supported by the Central South University Student Innovation Training Project (grant number: XCX2021068).

Author’s contributions:

CYH, HCY, and HJT had the idea for the article; HCY, ZBX, and ZPW carried out the distribution and collection of questionnaires; CYH, HCY completed data processing and analyses; CYH, HCY finished the figures and the tables; CYH and HJT made critical revisions; HJT, ZNL proofread the manuscript. All authors read and approved the final manuscript.

Acknowledgements:

We are thankful to many scientists in the field whose seminal works are not cited due to space constraints. We would like to express our gratitude to all those who helped us during the writing of this review.

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No competing interests reported.

The relationship between gender identity and depressive symptoms in adolescents: A moderated mediation model of self-efficacy and family functioning

Status:

Version 1

Abstract

Figures

1 Background

2 Research Methods

3 Results

4 Discussion

4.1 Transgender adolescents are at higher risk of depression than cisgender adolescents

4.2 Gender Identity Influences Depression Symptoms through Self-Efficacy

4.3 Indirect moderating role of family functioning in gender identity and depression symptoms

4.4 Implications and limitations

5 Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1