Effect of gender identity on the association between gender dysphoria and suicidality via appearance anxiety among transgender and gender-diverse young people: moderated mediation study

Background Gender dysphoria is associated with suicidality among transgender and gender-diverse (TGD) people. Gender dysphoria also results in a stress on appearance. Aims The objectives of this study were to examine: (a) whether appearance anxiety mediates the effect of gender dysphoria on suicidality; and (b) whether gender identity moderates the mediating effect of appearance anxiety. Method A total of 117 769 college and university students were recruited in this cross-sectional study from Jilin Province, China. After screening based on participants' gender identity, 2352 TGD young people (aged from 15 to 25 years) were divided into three subgroups: female to male (FTM), male to female (MTF) and non-binary. Self-report inventories measured gender dysphoria, suicidality and appearance anxiety. A structural equation model was run to examine the relationships among TGD gender identity, gender dysphoria, appearance anxiety and suicidality. Results Among TGD young people, gender dysphoria was significantly positively associated with suicidality (beta = 0.15, 95% CI = 0.11-0.18, P < 0.001). Appearance anxiety partially mediated the association between gender dysphoria and suicidality (beta = 0.07, 95% CI = 0.05-0.08, P < 0.001). Gender identity moderated the mediating effects: compared with individuals with FTM identity, among those with MTF and non-binary identities, gender dysphoria showed stronger positive effects on appearance anxiety, and appearance anxiety showed greater effects in mediating the association between gender dysphoria and suicidality. Conclusions Among TGD young people, gender dysphoria is significantly associated with suicidality via appearance anxiety, with gender identity moderating the mediating effects. Diverse treatments should consider the heterogeneity of TGD subgroups, with the aim of limiting the tendency of gender dysphoria to trigger appearance anxiety, thus further buffering against the risk of suicide.