This study was reviewed and determined to be exempt from institutional review board approval (application 24-001890) by the Mayo Clinic institutional review board. This included a review of the finalized survey, recruitment email, and recruitment process as outlined in the application. Although this research focused on a minority population, this study was found to be exempt due to the lack of identifying information collected. Informed consent was collected in the form of a recruitment email that emphasized the optional nature of the survey, the benefits of completing the survey, and the fact that no known risks were identified in association with completing the survey. No identifiable information was recorded during the survey, and responses were recorded using HIPAA (Health Insurance Portability and Accountability Act)-compliant software. The participants were not compensated.

The questionnaire was developed by the survey team through an iterative process as no validated questionnaire existed (see the adherence to the Checklist for Reporting Results of Internet E-Surveys protocol [13] in Checklist 1). Survey questions collected information about social media use, social support groups, and demographic characteristics. Social media use information ranged from sites used, hours used, and adverse effects noted. Social support questions gathered information on support groups centered on past participation and desire for present participation. Demographic information collected included age, gender, race and ethnicity, educational level, religious affiliation, and income. No other identifiable information was collected. Volunteers were recruited via email through the listserv of the lesbian, gay, bisexual, transgender, and queer employee resource group to review the questionnaire and provide feedback to the survey team. We had 3 volunteers who provided feedback on the questions and answer choices. The full survey is available in Multimedia Appendix 1.

TGD people receiving care from the Transgender and Intersex Specialty Care Clinic (TISCC) at the Mayo Clinic in Arizona were recruited for this study. There were no exclusion criteria among this population. A list of emails was compiled from patients who were seen at the TISCC at the Mayo Clinic in Arizona between August 16, 2021, and August 14, 2024. The list of emails was screened, and duplicates were removed. Emails were sent out with individualized links, which only allowed for 1 response for each individual.

Using this list, surveys with informed consent documentation were sent out via email with reminders sent at 10 and 20 days after initial survey distribution. Recruitment and survey completion took place over the months of September 2024 to October 2024.

Continuous variables were described using means, SDs, medians, IQRs, and ranges. Categorical variables were described using frequencies and proportions. Group comparisons were conducted using the Kruskal-Wallis test and chi-square test for continuous and categorical variables, respectively. All analyses were carried out using SAS (version 9.4; SAS Institute).

A total of 48 responses, out of 236, were received, yielding a response rate of 20%. Additional demographics can be found in Table 1.

A total of 50% (24/48) of the respondents indicated that their support came from a significant other, spouse, partner, or in-person friends as evidenced in Table 2. In total, 12.5% (6/48) of the respondents reported that their primary source of support regarding their gender identity was online friends or social media.

Regarding social media use as support for gender identity, 64.6% (31/48) of the respondents reported that they used at least one social media platform with the primary purpose of interacting with other queer or TGD people. The most common social media sites used with this as the primary purpose were Discord, Reddit, and Instagram, in that order.

Nearly 70% of respondents (31/48, 64.6%) reported experiencing transphobia at least monthly, with 35.4% (17/48) reporting experiencing transphobia at least weekly. Nearly 60% of the respondents reported that they were exposed to hate and/or transphobia on social media (27/48, 56.3% and 26/48, 54.2%, respectively), with these being the most common adverse experiences reported in relation to social media. Other common reported adverse experiences included self-consciousness and overuse.

In free-text responses, participants mentioned that social support groups helped allow attendees to “meet others like me” and that they helped in “extending my support network.” Other responses mentioned the importance of social support groups, especially after recently coming out.

Among the 14 participants who reported that they had participated in a social support group but were no longer attending, responses were mixed about the effectiveness of support groups (Table 3). Some respondents reported that they were helpful, stating that “community is important when I first came out” and “social support groups are helpful by providing people with a safe space to exist.” However, other respondents reported that they were less helpful, citing “differences” between themselves and other participants. Of these 14 respondents, approximately half (7/14, 50%) reported that they either were or were maybe interested in attending a social support group once again. Responses referenced the importance of making friends and social connections, whereas others stated the difficulties of making time for such commitments.

In total, from the population of respondents who were not currently attending a support group, 56.4% (22/39) reported that they either were interested or were maybe interested in attending a social support group. Respondents who were interested in attending a group cited wanting more “social interaction,” “community,” and “support.” Some respondents who were not interested in attending a social support group reported that their support systems were “enough” and “adequate.”

In a group of TGD people presenting to a tertiary care clinic, most (33/48, 65%) used social media to connect with people in their community. However, a smaller percentage (2/48, 4.2%) turned to social media as their primary source of social support. Among those who used social media, Reddit, Discord, and Instagram were the most popular social media sites used by respondents specifically for the purpose of interacting with other queer and transgender people. Our survey also demonstrated concerning risks, including exposure to hate, transphobia, and self-consciousness in association with social media use, but also benefits in finding community and support.

Beyond the use of social media, our results demonstrated that individuals such as spouses, friends, and family are important for social support. In our study, many of those who were attending a social support group reported that they found participation to be beneficial, especially for social support and for finding others in the community like themselves. Among those who had attended a social support group but did not find it beneficial, a common theme was differences between other participants and themselves. Among respondents who had never attended a support group, many reported some level of interest in attending a support group and cited interest in finding community, support, and others like themselves. Among those who did not report interest in attending support groups, many reported already having enough support among family and friends or that they were concerned about differences (including demographic differences such as age and years since transition began) between potential support group participants and themselves. This points to social support groups as a potential valuable resource, especially for those without other avenues of support.

Prior studies have demonstrated the importance of social media as a tool for social support among TGD populations, although more research on social media use as support for TGD individuals has been focused on youth populations [14]. Social media has been shown to facilitate transgender adolescents’ connections with peers and identification with role models. Among lesbian, gay, bisexual, transgender, and queer adults, social media has been identified as a place to seek social support from other individuals who share facets of one’s identity (such as sexual orientation and race) [15,16]. The use of social media among younger populations has been thoroughly studied and shown to have effects such as exposure to cyberbullying and impacts on mental health [17]. Past studies have shown that, among TGD adults, exposure to transphobia, cyberbullying, and victimization has been noted as a potential adverse effect of social media use [18,19]. Beyond social media and known friends and family, in-person support groups have been found to be beneficial for marginalized communities [20] and specifically TGD people [21]. This is consistent with other studies [22] that have shown that TGD people who have never attended a support group view them as ways to find peer support and community. Social workers can engage patients and their families in the forming of these support groups and look to well-established clinics for resources [23].

The limitations of this study include the small sample size as well as the lack of an existing validated questionnaire. As no validated questionnaire exists specifically for the purpose of assessing social support among TGD people in relation to gender identity, we had to create our own. Additionally, our survey response rate was 20% (48/236). A systematic review found that the average response rate in counseling journals is approximately 34.2% [24], which puts our response rate slightly below but within 1 SD of the average from the latter study. Still, this relatively low response rate could introduce nonresponse bias, and to better understand our population, we will need a future study with a strategy for a higher response rate. Finally, our sample for this study comprised patients at the TISCC at the Mayo Clinic in Arizona, which is not demographically representative of the TGD community across the country. Thus, our survey suffers from nonresponse bias and, additionally, may not be generalizable to transgender adults across the United States.

Our data help further the understanding of social media use and social support groups for TGD people to better inform physical and mental health professionals as to how to best meet the needs of TGD people. This study found that social media is already being used by TGD people for the purpose of interacting with other queer and transgender people, but also that there are risks associated with its use. With both positive and negative effects of social media use among TGD adults, counseling with patients seeking social support can be focused on safety in use. Although more research on this is necessary, forums where interactions occur among known groups with moderators (such as Discord and Reddit, identified by survey respondents as being used for connecting with other queer individuals) may provide safer ways to find social support.

In addition to social media, support groups were reported by many attendees to be helpful for finding social support, especially early on in one’s transition and when other avenues of support are not present. Offering support groups as part of TGD care may be something to consider given the disproportionate social stigma and resultant health disparities faced by this population.