It will not be news to anyone reading this that transgender people are more likely than non-transgender people to attempt suicide. The statistics about transgender suicide risk are among the best-known facts about transgender people. The oft-cited study by Grant and colleagues suggests that 41% of transgender people attempt suicide at least once in their lives.1 Other studies put this proportion closer to one-third, which is still dramatically higher than the suicide attempt rate of the general population (~5%). A less-cited study found that transgender veterans were 20 times more likely to attempt or complete suicide than non-transgender veterans.2 Additionally, transgender people have high rates of chronic suicidality. In one study, nearly 40% of transgender people who had attempted suicide had made three or more attempts in their lifetime.3
Interestingly, people cite this increased suicide rate to support conflicting arguments and competing goals. We hear it referenced in emotional charges for increased social acceptance of gender diversity. We hear it in political speech calling for equal rights and trans-inclusive policies. We also read it in op-eds suggesting transgender people's identities are the result of mental illness. And this week, I read it in a Twitter post from a conservative Christian who believes counselors should discourage people from transitioning.
How can so many different causes all use the same statistics as evidence? Because they have different understandings of why trans people are more likely to commit suicide. In the Twitter post I referenced (see it here), Heath Lambert, associate professor of biblical counseling, stated that "transgender persons have much higher risks of suicide after gender reassignment than the general population." His phrasing suggests that transitioning may be the source of increased suicide risk, so he uses the high rate of suicide to support his argument that transgender people are confused and should be counseled away from a gender transition. Meanwhile, the speeches calling for acceptance and equal rights appear to link the high rates of suicide with experiences of rejection, harassment, and discrimination.
It is clear that beyond knowing that trans people are more likely than non-trans people to be suicidal, it is critical that psychologists and counselors understand the reasons for that increased risk. This allows us to figure out how to intervene. If we all truly want what is best for trans people, and we want to help decrease trans people's risk of dying by suicide, then we need to have a more complete picture of what leads trans people to attempt to end their lives.
So let's look at the research. I hopped on Google Scholar, EBSCO's Academic Search Premier, and Proquest, and pulled every peer-reviewed article that contained the words suicide, suicidal, or suicidality in the title or abstract and looked at risk factors discretely for transgender people (as opposed to studies that look at risk factors/predictors of suicidality for "LGBT people"). In total, there were 12 papers that examined possible factors of suicidal thinking and behavior in transgender people.
At the end of this post, I have provided my reading notes, listing the suicide-related results from each of the studies, with each study clearly cited.
What the research says about suicide risk factors for transgender people:
Lack of support predicts suicide attempts
Studies found that transgender people who had experienced family rejection were more likely to have attempted suicide. Transgender people whose parents supported their transgender identity were significantly less likely to seriously consider suicide than transgender people whose families did not support their identity. Transgender people with parental support were also less likely to have acted on suicidal thinking, meaning they had a lower suicide attempt rate than people whose parents did not support them.
Discrimination predicts suicide attempts
Transgender people who lived in states where LGBT people were less protected from discrimination had higher levels of suicidality than transgender people who lived in less politically-hostile states. And across the board, transgender people who had experienced discrimination were more likely to have attempted suicide.
Transgender-related abuse/violence greatly increases suicide risk
Transgender people who have experienced verbal, physical, or sexual abuse/assault due to their transgender identity or gender expression are substantially more likely to have attempted suicide. The more frequent/regular this abuse was, the more likely a transgender person was to have attempted suicide. Additionally, higher rates of transgender-related abuse/violence were linked with a greater number of suicide attempts, suggesting what researchers call a "dose-redose" effect: the more a person experiences transgender-related abuse/violence, the more chronic and severe their suicidality appears to be.
Increased visibility as trans predicts increased suicidal behavior
Transgender people who report being easily identifiable as trans (either through consistent self-disclosure or being visibly trans) are more likely to seriously consider or attempt suicide, when compared to transgender people who report not being regularly perceived as transgender. This appears to be due to increased experiences of gender-related discrimination, harassment, and violence.
Transgender- and body-related shame are big risk factors
Transgender people who have higher levels of internalized transphobia, or negative beliefs about being transgender are more likely to consider and/or attempt suicide. Transgender people are also at greater risk if they experience body shame, particularly when it is in regard to their weight or how other people perceive their bodies.
Transitioning ultimately reduces suicide risk, but it's not always a smooth path
Having identity documents that matched the transgender person's current gender presentation (as opposed to their sex-assigned-at-birth) was associated with reductions in suicidal ideation. Among transgender people who desired a medical transition, having reportedly completed medical transition steps was associated with reduced suicidal ideation and reduced suicide attempts. This is further supported by studies of non-suicidal psychopathology (e.g., depression) which found that psychological distress significantly declined following hormone therapy and/or surgery.4 However, among transgender people who had seriously considered suicide, those who reported being "in transition" were more likely to have recently attempted suicide than people who desired a medical transition but had not yet started. This suggests that while medically transitioning is a beneficial step for those seeking it, the process may be emotionally difficult for people already in psychological distress - possibly due to increased visibility as trans or to changes in hormones and emotion regulation strategies.
When suicidal ideation is related to being transgender, it is particularly dangerous
Of transgender youth who had seriously considered suicide, the more the suicidal thoughts were related to being transgender, the more likely a youth was to have attempted suicide.
Adolescents and young adults are particularly at-risk
Multiple studies found that younger transgender people were more likely to seriously consider and/or attempt suicide than older transgender people.
Intersecting identities matter in terms of suicide risk
Multiple studies found that transgender people of color were at greater risk of having attempted suicide than white transgender people. Transgender people with HIV and/or disabilities also had increased risk of suicidality.
Gender identity is a significant, but complicated, predictor of suicidal behavior
Multiple studies found that transgender men are more likely to have attempted suicide in their lifetime than transgender women. However, when they examined recent suicide attempts, researchers found that trans women were more likely to have attempted suicide in the past 12 months. This suggests that trans men's increased prevalence of suicidal behavior is due to earlier-in-life attempts, which taper off, perhaps due to transition. Trans women then appear to be more likely than trans men to be suicidal during later stages of transition. I could not find any research examining suicidal ideation or behavior in people with non-binary gender identities.
General risk factors are important for transgender people, too
Trans people are more likely to have attempted suicide if they have struggled with substance abuse, have been homeless, or were currently depressed. Social isolation and loneliness were also found to predict increased levels of suicidal thinking and behavior, as were lower levels of education and income. Importantly, studies suggest that transgender people are more likely than non-transgender people to experience all of these factors.
Results are mixed with regard to help-seeking
In the general population, people seeking mental health treatment have higher rates of suicidal thinking and behavior. This suggests a pattern of seeking help when one is in extreme psychological distress. One study found this to be true for transgender people, but other studies found that there was no suicide risk difference between transgender people seeking treatment and those not. This inconsistency suggests that trans people may be less likely than the general population to seek mental health care even at times of severe mental health struggles.
So what does this all mean?
Contrary to the messages of Mr. Lambert (the aforementioned biblical counseling professor), nothing in any published research even remotely suggests that "confusion" or post-transition "regret" leads trans people to take their lives. Instead, the research consistently points to external experiences of oppression as a major culprit for trans people's high suicide rate. Discrimination, harassment, rejection, internalized shame - these are the experiences that are linked with trans people's increased suicide risk. The internal experience of gender dysphoria also appears to be important, which is why transitioning may reduce risk. (I will note, as a non-scientific observation, that oppression-based experiences, such as misgendering, gender role pressure, and internalized shame, can amplify the way a person experiences their own gender dysphoria... so even this more internal factor is probably not separate from trans people's social context.) So, again you ask, what does this all mean? It means we as a society need to do better by trans people, because the oppression they face is basically klling them.
Okay, and what does this mean for mental health care providers in particular?
First, knowing what makes a transgender person more likely to experience serious suicidal thinking or behavior will allow you to properly assess suicide risk in your clients. If a trans person links their suicidal desires to being transgender (e.g., "Being transgender is so terrible that I don't want to live anymore," or "at night I think about how hard it is to be trans and how much I hate myself for being trans and it makes me want to die"), you now know that research suggests that is a huge red flag for risk of a suicide attempt. You also now know that if, for example, your client is a person of color or has experienced abuse related to being transgender or fits another risk factor described above, you should be monitoring for suicidal ideation more regularly than you would for a lower risk client.
Second (and this is the really important piece, to me), understanding what is associated with and contributing to trans people's suicidal thinking and behavior helps us target our interventions and treatment. But we're therapists, you might be saying - You just told us oppression was the culprit, and as much as we want to, we can't change society overnight. How do we help trans people so that this oppression no longer leads to so much suicidality? Well, good point and great question! I have some ideas:
- Trans people have more to cope with than the general population. Their coping skills need to be extra effective, which is one way that therapy can be very beneficial.
- Helping transgender people understand that much of the psychological distress they feel is the result of this oppressive social context and minority stress can also be a really beneficial route to take in therapy. Often, trans people have internalized the messages that they are crazy or that something is wrong with them, and providing this context can help normalize their reactions/experience and counter that "crazy" message. The Hendricks & Testa (2012) and Austin & Craig (2015) articles linked on my resources page both do a great job of explaining how to use the Minority Stress Model to frame trans people's psychological distress in therapy
- A major part of what we can do as therapists is to reduce the shame transgender people experience around being trans. Internalized transphobia and body shame are predictors of suicidality and are difficulties that I believe can be addressed in therapy. Again, the Austin & Craig (2015) article on my resources page describes a CBT-based approach to working with internalized transphobia.
- As we would with all clients, we must focus not just on mitigating risk factors but also on boosting resilience/protective factors. The literature I discussed here suggests that efforts to help parents/family support a trans loved one would be an effective way of reducing that trans person's risk of attempting suicide. Anneliese Singh of University of Georgia is one of the psychology researchers doing amazing work on resilience factors for trans people. Familiarize yourself with the literature and make increasing resilience factors one of your goals for therapy.
- My own forthcoming research suggests that a protective factor (though I/the field have yet to directly connect it with changes in suicide risk) is transgender community belongingness. Helping a trans person get connected with the trans community and feel like they belong there, serve a purpose, etc., is appropriate and important work for the therapy office.
- I believe it is our ethical responsibility as therapists to help trans people seeking transition to transition. By connecting your clients with transition-related health care, you can ultimately reduce their suicide risk. My former mentor, Dr. Stephanie Budge (2015), has published a case study (you guessed it- linked on my resource page) of the process of evaluating a trans person and providing a referral letter for medical transition. When possible, therapists should also be available to provide coping strategies and support during the difficult early "in-between" stages of transitioning. In these stages, a person may be taking important, exciting, validating, and ultimately beneficial steps, such as starting hormones or beginning to dress as they want, but is also likely going through particularly challenging processes, as well, like coming out, being more visibly trans or andrognyous, etc.
- Finally, we would be doing our clients a disservice if we didn't give them the space to connect with the positive aspects of being transgender. I have heard trans people lose hope because all they can see are the negative parts of their identity, experience, and process. Budge (2014) (yep, on my resources page) discusses the balance we must take as therapists to recognize and validate the real challenges trans people face, while also holding up or helping them discover the positive aspects of their identities and experiences. There has been a small body of qualitative research, in which trans people themselves describe what they like about being trans and how being trans and/or transitioning has benefitted them. This will be the topic of a future blog post.
The section in which I directly list and cite all of the previously-discussed findings so you all know I wasn't pulling any of this out of thin air
The following is my list of the suicide-related findings from each of the studies published on suicide risk factors for trans people:
- Bauer, G. R., Scheim. A. I., Pyne, J., Travers, R., & Hammond, R. (2015). Intervenable factors associated with suicide risk in transgender persons: a respondent driven sampling study in Ontario, Canada. BMC Public Health, 15. doi: 10.1186/s12889-015-1867-2
- Transgender people who had social or parental support of their transgender identities have significantly less suicidal ideation, meaning they are less likely to seriously consider suicide. Of those who seriously considered suicide, those with strong support were 82% less likely to attempt suicide than those without support.
- Transgender people who express low internalized transphobia are 66% less likely to have suicidal ideation than people who express high levels of internalized transphobia. Among those with suicidal ideation, low internalized transphobia was associated with a 76% decrease in attempts.
- Transgender people whose identification documents matched their gender identity are substantially less likely to seriously consider or attempt suicide.
- Transgender people who had undergone hormone replacement therapy or a gender confirmation surgery were less likely to seriously consider or attempt suicide than those who desired such medical changes but hadn't started.
- Among transgender people who are seriously considering suicide, those in the process of medically transitioning are more likely to attempt suicide than those who desire a medical transition but haven't started. The risk is not present when people report having completed a medical transition.
- Clements-Nolle, K., Marx, R., & Katz, M. (2006). Attempted suicide among transgender persons. Journal of Homosexuality, 51, 53-69. doi: 10.1300/J082v51n03_04
- Transgender people who are younger than 25 years old are more likely to attempt suicide.
- Transgender people who are depressed are more likely to attempt suicide.
- Transgender people with a history of substance abuse are more likely to attempt suicide.
- Transgender people who have been sexually assaulted are more likely to attempt suicide.
- The more a transgender person has experienced gender-based discrimination and gender-based victimization/violence, the more at risk they are for attempting suicide.
- Effrig, J. C., Bieschke, K. J., & Locke, B. D. (2011). Examining victimization and psychological distress in transgender college students. Journal of College Counseling, 14, 143-157.
- Mental health help-seeking was not associated with suicide attempts for transgender college students.
- Goldblum, P., Testa, R. J., Hendricks, M. L., Bradford, J., & Bongar, B. (2012). The relationship between gender-based victimization and suicide attempts in transgender people. Professional Psychology: Research and Practice, 43, 468-475, doi: 10.1037/a0029605
- Transgender people who have experienced gender-based violence are four times more likely to have attempted suicide than transgender people who have not experienced gender-based violence.
- Increased experiences of gender-based violence are associated with an increased number of lifetime suicide attempts. [Goldblum]
- Grossman, A. H., & D'Augelli, A. R. (2007). Transgender youth and life-threatening behaviors. Suicide and Life-Threatening Behaviors, 37, 527-537. doi: 10.1521/suli.2007.37.5.527
- Experiences of gender-related verbal and physical abuse by parents was significantly higher in transgender youth who had seriously considered or attempted suicide than in those who had not.
- Transgender youth who attempted suicide were more likely to feel unsatisfied with their body weight and more likely to be concerned about how others' thought about their bodies than transgender youth who had not attempted suicide.
- Of transgender youth who had seriously considered suicide, those who attempted reported higher instances of transgender-related suicidal ideations than those who did not attempt.
- Haas, A. P., Rodgers, P. L., & Herman, J. L. (2014). Suicide attempts among transgender and gender non-conforming adults: Findigns of the National Transgender Discrimination Survey. Report published by American Foundation for Suicide Prevention and The Williams Insititute
- Among transgender adults, those less than 25 are more likely to report having attempted suicide.
- Transgender people of color are more likely to have attempted suicide.
- Transgender people with lower incomes and/or lower education levels are more likely to have attempted suicide.
- Being visibly trans is associated with increased likelihood of a past suicide attempt.
- Transgender people with HIV, disabilities, and/or severe mental health conditions are more likely to have attempted suicide. [Haas]
- Transgender people who have been rejected by their families are more likely to have attempted suicide.
- Transgender people who have been victims of gender-related discrimination, harassment, or violence are more likely to have attempted suicide.
- Transgender people who have experienced homeslessness are more likely to have attempted suicide.
- Maguen, S., Shipherd, J. C. (2010). Suicide risk among transgender individuals. Psychology & Sexuality, 1, 34-43. doi: 10.1080/19419891003634430
- Transgender people who were female assigned at birth were more likely to have attempted suicide in the past.
- Transgender people who had experience transgender-related violence were more likely to have attempted suicide in the past.
- Mental health help-seeking was not associated with changes in suicide risk for transgender adults.
- Mathy, R. M. (2002). Transgender identity and suicidality in a nonclincal sample: Sexual orientation, psychiatric history, and compulsive behaviors. Journal of Psychology & Human Sexuality, 14, 47-65. doi: 10.1300/J056v14n04_03
- Transgender people who have attempted suicide are more likely to have sought mental health treatment in the past.
- Transgender people who have attempted suicide are more likely to report currently having difficulty controlling substance use.
- Nuttbrock, L., Hwahng, S., Bockting, W., Rosenblum, A., Mason, M., Macri, M., & Beck, J. (2010). Psychiatric impact of gender-related abuse across the life course of male-to-female transgender persons. The Journal of Sex Research, 47, 12-23. doi: 10.1080/00224490903062258
- Transgender people who reported having experienced frequent gender-related abuse were four times as likely to have attempted suicide as individuals who did not report gender-related abuse.
- Transgender people who reported having experienced periodic gender-related bause were twice as likely to have attempted suicide as individuals who did not report gender-related bause.
- Perez-Brumer, A., Hatzenbuehler, M. L., Oldenburg, C. E., & Bockting, W. (2015). Individual- and structural-level risk factors for suicide attempts among transgender adults. Behavioral Medicine, 41, 164-171. doi: 10.1080/08964289.2015.1028322
- Trans women are more likely to have recently attempted suicide (within past 12 months), but trans men have greater lifetime suicide risk.
- Trans people of color are more likely to attempt suicide than white trans people.
- Transgender people with higher levels of internalized transphobia are at increased risk of attempting suicide.
- Transgender people who have achieved a college degree are less likely to attempt suicide.
- Transgender people who lives in states with political climates that are stigmatizing to LGB people are more likely to attempt suicide.
- Testa, R. J., Sciacca, L. M., Wang, F., Hendricks, M. L., Goldblum, P., Bradford, J., & Bongar, B. (2012). Effects of violence on transgender people. Professional Psychology: Research and Practice, 43, 452-459. doi: 10.1037/a0029604
- Transgender people who have experienced sexual violence are more likely to have attempted suicide.
- Transgender people who have experienced physical violence are more likely to have attemtped suicide.
- Yadegarfard, M., Ho, R., & Bahramabadian, F. (2013). Influences on loneliness, depression, sexual-risk behaviour and suicidal ideation among Thai transgender youth. Culture, Health & Sexuality, 15, 726-737. doi: 10.1080/13691058.2013.784362
- Transgender youth aged 15-19 have higher levels of suicidal ideation than transgender young adults aged 20-25.
- Yadegarfard, M., Meinhold-Bergmann, M. E., & Ho, R. (2014). Family rejection, social isolation, and loneliness as predictors of negative health outcomes (depression, suicidal ideation, and sexual risk behavior) among Thai male-to-female transgender adolescents. Journal of LGBT Youth, 11, 347-363. doi: 10.1080/19361653.2014.910483
- Transgender youth who experience family rejection are more likely to have seriously considered suicide.
- Trangender youth who reported increased levels of social isolation and/or loneliness are more likely to have seriously considered suicide.
Notes / References
1 Grant, J. M., Mottet, L. A., Tanis, J., Harrison, J., Herman, J. L., & Keisling, M. (2011). Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force. http://www.thetaskforce.org/static_html/downloads/reports/reports/ntds_full.pdf ↩
2 Blosnich, J. R., Brown, G. R., Shipherd, J. C., Kauth, M., Piegari, R. I., and Bossiarte, R. M. (2013). Prevalence of Gender Identity Disorder and suicide risk among transgender veterans utilizing Veterans Health Administration care. American Journal of Public Health, 103. ↩
3 Goldblum, P., Testa, R. J., Hendricks, M. L., Bradford, J., & Bongar, B. (2012). The relationship between gender-based victimization and suicide attempts in transgender people. Professional Psychology: Research and Practice, 43, 468-475, doi: 10.1037/a0029605↩
4 Keo-Meier, C. L., Herman, L. I., Reisner, S. L., Pardo, S. T., Sharp, C., & Babcock, J. C. (2015). Testosterone treatment and MMPI-2 improvement in transgender men: A prospective controlled study. Journal of Consulting and Clinical Psychology, 83, 143-156. doi: 10.1037/a0037599↩