The short answer is no. Research and anecdotal evidence confirm there is no link between testosterone therapy and aggression in trans men and nonbinary people designated female at birth. Longer answer coming soon.
Self-Compassion & Trans People
On Feeling "Wrong," Experiencing Shame, and Practicing Self-Compassion as a Trans Person
Clients who have gender identities that differ from the sex they were assigned at birth often come into my office with a great deal of shame. And how could they not? As one client recently put it after reading one of Sam Dylan Finch's excellent writings, "I feel like I am constantly apologizing." I do not know a single out trans person who has not had someone tell them directly that they are wrong about their own gender. And if someone manages to avoid this direct interpersonal invalidation, all they need to do is watch their TV for long enough or read the comments of any trans article on a major news site to hear a rejection of the validity of all trans people's genders, identities, existence. Just trying to navigate a world that assumes your gender matches your assigned sex is a fairly constant experience of being told something about you is wrong. I was female assigned at birth and have a clear memory of being told I was in the wrong line when I tried to line up with the boys in preschool. A seemingly simple decision of where to use a toilet or a sink can be an exercise in being told you don't belong.
This goes beyond stigma. This is not unrelated to but IS different from blatant anti-transgender beliefs, experiences of prejudice and hate. If you are trans and reading this, I imagine we are on the same page. You've either already thought about this or I've just given words to feelings and experiences that you've had for years. If you aren't trans, imagine existing in a world where everyone assumes you are a gender different from the gender you actually are. If you are a cisgender woman, imagine what it would be like to have people constantly expecting you to act or look like a man, to get in the boys' line, or to shop in the men's section, use the men's restroom. Imagine that they talked about you by saying "he" and "him." If you are a cisgender man, imagine what it would be like to have people constantly expecting you to act or look like woman. Imagine people talking about you by saying "she" and "her." What would it feel like? You'd be confused at first, perhaps angry, indignant. Would you correct them? What would it feel like to keep having to correct people? Now, importantly, imagine what it would start to mean that you have to keep correcting them.
What it means is someone is wrong in this situation. Either their expectations and assumptions about you are wrong or you are wrong. I don't think a human can exist who wouldn't start to wonder if they were the ones that were wrong in this situation. For many trans people this looks one of two ways: a) That wondering becomes believing and suddenly they understand themselves as wrong, as broken; and/or b) They engage in an almost all-consuming effort to PROVE that they aren't wrong - to prove it to others and to prove it to themselves. Not all trans people respond in these ways, but many do. And it is incredibly damaging. After all, cisgender friends and readers, can you imagine how you might prove that your gender is what you say it is? What could you offer as proof? Imagine how you would demonstrate your woman-ness, your man-ness, the validity of your identity as a woman or a man? Cisgender people often think they can rely on their biology or their sex assignment or perhaps how masculine or feminine they are to prove their gender, but it turns out that none of those things really get at our internal understanding of ourselves as gendered people. Until we can find a way to directly experience the actual thoughts, emotions, and internal experiences of another person, we as society will never be able to have reliable "proof" of anyone's gender. Cisgender people are never asked to prove their gender, so they often fail to realize that when they ask (directly or indirectly) this of trans people, they are asking for something that is impossible. When trans people try to prove their gender, they are being set up to fail.
So both a and b ultimately result in a deep (sometimes very private) shame. A deep sense that something isn't right about you.
And what is so frustrating about all of this is that of course, there isn't anything wrong with trans people's gender. Trans people aren't the ones who are wrong. Society's gender system is wrong. So trans people are out here existing with this heavy sense of not-rightness, when they really are the ones who are right in this situation.
And most trans people come to understand this. Most trans people quite literally battle to accept themselves and to carve a place for themselves and their gender(s). But even as they achieve victories in this battle, they do so on the other side of years, maybe decades - a lifetime of understanding themselves as wrong, as failures or mistakes, as something that needs fixing. And if there's anything we know about brains, it's that the more you use a set of synapses, the easier it is to use them, the harder it is to not use them, and the more likely you are to use them in similar situations in the future. And thinking that you are wrong or feeling shame - these internal experiences are actual sets of synapses firing. So even as trans people start to understand themselves as NOT WRONG, as VALID, they are coping with these brains that have been wired to experiencing themselves as wrong, as invalid.
But another important thing we know about brains is that they can change. If we were in person together, this is the point in my talk where I'd say, "Raise your hand if you've heard of neuroplasticity." (You don't have to raise your hand if you're reading this and you've heard of it.) Neuroplasticity is a fancy word for the ability for our brain wiring to change. It turns out, this is something that human's brains are pretty adept at. It's why we are good learners. It's why we can change unhealthy habits. Heck - it's why therapy works. And what this means for trans people who have gotten very good and internalizing all that rejection and the messages of being wrong, is that their brain wiring that makes them prone to shame, that makes them feel wrong even as they start to know that they aren't - ALL THIS CAN CHANGE.
But it takes some effort. Most trans people (and listen, so we are clear - I include myself in this boat) will have to put some deliberate work into shifting that wiring that makes them move so quickly to understanding themselves as wrong, to being ashamed for something they've done, for something they are - that wiring that, as my client put it, makes us feel like we have to apologize all the time. I think the antidote is deliberate self-compassion practice. Now, self-compassion is kind of like mindfulness in that many of us can say the word and talk about how great it is, but we don't always have a clear sense of what it actually means or how to practice it. Fortunately for everyone, other people have done some great work in this area. So I'm not going to make this piece any longer, and instead will refer those of you interested in building your self-compassion, in being deliberate about shifting your understanding of yourself from invalid to valid from wrong to worthy of love and acceptance... to some outside resources:
First, a post by the folks at Happify includes a nice infographic on what self-compassion actually is and what it isn't. Check it out at EverydayFeminism.
Second, I recommend starting self-compassion practice by engaging in loving-kindness meditation. This is a compassion meditation, based the Buddhist Metta mantra and meditation, which cultivates compassion for loved ones, strangers, enemies, and ourselves. I find it helpful, because it reminds me that engaging in self-compassion is really an act of directing inward all the compassion that we try to provide those around us. The Center for Healthy Minds at University of Wisconsin has a 30-minute guided meditation that I really like. You have to sign up to receive the download, but I can promise you I have yet to receive spam/solicitation from them. Sign up for their compassion training here: www.centerhealthyminds.org/well-being-tools/compassion-training.
Finally, psychologist Dr. Kristen Neff offers some guided meditations and exercises that specifically focus on self-compassion: www.self-compassion.org/category/exercises.
8 Things the Statistics Actually Say About Trans Suicide
Author’s note: If you are thinking about hurting yourself or ending your life, please reach out and get help. We want you to stay alive. National Suicide Hotline: 1 (800) 273-8255; National Crisis Textline: Text “GO” to 741-741; Trans Lifeline: 877-565-8860; Trevor Helpline for LGBT Youth: 1-866-7386.
I have seen a growing number of people citing statistics about increased suicide risk as evidence that therapists/psychologists/counselors/society should not support trans people’s identities and transitions. Gina Loudon told Fox News that those who supported trans people’s right to transition were “science deniers,” claiming that research has found that trans people’s suicide risk increases 20-fold when they transition (spoiler: that statistic is inaccurate). Michael Cook recently penned a blog post titled “What do the statistics say about transgender mental health?”, in which he concluded that the idea that trans people’s psychological stress will be relieved through transitioning is pure deception that runs counter to the evidence. Heath Lambert, professor of biblical counseling who counsels trans people to avoid transition, defends his position by stating that trans people who have transitioned still have higher rates than the general population.
I’ll be clear: Trans people do have increased suicide risk. Across all demographics, if a person is transgender they are more likely to seriously consider and attempt suicide.1 The research, however, just flat out does not support the above views that this increased risk is due to some instability associated with undergoing a gender transition. I propose we take a thorough look at the statistics and the science on trans suicide, so we can get a grasp on what we do know about trans people’s suicide risk. Below are 8 consistent findings from the literature on trans suicide.
1. Rejection and lack of support increase risk of suicidality.
Researchers who conducted the National Transgender Discrimination Survey found that trans people who were rejected by their families were twice as likely to have attempted suicide as trans people who were not rejected.1 Studies have also found that the less social support a transgender person experiences and the more lonely they feel, the more likely they are to seriously consider suicide.2 Family and peer acceptance and support, on the other hand, have been found to be associated with decreases in suicidality, depression and anxiety.3,6 This fits with Dr. Thomas Joiner’s evidence-based Interpersonal Theory of Suicide, which suggests that suicidality emerges when people simultaneously feel that they are a burden to others and lack a sense of belonging.
2. Suicide risk increases when trans people experience discrimination.
Discrimination greatly contributes to suicide risk.4 For example, in one study, trans people who had lost a job for being trans were more than 50% more likely to have attempted suicide than trans people who had not experienced employment discrimination.1 This actually extends to the policy level and general political climate, too. A study published this year in Behavioral Medicine found that trans people have increased suicide risk if they live in states that lack legal protections for LGBT people.5
3. Trans people who experience shame about being trans or about their bodies are more likely to be suicidal.
Trans people may internalize the negative messages about trans people that are perpetuated by media, society, and bigots. They are internalized as negative beliefs about transgender people or negative gender-related beliefs about themselves, and are often experienced as shame about being transgender. This is called internalized transphobia. A piece of this can also be the shame that some trans people feel about the way their body looks and/or is perceived by others. Research has found that both of these experiences (internalized transphobia and body shame) are associated with increased suicide risk.5,6,7
4. Trans people who are easily identifiable as trans are at greater risk of attempting suicide.
Research shows that suicide risk increases as a trans person’s visibility increases. That is, when a trans person is consistently open about being trans or is regularly perceived as trans by others, they are more likely to seriously consider or attempt suicide. This increase is due in part to increased experiences of gender-related discrimination, harassment, and violence.1,8 This likely also explains the mixed findings about medical transitions and suicide risk.
5. Undergoing an affirming medical transition does not make trans people more suicidal. In fact, it reduces suicide risk.
This is a big one. A lot of people who argue against supporting/affirming a person’s transition try to make the case that transitioning makes trans people more suicidal. They often cite a thoroughly debunked study from the 1970s or a gross misrepresentation of recent research. This argument might also come from a misunderstanding of a more recent study, which found that transgender people who have had some form of gender affirmation surgery were slightly more likely to have attempted suicide in their lives than those who who had not (43% vs. 39%). This difference was more pronounced when looking at people who had taken any medical transition steps (e.g., hormone replacement therapy).1 This doesn’t mean trans people who have transitioned are more likely to attempt suicide than trans people who don’t transition - it means they are more likely to have attempted at one point in their life. These are very different statements, and the former is not supported by other research. The only published longitudinal studies which have reliably measured mental health of transgender people before transitioning and again after beginning that transition found that medical transitions significantly reduce psychological distress.9 A recent study out of Canada further clarified these findings by evaluating differences in current suicidal thinking and past-year suicide attempts at various stages of transition. Trans people who were on hormones were half as likely to have seriously considered suicide in the past year. Trans people who reported that their medical transition was complete were 62% less likely to have seriously considered suicide. They were also significantly less likely to have recently attempted suicide. Of trans people who had seriously considered suicide in the past year, those who said they were in the process of transitioning were more likely to have attempted suicide than those who had completed a transition and those who wanted to transition but hadn’t started.6 The finding that trans people who are seriously considering suicide may experience an increased risk of attempting when they are “in the process of” a medical transition is not surprising. It is a safe assumption that this increase in risk is due to initial increases in visibility (e.g., coming out, being more visibly non-conforming) that, in the beginning, offset the reduction of psychological distress transition has been found to have. So in sum, existing evidence overwhelmingly shows that medical transitions, when desired, are linked to improved mental health and suicide risk reduction, though the difficulties of beginning a transition may increase suicidality of those already considering suicide. It is important to also note that despite the reduction in risk, trans people who have transitioned are still at greater risk of attempting suicide than non-transgender people.10 The rest of this post should help explain why the risk persists.
6. Trans people who survive trans-related violence and abuse are substantially more likely to attempt suicide.
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.4,7,11,12 An unfortunately, these studies and others also show that it is not uncommon for trans people to experience harassment, physical assault, and/or sexual assault due to bias. For example, 35% of trans people reported being physically assaulted in school for being trans or gender non-conforming. That percentage was higher for trans people of color and trans people who were visibly identifiable as trans or gender non-conforming.8
7. Trans people are more likely to experience general risk factors for suicide.
The experiences and characteristics that make anyone more likely to be suicidal also make trans people more likely to have seriously considered or attempted suicide. These include, but are not limited to: youth, alcohol and substance abuse, trauma, homelessness, lower education levels, depression, and severe mental health issues.3,4,5,13 Unfortunately, research suggests that (besides age), trans people are more likely than the general population to experience these risk factors.1
8. Intersecting identities matter.
Belonging to other minority and/or sitgmatized groups increases trans people’s risk of seriously considering and attempting suicide. For example, studies consistently show that trans people of color have higher rates of suicide attempts than white trans people. Trans people with HIV and/or disabilitites are also at increased risk, as are low-income and homeless trans people.5,8
Edited on 11/2/2015 to include suicide prevention / crisis resources.
References
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
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
Budge, S. L., Adelson, J. L., & Howard, K. A. S. (2013). Anxiety and depression in transgender individuals: The roles of transition status, loss, social support, and coping. Journal of Counseling and Clinical Psychology, 81, 545-567.
Clements-Nolle, K., Marx, R., & Katz, M. (2006). Attempted suicide among transgender persons. Journal of Homosexuality, 51, 53-69. doi: 10.1300/J082v51n03_04
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
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
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
Haas, A. P., Rodgers, P. L., & Herman, J. L. (2014). Suicide attempts among transgender and gender non-conforming adults: Findings of the National Transgender Discrimination Survey. Report published by American Foundation for Suicide Prevention and The Williams Insititute.
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
Dhejne, C., Lichtenstein, P., Boman, M., Johansson, A. L. V., Langstrom, N., & Landen, M. (2011). Long-term follow-up for transsexual persons undergoing sex reassignment surgery: Cohort study in Sweden. PLOS One. doi: 10.1371/journal.pone.0016885
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
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
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