Suicide Among Transgender and Gender-Nonconforming People

ABSTRACT

Transgender and gender-nonconforming (TGNC) individuals are those whose gender identity or expression does not align with the conventional concept of being a man or a woman. TGNC encompasses several gender designations such as trans, transgender, genderqueer, gender fluid, and pangender. Individuals who identify as TGNC represent up to 0.5% of the adult population.1

People in the TGNC community face discrimination and social disparities and experience an alarming rate of sexual or physical assaults, bullying, and job discrimination.2 Compared to the general population, suicide occurs more often among those who identify as TGNC, with lifetime suicide attempt rates between 30% and 81%.3-6 In comparison, the incidence of attempted suicide in the general population annually is under 1%,7 with a prevalence of just below 5%.6 The lifetime prevalence rate of suicide attempts among lesbian, gay, and bisexual adults is between 10% and 20%.8 Nonsuicidal self-injuries, like ever cutting, hitting, or burning oneself, occur in 19%-38% of the trans population: 58% among men and 26% among women.6 Of those who identify as trans, males are consistently more at risk for suicide than are females.6 It is important to understand the factors leading to these issues and to implement interventions that mitigate self-harm or completed suicide. This narrative review includes the most pertinent literature from the past 17 years on issues related to suicide among those who identify as TGNC.

PSYCHIATRY

In TGNC individuals, the lifetime prevalence rates of Axis I diagnoses, affective problems, and anxiety were estimated at 70%, 60%, and 28%, respectively, while Axis II conditions were less common at 15%.6 Prevalence rates of substance abuse, eating disorders, or psychosis were noted at 16%, 2%, and 1%, respectively.6 Although such high rates of mental health issues are consistently reported, there is disagreement regarding gender specificity—the prevalence of mental health issues for each gender remains unclear.6 Higher rates of co-occurring autistic traits are reported in persons with gender dysphoria and affect men more than women.6 Despite fewer Asperger’s syndrome diagnoses, autistic traits may be higher in TGNC individuals and those with gender dysphoria compared to the general population, yet lower than in people with a diagnosis in the autism spectrum.6

SUICIDE RISK

In all populations, a history of attempted suicide is the strongest predictor of ultimately killing oneself.1 Risk factors for suicide include old age, male gender, unemployment, mood disorders, anxiety or panic attacks, psychiatric hospitalizations, or a history of self-injury.9 These risk factors account for only some of the suicides within the TGNC community, since these individuals face unique challenges and discrimination and experience elevated rates of institutionalized prejudice, bullying, violence, and physical attacks.10 Suicidal thoughts and attempts are more common in those who experience discrimination or physical victimization.10 When assessing suicide risk in these patients, it is best to discuss past experiences of prejudice, maltreatment, and violence.

Family rejection induces suicidal behaviors.11 TGNC individuals who experienced family rejection were over 3 times more likely to attempt suicide compared to those who did not have these experiences.11 Familial stability can counter negative self-esteem and bolster mental health.

• It is important to assess the risk of suicide among transgender and gender-nonconforming patients and discuss past experiences of prejudice or maltreatment to prevent further victimization.
• Fostering social inclusion and facilitating open access to medical care promotes a positive outcome.
• Familial stability can help counter negative self-esteem and strengthen mental health; parental and peer support imparts better self-acceptance and well-being.

Internalized transphobia refers to a negative self-concept about gender identity even if it remains unconscious.12 These feelings can include self-hate or shame. Internalized transphobia increases the likelihood that someone will attempt or complete suicide.8 Those with a racial or ethnic minority status or less education incur a greater risk. Psychotherapy is indicated to help mitigate internalized transphobic self-concepts.8 To improve outcomes, suicidal issues should be overtly addressed. Unfortunately, many of these individuals also experience discrimination in the health care system.13

Denial of appropriate bathroom or housing access also elevates the risk for suicide. TGNC college students victimized in this manner are distressed and commit suicide at a relatively high rate.14,15 The National Transgender Discrimination Survey data14 recommend techniques for colleges and universities to counter such issues. Stress decreases when all students have safe bathroom access and stable housing. Physicians can be leaders in the community by advocating on behalf of their TGNC patients and recommending legislation to counter victimization and improve societal attitudes.

Identity and experience among trans individuals are diverse. Some express their gender differences, while others choose to hide their feelings. Many are subjected to gender-related hostility and insensitivity. Negative mental health consequences can be minimized by identifying those subjected to gender-based violence and preventing further victimization through antivictimization programs, which promote the well-being of youth.1,16 Other important interventions include fostering social inclusion, reducing discrimination or violence, and facilitating access to medical care.1,16

Suicide rates of Lebanese TGNC women are similar to those in the United States.17 These women experience high levels of depression (66%) and suicide attempts (46%) but receive little counseling or treatment.17 University students in Lebanon rarely seek such help, possibly due to societal norms.18 Lack of support and integration was associated with suicide attempts, while lower suicide rates were noted in Lebanese students with good familial and social support.18

In Turkey, the suicide rate between 1990 and 2000 was 2-3/100,000,19 which is lower than that in the United States and most European countries. Attempted and completed suicides in Ankara were less frequent than in many other Turkish cities.19 Turkish citizen suicides were most common in the 15- to 24-year age group, consistent with international epidemiologic reports.19

Transsexual individuals evidence a high risk of suicide, particularly during adolescence.19 They may not mention their sexual identity issues even after an attempted suicide, fearing negative attitudes from medical personnel.19 Thus, psychiatric patients should be screened for gender identity issues after an attempted suicide. Positive clinician attitudes are enhanced by increasing experience with and knowledge of transsexual patients.19

Group therapy, self-help, and family support can be helpful interventions. These 3 modes of therapy often span many cultures. Therapy stresses improving personal adjustment with support and may mitigate risks for future suicidal thoughts, especially among adolescent patients.19

SUICIDE PRECIPITANTS

Lack of belongingness is a key component of suicidal ideation, which is particularly relevant in TGNC populations.20 Serious suicidal behavior (ie, lethal or near-fatal attempts) is most likely to occur in the context of thwarted belongingness, perceived burdensomeness, hopelessness, reduced fear of suicide, and elevated tolerance toward physical pain.20 Social isolation is another reliable predictor of suicidal ideation, attempts, and completed suicide. The perception of burdensomeness plays a key role in the etiology of suicide; it comprises feelings of self-hatred and the belief that one is flawed and a liability to others.20

PROTECTION

Canadian researchers21 revealed 3 ways to prevent suicide attempts in the TGNC community: better social support from family, greater emotional stability, and child-related activities that promote self-esteem. Emotional stability is protective since it enhances the ability to resist suicidal ideation, and the reduction of child-related fears decreases the likelihood of suicidal behavior. Less internalized transphobia, legal documents that reflect one’s perceived gender, access to gender-affirming surgery (if indicated), and social support also decrease suicidality.1 Further protection can be provided by teaching people how to control self-dangerous thoughts, facilitating societal acceptance, and providing appropriate access to professional interventions. Youth living in communities that are supportive of transgender rights are less likely to attempt suicide even after controlling for other risk indicators such as a history of physical abuse, depression, substance abuse, or peer victimization compared to those living in nonsupportive communities.1,21

States with antibullying laws to reduce sexual orientation and gender identity discrimination have lower rates of homophobic victimization and harassment than states without these protections.22 High school gay-straight alliance and student-led clubs open to all youth who support lesbian, gay, bisexual, and trans students similarly confer a beneficial role.22 These clubs aim to reduce prejudice and harassment within the school environment. Parental and peer support imparts positive mental health, self-acceptance, and well-being. Trans-identified youth who retained friends after disclosing their sexual identity experienced higher self-esteem, less depression, and fewer suicidal thoughts than those who had lost friends by such disclosure.22 Table 1 provides areas of support for TGNC individuals and their potential impact on suicide reduction.

CONCLUSION

Suicidal behaviors in the TGNC community often follow high levels of stigmatization, discrimination, violence, or internalized transphobic feelings. Suicide risk could be potentially decreased by addressing these issues clinically.

One societal goal is to better accept individuals of all gender identities. Health care professionals can work toward this goal of acceptance and minimize prejudice by conveying positive attitudes toward TGNC patients. Mental health care for patients who identify as TGNC should include assistance with acceptance of their identities, wellness promotion, and treatment of suicidal risk factors. It is also important to nurture the patient’s perception of his or her ability to resist suicide attempts—teaching techniques to minimize such thoughts empowers these individuals to overcome the desire to end their life and may reduce rates of completed suicides as well. Improved mental health and self-esteem translates to greater safety for these patients.

The best way for health care personnel to address disparities is by being supportive. This support can apply in the clinical arena as well as in the broader societal context. Patients should receive routine medical and psychiatric treatment and assistance with overcoming familial or societal barriers.23 A good patient-to-doctor relationship enhances the ability of clinicians to quickly recognize the risk factors for suicide in this population and productively intervene on behalf of patients with TGNC identity.

Submitted: January 12, 2018; accepted February 15, 2018.

Published online: June 21, 2018.

Potential conflicts of interest: None.

Funding/support: None.

REFERENCES

1. Bauer GR, Scheim AI, Pyne J, et al. Intervenable factors associated with suicide risk in transgender persons: a respondent driven sampling study in Ontario, Canada. BMC Public Health. 2015;15(1):525. PubMed CrossRef

2. Brown A. Confronting Prejudice—Safety & Tips. Coavp.org website. http://www.coavp.org/confronting-prejudice-safety-tips.html. Accessed May 31, 2018.

3. Clements-Nolle K, Marx R, Katz M. Attempted suicide among transgender persons: the influence of gender-based discrimination and victimization. J Homosex. 2006;51(3):53-69. PubMed CrossRef

4. Maguen S, Shipherd JC. Suicide risk among transgender individuals. Psychol Sex. 2010;1(1):34-43. CrossRef

5. Injustice at every turn: a report of the National Transgender Discrimination Survey. National LGBTQ Task Force website. http://www.thetaskforce.org/downloads/reports/reports/ntds_full.pdf. Accessed May 31, 2018.

6. Mueller SC, De Cuypere G, T’ Sjoen G. Transgender research in the 21st century: a selective critical review from a neurocognitive perspective. Am J Psychiatry. 2017;174(12):1155-1162. PubMed CrossRef

7. Centers for Disease Control and Prevention. Suicide facts at a glance. https://www.cdc.gov/violenceprevention/pdf/suicide-datasheet-a.pdf. Accessed May 31, 2018.

8. Perez-Brumer A, Hatzenbuehler ML, Oldenburg CE, et al. Individual- and structural-level risk factors for suicide attempts among transgender adults. Behav Med. 2015;41(3):164-171. PubMed CrossRef

9. Brown GK, Beck AT, Steer RA, et al. Risk factors for suicide in psychiatric outpatients: a 20-year prospective study. J Consult Clin Psychol. 2000;68(3):371-377. PubMed CrossRef

10. Barboza GE, Dominguez S, Chance E. Physical victimization, gender identity and suicide risk among transgender men and women. Prev Med Rep. 2016;4:385-390. PubMed CrossRef

11. Klein A, Golub SA. Family rejection as a predictor of suicide attempts and substance misuse among transgender and gender nonconforming adults. LGBT Health. 2016;3(3):193-199. PubMed CrossRef

12. Kaplan AB. Internalized trans-phobia. Transgender Mental Health website. https://tgmentalhealth.com/2011/03/25/internalized-trans-phobia/. Accessed May 31, 2008.

13. Bradford J, Reisner SL, Honnold JA, et al. Experiences of transgender-related discrimination and implications for health: results from the Virginia Transgender Health Initiative Study. Am J Public Health. 2013;103(10):1820-1829. PubMed CrossRef

14. Seelman KL. Transgender adults’ access to college bathrooms and housing and the relationship to suicidality. J Homosex. 2016;63(10):1378-1399. PubMed CrossRef

15. The Obama administration transgender bathroom policy has spurred an 11-state lawsuit. Newsweek website. http://www.newsweek.com/obama-transgender-bathroom-policy-lawsuit-463533. Accessed May 31, 2018.

16. Goldblum P, Testa RJ, Pflum S, et al. The relationship between gender-based victimization and suicide attempts in transgender people. Prof Psychol Res Pr. 2012;43(5):468-475. CrossRef

17. Kaplan RL, Nehme S, Aunon F, et al. Suicide risk factors among trans feminine individuals in Lebanon. Int J Transgenderism. 2016;17(1):23-30. PubMed CrossRef

18. El Kahi HA, Abi Rizk GY, Hlais SA, et al. Health-care-seeking behaviour among university students in Lebanon. East Mediterr Health J. 2012;18(6):598-606. PubMed CrossRef

19. Y×¼ksel Åž, AslantaÅŸ Ertekin B, ×–zt×¼rk M, et al. A clinically neglected topic: risk of suicide in transgender individuals. Noro Psikiyatri Arsivi. 2017;54(1):28-32. PubMed CrossRef

20. Van Orden KA, Witte TK, Cukrowicz KC, et al. The interpersonal theory of suicide. Psychol Rev. 2010;117(2):575-600. PubMed CrossRef

21. Moody C, Smith NG. Suicide protective factors among trans adults. Arch Sex Behav. 2013;42(5):739-752. PubMed CrossRef

22. Russell ST, Fish JN. Mental health in lesbian, gay, bisexual, and transgender (LGBT) youth. Annu Rev Clin Psychol. 2016;12(1):465-487. PubMed CrossRef

23. Aldrin S. Transgender is not a verb: three ways to provide compassionate care to trans patients. Society of Teachers of Family Medicine website. https://blog.stfm.org. May 31, 2018. Accessed January 6, 2016.