Intervenable factors associated with suicide risk in transgender persons
Across Europe, Canada, and the United States, 22–43 percent of transgender (trans) people report a history of suicide attempts.
We aimed to identify intervenable factors (related to social inclusion, transphobia, or sex/gender transition) associated with reduced risk of past-year suicide ideation or attempt, and to quantify the potential population health impact.
Methods
The Trans PULSE respondent-driven sampling (RDS) survey collected data from trans people age 16+ in Ontario, Canada, including 380 who reported on suicide outcomes.
Descriptive statistics and multivariable logistic regression models were weighted using RDS II methods. Counterfactual risk ratios and population attributable risks were estimated using model-standardized risks.
Results
Among trans Ontarians, 35.1 percent (95 percent CI: 27.6, 42.5) seriously considered, and 11.2 percent (95 percent CI: 6.0, 16.4) attempted, suicide in the past year.
Social support, reduced transphobia, and having any personal identification documents changed to an appropriate sex designation were associated with large relative and absolute reductions in suicide risk, as was completing a medical transition through hormones and/or surgeries (when needed).
Parental support for gender identity was associated with reduced ideation. Lower self-reported transphobia (10th versus 90th percentile) was associated with a 66 percent reduction in ideation (RR = 0.34, 95 percent CI: 0.17, 0.67), and an additional 76 percent reduction in attempts among those with ideation (RR = 0.24; 95 percent CI: 0.07, 0.82).
This corresponds to potential prevention of 160 ideations per 1000 trans persons, and 200 attempts per 1,000 with ideation, based on a hypothetical reduction of transphobia from current levels to the 10th percentile.
Large effect sizes were observed for this controlled analysis of intervenable factors, suggesting that interventions to increase social inclusion and access to medical transition, and to reduce transphobia, have the potential to contribute to substantial reductions in the extremely high prevalences of suicide ideation and attempts within trans populations.
Such interventions at the population level may require policy change.
Discussion
Our findings provide evidence that social inclusion (social support, gender-specific support from parents, identity documents), protection from transphobia (interpersonal, violence), and undergoing medical transition have the potential for sizeable effects on the high rates of suicide ideation and attempts in trans communities.
In contrast, we did not find statistically significant effects for social transition, gender support from sources other than parents, or religiosity/spirituality, other than an unexpected finding regarding strong gender support from leaders.
Given that statistical power was not high, as evidenced by the width of our confidence intervals, a lack of statistical significance does not mean that these other factors should be dismissed, as smaller effects may exist below the threshold for detection.
Our results provide support for the potentially strong impact of trans-specific discrimination or harassment (e.g., experiences of transphobia), interpersonal factors (e.g., strong parental support for gender identity or expression) and structural factors (e.g., having an identity document with a gender marker concordant with one’s lived gender) on suicide ideation or attempts.
This reinforces our earlier descriptive findings that risk of suicide ideation and attempts varied greatly among trans people [2], and reinforces the need to look beyond proximal determinants toward sites of early prevention or intervention.
It is not clear to what extent results from this study may also apply to gender non-conforming cisgender persons, but we note that among sexual minority youth, early gender non-conformity has been associated with increased suicidal behaviour or risk, a process that may be mediated by gender harassment or bullying [53–55], or by parental disapproval of gender expression [55].
The large effect sizes observed support the possibility for preventing suicidal ideation and attempts in a large number of individuals.
Using the transphobia results as an example, combining the population effects of a reduction in ideation and a reduction in attempt risk among the reduced cases of ideation, and given a population estimate of 53,500 trans adults in Ontario [26], we would estimate that reducing experiences of transphobia could prevent 8,560 trans persons in the province from experiencing suicidal ideation and 4,601 persons from a suicide attempt within a year.
Our results represent the most detailed analysis of this issue to date; our study was based on a respondent-driven sample of trans people from a large provincial geographic area. The analysis takes account of differential probability of recruitment related to differences in network size, but other biases unrelated to network size may remain [56].
Our use of past-year suicide-related measures represents an improvement over studies that used lifetime measures, as we are able to analyse impact on recent or current risk, which is most relevant to prevention.
However, temporality remains a concern. It is possible that some potential causes occurring in the past year followed rather than preceded the outcome. This is one potential explanation of the unusual finding of support from a leader (teacher, supervisor, institution) being associated with increased suicide attempts among those with ideation, in that an attempt may trigger the involvement of leaders.
Moreover, as we were unable to determine the exact sequences of events for each participant, it is likely that we have partially controlled for some mediating effects or not controlled for some confounding.
For example, borderline personality disorder is adjusted for as a confounder, though it is possible that for some participants its etiology includes experiences of transphobia such as those we assess, and it may thus play a mediating role.
Despite these limitations, we attempted to address temporality within a cross-sectional design through time designations within questionnaire items (e.g., childhood abuse prior to the age for inclusion in this study) and use of past-year outcomes.
Our finding that completing a medical transition was associated with reduced risk has implications for interpretation of existing studies on completed suicides.
Because trans people are not identifiable in death records, and because completed suicides may occur among those who know they are trans but are not known by family members to be trans, valid studies of completed suicides have only been done where patient records from gender clinics have been matched to population death records (e.g., in Sweden [15]).
Our results suggest these estimates of completed suicide among those who have medically transitioned likely underestimate the risk of suicide among broader trans communities.
As all surveys are, by definition, studies of survivors, survival bias remains an issue. Frequencies for attempts will likely be underestimated. Factors that predict lethality may be missed, if those who completed suicide differ from those who survived attempts.
Given that we assessed suicide attempts only among those who indicated past-year serious consideration, our data may also have missed additional attempts that were impulsive and unplanned.
Moreover, past-year prevalence may not represent a first incident of suicide ideation or attempt; thus, this analysis cannot distinguish between factors that lead one to first become suicidal versus to continue being suicidal.
Proximal factors theorized and demonstrated to increase risk of suicide ideation and/or attempts (e.g., risk factors from epidemiological research and interpersonal factors from Joiner’s Interpersonal Model [43]) were conceptualized as mediators, but not included in these analyses.
Moreover, our analysis could not disaggregate effects of intervenable variables on other intervenable variables. For example, it is possible that increased parental support for gender may affect whether or not someone is able to medically transition; it is also possible that medical transition results in increased parental support for gender, as parents are able to more clearly see their child in their felt gender.
These areas represent opportunities for future research. In general, suicide research regarding gender and sexual minorities has tended to overlook existing theoretical frameworks within suicidology [57], though they are not incompatible with other frameworks or methods.
Future research with trans populations could draw on interdisciplinary theories as well as evidence from trans-specific and broader population research on suicide ideation and attempts to study mediated pathways.
Future prospective cohort studies of broadly defined trans populations are needed to alleviate many of the limitations of this and other studies. With prospective data, we may be able to differentiate between factors that cause initial ideation and factors that prolong its duration, as well as those that lead to first and repeated attempts.
We could also begin to study completed suicides in a non-clinical trans population, at least among those who are willing to identify as trans to researchers.
Moreover, with clear information on temporality, we would be able to design better controlled and more valid analyses, and to examine mediated pathways (including pathways between intervenable factors as well as proximal factors) to better understand the process through which social marginalization may impact suicide ideation and attempt.
Our goal of evaluating intervenable factors should be interpreted as a screening of potential strategies rather than an analysis of actual population intervention effects.
While background factors are structured to represent those that are in the past, unchangeable, or not likely to change in response to other factors in the model, our analytic approach then considers intervenable factors singly; it was not possible to tease apart causal pathways among these factors and combining them into one model would by default serve to prioritize the proximal causal factors while reducing the effect sizes of other potentially important causes [58] (a general effect of multivariable models that is not often explicated but is commonly understood with regard to control for a mediator reducing a causal effect [59, 60]).
Depending upon inter-individual variation, as in all individual-level studies, also results in an inability to detect simultaneous effects at the group level [61].
For example, reducing transphobic assaults from the current prevalence of 21.2 to zero percent may affect suicide risk not only by saving individuals from the trauma of hate-based assault, but may have additional effects on these individuals and others based on living in a society where transphobic assaults do not occur, versus where they are common.
Conclusions
Our findings support a strong effect for social exclusion, discrimination and lack of medical transition (for those needing it) on suicide ideation and attempts, and potentially on the survival of trans persons.
This adds support to the larger discussion regarding social impacts on suicide risk in groups experiencing marginalization, such as Indigenous communities and sexual minorities. Our team has previously published recommendations for suicide prevention efforts with trans persons, based on descriptive analyses of these data [2].
The present analysis provides stronger support for those recommendations, including attention to social support and protection from discrimination, by showing that these effects remain after adjusting for potential confounding by background.
It also suggests additional targets for intervention. Specifically, while gender recognition is recognized as a human right for trans people in Ontario [62], we have provided the first evidence of its potential to reduce suicidality.
Since our data were collected, the surgical requirement for changing the sex/gender designation on an Ontario birth certificate has been eliminated. Such legal and policy changes can be considered public health interventions worthy of longer-term evaluation.
In addition, parental support has been previously associated with reduced suicide risk for sexual minority [63] and trans [64] youth, but our results demonstrate the importance of parental support for gender identity among adults, suggesting a need for all-ages family interventions.
Finally, we found that among those reporting a need to medically transition through hormones and/or surgeries, suicidality was substantially reduced among those who had completed a medical transition (this involved varying procedures based on personal needs [16]).
Despite potentially large reductions in risk for those completing medical transition, the period of being in process did not represent a clear mid-point in risk. While suicidal ideation was significantly reduced for those in process versus those who were planning to transition but had not begun, among the sub-group considering suicide the attempt rate was highest among those in process.
These results call into question the safety of clinical practices that delay transition treatments until depressive symptoms or suicidality are well-controlled, and of procedural practices that require or result in long delays in the medical transition process, but also suggest need for supports for those who may feel suicidal while in the process of transitioning.
Our findings strongly suggest that interventions aimed at increasing social inclusion, reducing transphobic discrimination and violence, and facilitating access to medical transition should be considered as part of a comprehensive approach to suicide prevention in trans populations, and evaluated to assess effectiveness.
Such interventions need not supplant individual-level or therapeutic approaches (e.g., psychotherapy, crisis services), but have the potential to reduce suicide ideation and attempts by targeting stigma and social exclusion as fundamental causes of disparities.
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