Suicide Risk Among Transgender People: A Prevalent Problem in Critical Need of Empirical and Theoretical Research

Abstract

Transgender individuals are at increased risk for suicide relative to nontransgender people. Despite this, research on transgender people's risk for suicide mirrors their marginalization at the societal level; there is simply not enough research dedicated to understanding increased suicide risk among transgender people. This article presents a brief review of what is known regarding the prevalence and correlates of suicide-related thoughts and behaviors among transgender people and offers perspective regarding what theories of suicide may be pertinent to understanding and addressing increased suicide risk within this population. We also summarize strengths and limitations of the current body of work to provide impetus for additional and improved research on this important problem.

Transgender individuals are at higher risk for suicide relative to nontransgender people (Marshall et al. 2016). Although there are no official estimates of deaths by suicide among transgender people, one study in Sweden showed that transgender individuals undergoing gender affirmation surgery were at 19 times greater risk for dying by suicide than the general population (Dhejne et al. 2011). Researchers using primarily convenience samples have discovered that an alarming percentage (18–45%) of transgender adults and youth have attempted suicide in their lifetime, which is drastically higher than the general population (4.6%; Clements-Nolle et al. 2006; Goldblum et al. 2012; Grossman and D'Augelli 2007; Haas et al. 2014; Kessler et al. 1999; Maguen and Shipherd 2010). Among those who have attempted, more individuals report multiple (19%) than single attempts (9%; Goldblum et al. 2012). Regarding suicide ideation, past year prevalence rates among transgender people (10–15%; Grossman and D'Augelli 2007; Mustanski et al. 2010) surpass percentages in the general population (3.7%; Crosby et al. 2011). Such high prevalence rates of suicide ideation and attempts among transgender individuals seem closely tied to their gendered experience. One study demonstrated that all transgender youth who attempted suicide reported that at least one attempt related to their gender identity (Grossman and D'Augelli 2007), and 16% of transgender persons thought about suicide when they first “felt” transgender (Testa et al. 2014).

These prevalence rates clearly emphasize a critical need for empirical and theoretical work toward understanding and preventing suicide in this population. Unfortunately, the present literature mirrors the marginalization experienced by this population; there are simply not enough studies devoted to suicide risk among transgender individuals. To provide impetus for additional and improved research on this important problem, we present a brief review of what is known regarding the correlates of suicide risk among transgender people, offer theoretical perspectives, and summarize literature strengths and limitations.

Correlates of Suicide Risk Among Transgender People

Primarily quantitative, cross-sectional studies on convenience samples have investigated correlates of suicide risk among transgender people. In general, this research has identified individual (i.e., demographic or internal factors such as sex and mental health symptoms) and environmental (e.g., social support) factors that associate with suicide ideation and attempts. Given the burgeoning distinction between factors that cause suicide ideation and those that turn such ideation toward suicidal action, we review individual and environmental factors separately for suicide ideation and attempts (Klonsky and May 2014).

Correlates of suicide ideation

Few individual factors associated with suicide ideation have been identified among transgender people. Transgender individuals assigned female sex at birth, who plan to transition, or who have already transitioned report greater suicide ideation than their peers (Rood et al. 2015). In addition, expectations of negative reactions toward their gender identity and internalized transphobia are associated with higher suicide ideation (Testa et al. 2017). Individual factors that are potentially protective against suicide ideation include perceived coping abilities, optimism, gender identity acceptance and disclosure, and reasons for living (Moody and Smith 2013; Moody et al. 2015; Testa et al. 2017). Interestingly, Moody et al. (2015) found that transgender people with intentions to or who actually transition reported less suicide ideation, which contrasts aforementioned findings by Rood et al. (2015). These discrepant findings may be explained by an environmental factor that moderated the association between transition status and suicide ideation. That is, individuals who planned to transition or had already transitioned and also experienced discrimination reported greater suicide ideation than those who did not plan to transition and did not experience discrimination (Rood et al. 2015).

In addition to discrimination, environmental factors that are associated with higher levels of suicide ideation include sexual and physical violence victimization, rejection, social disconnectedness, and perceived burdensomeness (Rood et al. 2015; Testa et al. 2017). Several environmental factors were identified as protective against suicide ideation, including cognizance of and connection with other transgender individuals (Testa et al. 2014), social support from friends and family, perceived available help for suicide thoughts, and concerns about effects of suicide on family and children (Moody and Smith 2013).

Correlates of suicide attempts

Greater empirical attention has been given to correlates of suicide attempts than to suicide ideation. Individual factors associated with suicide ideation that were also associated with suicide attempts included internalized transphobia (Perez-Brummer et al. 2015) and assigned female sex at birth (Maguen and Shiperd 2010). Other individual correlates included younger age, multiracial identity, American Indian/Alaskan Native identity, lower education, low income, HIV-positive status, mental or physical disabilities, substance abuse, depression, previous psychiatric hospitalizations, weight and body dissatisfaction, and suicide ideation specific to expected negative future regarding their gender identity (Clements-Nolle et al. 2006; Grossman and D'Augelli 2007; Haas et al. 2014; Maguen and Shiperd 2010). Finally, unlike its negative association with suicide ideation, disclosure was positively associated with suicide attempt history among transgender people (Haas et al. 2014), which may also be because of its relation with increased discrimination (Rood et al. 2015).

Numerous environmental factors are associated with suicide attempt history among transgender individuals. Victimization experiences of childhood maltreatment, harassment, bullying, and sexual and physical violence victimization—including by law enforcement and coworkers—were associated with suicide attempt history (Clements-Nolle et al. 2006; Goldblum et al. 2012; Grossman and D'Augelli 2007; Haas et al. 2014; Maguen and Shiperd 2010; Testa et al. 2012). Furthermore, experiences of stigma and rejection, such as by family, friends, and healthcare providers, were associated with suicide attempt history (Clements-Nolle et al. 2006; Klein and Golub 2016; Haas et al. 2014; Perez-Brummer et al. 2015).

Theoretical Perspectives

The research on suicide risk among transgender people has largely been empirical, with little theoretical considerations. Nonetheless, existing theories of suicide may be applicable to transgender people, as the individual and environmental correlates of suicide ideation and attempts reviewed were similar to those found in nontransgender samples with the difference that transgender people may face many more possible internal and external stressors (e.g., body dissatisfaction and discrimination). For example, traditional theories of suicide highlight pertinent factors to transgender people such as social estrangement (e.g., societal stigma; Durkheim 1897), hopelessness (e.g., expectations of negative reactions to gendered self; Beck 1967), unbearable psychological pain (e.g., body dissatisfaction; Shneidman 1985), and desire to escape aversive self-awareness (e.g., internalized transphobia; Baumeister 1990). However, these theories share inabilities in distinguishing people who think about suicide from those who attempt, and die, by suicide.

Over the past decade, ideation-to-action frameworks have been introduced to improve upon previous theory limitations (Klonsky and May 2014). Joiner (2005) proposed the interpersonal–psychological theory of suicide, positing that suicide ideation results from hopelessness and thwarted interpersonal needs, which only progresses to near-lethal suicide attempts or deaths when an individual has capability to overcome the fear and pain involved in suicide. Guided by this work, Klonsky and May (2015) developed a three-step theory of suicide, which proposes that concurrent hopelessness and emotional pain cause suicide ideation, the severity of which social connectedness buffers. Individuals engaging in suicide ideation do not attempt suicide unless they have the capacity to do so, which involves dispositional (i.e., genetically driven fearlessness and pain insensitivity), acquired (i.e., fearlessness and pain insensitivity gained through habituation), and practical factors (i.e., means that facilitate carrying out a suicide attempt, e.g., access to and knowledge about lethal methods).

The individual and environmental correlates of suicide ideation and attempts reviewed provide preliminary support for the usefulness of the three-step theory. Transgender persons' expectations of rejection and discrimination (Testa et al. 2017) paired with intense psychological pain, such as internalized transphobia, may promote severe suicide ideation (Klonsky and May 2015). Furthermore, several environmental correlates associated with increased suicide ideation such as social rejection, stigma, and disconnection support the theory's position that social connectedness would buffer ideation (Moody and Smith 2013; Rood et al. 2015; Testa et al. 2014, 2017). Less is known about whether the theory's tenet regarding suicide capacity is applicable to transgender individuals' risk for suicide attempts. Transgender individuals' widespread physical and sexual violence victimization (e.g., by family and police force; Clements-Nolle et al. 2006; Haas et al. 2014) may habituate them to pain and fear involved in suicide attempts. Even less is known about what practical factors might facilitate transgender persons' suicide capacity. Given that transgender people are vulnerable to use substances to cope, substances may be an accessible means to suicide (Klein and Golub 2016; Tebbe and Moradi 2016). Future work should test whether the three-step theory is applicable to the transgender population and, if necessary, revise such theory to be suitable to this population.

Literature Strengths and Limitations

Notable strengths to the present literature include measuring suicide ideation and attempts separately, which is instrumental in distinguishing correlates for the two. In addition, the inclusion of qualitative methodology in some studies (e.g., Moody et al. 2015) revealed a rich view of transgender persons' experiences with suicide ideation and attempts. Similarly, some studies' focus on protective, rather than risk, factors showed potential for informing prevention and intervention efforts for suicide among transgender people. Finally, Moody and Smith (2013) thoroughly assessed the spectrum of gender identities. Continual open-ended assessment of gender identities, especially gender-fluid and other gender diverse identities, will be imperative to understand how suicide risk might differ for binary and nonbinary gender identities, and if so, what mechanisms underlie these differences.

Regarding limitations of the literature, greater focus geared toward social and medical transition desires and status will be important to clarify the role of individual and social reactions to one's transition in relation to suicide ideation and attempts. Relatedly, transgender and gender diverse individuals vary widely in their desired transition (e.g., whether or not to receive hormone-replacement theory, whether to legally change gender). Assessing how suicide risk may vary with individualized transitions, while simultaneously assessing one's relative satisfaction with the transition, may be informative to professionals monitoring suicide risk among transgender patients. Second, assessing access to care and healthcare professionals' treatment of transgender persons and how these interactions may impact suicide ideation will be crucial to improving suicide prevention and intervention within this population. Third, many studies combined lesbian, gay, bisexual, and transgender individuals and, therefore, were not included in this brief review. Separating gender minorities from sexual minorities will help shed light on risk factors specific to transgender individuals. Fourth, correlates of suicide ideation and attempts that received relatively little attention in the literature include mental health disorders (e.g., depression), nonsuicidal self-injury, and demographic variables (i.e., age, race/ethnicity). Inclusion of these variables will allow future work to expand on how variables interact, such as intersecting marginalized identities, to increase suicide risk.

Finally, future work would greatly benefit from improving on study methodology and design. Transgender individuals may be difficult to reach in certain communities. Thus, researchers may need to engage with the community through outreach and advocacy to develop needed rapport to conduct important research. Furthermore, study designs that go beyond cross-sectional, survey methodology will be critical to develop a more accurate picture of transgender individuals' risk for suicide. Longitudinal, particularly ecological momentary assessment methods could be useful for identifying individual and environmental factors that impact transgender persons' risk for suicide.

Conclusion

In summary, acquiring a better empirical and theoretical understanding of suicide ideation and attempts in the transgender population carries all of the same inherent difficulties of nonminority populations, which are then thoroughly compounded by the aforementioned biopsychosocial complexities faced by transgender people. Further complicating matters is the difficulty accessing such populations for research. This article has identified a host of important factors that need further study, which require increased research attention to advance the understanding of the etiology, prevention, and treatment of suicide ideation and attempts in this vulnerable population.

Acknowledgments

This work was supported, in part, by grant F31AA024685 awarded by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) to the first author. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIAAA or the National Institutes of Health.

Author Disclosure Statement

No competing financial interests exist.