Abstract
Objectives:
To measure prevalence and risk factors of poor mental health, suicidal ideation, and suicide attempt among transgender women in Jiangsu province, China.
Methods:
We surveyed 250 transgender women with mean age of 27.9 years from July 2018 to May 2019 in Jiangsu province, China. Logistic regression analysis characterized risk factors for mental health, suicidal ideation, and suicide attempt.
Results:
Many transgender women experienced discrimination, including verbal abuse (56.0%), physical abuse (32.0%), and sexual violence (32.0%) during their lifetime. Classification by the Kessler Psychological Distress Scale found 32.4%% to be in good mental health, while 24.0%, 16.8%, and 26.8% had mild, moderate, and severe psychological distress respectively. In multivariable logistic regression, severe psychological distress was correlated with bisexual orientation (vs. gay/lesbian, aOR = 2.9, 95%CI = 1.5–5.8), being unsure of sexual orientation (vs. gay/lesbian, aOR = 4.7, 95%CI = 1.8–12.8), experience of verbal abuse (aOR = 1.8, 95%CI = 1.1–3.1), and less severe with alcohol use (aOR = 0.6, 95%CI = 0.3–0.9) (P< 0.05). Many transgender women also reported suicidal ideation (22.0%) and prior suicide attempt (25.6%). Compared to no suicidal ideation, moderate (aOR = 4.9, 95%CI = 1.6–15.2) or severe psychological distress (aOR = 38.6) were associated with prior suicide attempt (P< 0.05). Residing in Jiangsu province (vs. not residing in Jiangsu, aOR = 0.3, 95%CI = 0.1–0.6) and higher income (vs. lower income, aOR = 0.6, 95%CI = 0.4–0.9) were protective factors for suicide attempt (P< 0.05).
Conclusion:
Chinese transgender women experience high levels of discrimination, abuse, poor mental health, suicidal ideation, and suicide attempts in Jiangsu province. Society-wide interventions need to be developed to mitigate transphobic discrimination among transgender women in China.
Keywords: Transgender women, Mental health, Suicidal ideation, Suicide attempt, Risk factors
1. Introduction
Over the past two decades, social science and public health research has furthered our understanding of gender identity as a social construct and not a biological determination (Lombardi, 2001; Steensma et al., 2013). Transgender persons are individuals who identify as a gender different from their assigned sex at birth (American Psychiatric Association, 2013). Conservative estimates suggest that 0.1–0.5% of the world’s population might be transgender, projecting more than 1,400,000 transgender individuals in China (Reisner et al., 2016). Transgender women (hereafter trans women) may bear the highest prevalence of HIV infection of any population worldwide (19.1%) and potentially in areas of China (14.8%), and are in urgent need of HIV prevention, treatment, and other health and social services including mental health (Baral et al., 2013; Yan et al., 2019).
Mental health disorders are a major public health issue for transgender persons, often ascribed to experiencing transphobic stigma, discrimination, and victimization from structures in mainstream society (e.g. schools, workplaces) and interpersonal violence and micro aggressions (Clements-Nolle et al., 2006; Garofalo et al., 2006). Transgender persons may also encounter stigmatization from lesbian, gay, and bisexual individuals (Mustanski et al., 2010). The systemic negative treatment of transgender persons may lead to adverse mental health outcomes, such as anxiety, depression, post-traumatic stress disorder (PTSD), self-injury, suicidal ideation and suicide attempt, and suicide (Perez-Brumer et al., 2015; Reisner et al., 2015). Ill mental health is also linked to increased risk for HIV among trans women (Operario and Nemoto, 2010).
Suicidal ideation, attempts, and suicide may be especially prevalent among trans women (Clements-Nolle et al., 2006; Tucker et al., 2019; Wolford-Clevenger et al., 2018). The incidence of suicide is higher in transgender persons compared to cisgender or non-transgender people (Marshall et al., 2016; Wolford-Clevenger et al., 2017). A longitudinal study in Sweden found that transgender persons were 19-times more likely to experience death from suicide compared to population controls (Dhejne et al., 2011). Furthermore, previous studies have found that 18–45% of transgender adults and youth have experienced suicidal thoughts during their lifetime, with an increasing trend across the life course (Clements-Nolle et al., 2006; Goldblum et al., 2012; Haas et al., 2014).
It is therefore urgent to investigate the prevalence of mental health and suicidal ideation and attempts among trans women, as a population with very high burden of HIV infection and unmet mental health needs. However, little is known about mental health and suicide among Chinese trans women. Better characterization of mental health, suicidal ideation, and suicide attempts in this population can help to develop effective HIV preventive intervention, screening programs, psychotherapy to address HIV and mental health problems and reduce suicidal ideation and attempts among Chinese trans women. In this study, we analyzed data collected from the first and largest cross-sectional survey of trans women in Jiangsu province, China, to explore risk factors and associations with mental health, suicidal ideation, and suicide attempt.
2. Methods
2.1. Study design
This study was implemented from July 2018 to May 2019 in Nanjing and Suzhou, two major cities in Jiangsu province. Jiangsu is an eastern-central coastal province of the People’s Republic of China, with 80.5 million residents in 2018. Nanjing is the capital of Jiangsu province with a population of 8.5 million. Suzhou is a major economic center and focal point of trade and commerce with a population of 10.7 million in its administrative area in 2018.
Participants were eligible if they met the following criteria: (1) lived in Jiangsu province; (2) were 18 years old or older; (3) were assigned male sex at birth but identify as a woman; and (4) were able to provide written informed consent. We used respondent-driven sampling (RDS) for recruitment. Details of the sampling methods have been presented previously (Yan et al., 2019). Briefly, formative research identified 23 trans women to start recruitment referrals (“seeds”) by collaborating with a Nanjing shelter specifically for trans women, and 15 seeds through Suzhou Rainbow, an LGBT community-based organization. Seeds were diverse in age, education, and occupation. They completed a comprehensive, internet-based socio-behavioral questionnaire and received approximately $30 USD. Each seed was encouraged to refer 3–10 peers and would receive an additional $15 USD incentive for each successful referral who participated in the study. We recruited a total sample of 250 trans women in Jiangsu province.
2.2. Data collection
The socio-behavioral questionnaire included demographic information, experiences of discrimination (i.e. experienced some degree of prejudice, disadvantage, or discomfort in school, job applications, workplaces, public spaces, or health settings because of their gender identity in their lifetime), mental health, PTSD screening, access to mental health services, suicidal ideation and suicide attempts, and alcohol and drug use. Discrimination measures included experiencing verbal abuse (i.e. being criticized, insulted, or denounced by other people because of their gender identity in their lifetime, consolidated as yes/no for analysis), physical abuse (i.e. experienced domestic violence, intimate partner violence, or physical beating because of their gender identity in their lifetime, yes/no), harassment (i.e. experienced restricted personal freedom, economic control, forced out of classrooms, home, workplace, school, or public spaces because of their gender identity in their lifetime, yes/no), and sexual violence (i.e. experienced being forced to have sex because of their gender identity in their lifetime, yes/no). Mental health status in the past month was assessed using the 10-item Kessler Psychological Distress Scale (K10) for anxiety and depression as previously applied in China (Xu et al., 2006). K10 responses were summed and categorized into four groups: (1) <20 for well or generally good mental health; (2) 20–24 potentially mild psychological distress or mental health disorder; (3) 25–29 potentially moderate psychological distress or mental health disorder; and (4) >30 potentially severe psychological distress or mental health disorder. In addition, four items were used to screen for PTSD; if a participant answered “yes” to at least three items, they were classified as likely having PTSD.
2.3. Ethics statement
The University of California San Francisco and the Jiangsu Provincial Center for Disease Control and Prevention institutional review boards approved the study protocol (No. JSJK2017-B001–02). All participants provided written informed consent.
2.4. Statistical analysis
Descriptive statistics are presented for demographic characteristics, sexual orientation, alcohol and drug use, psychological distress classification, experiences of abuse due to gender identity, suicidal ideation, and prior suicide attempt. Student’s t-test, Anova analysis, and the Cochran-Mantel-Haenszel Chi-square test (CMH-χ2) were performed to assess bivariate differences across mental health measures. We used a step-wise approach to build multivariable logistic regression models to explore the association between risk factors and severity of psychological distress/mental health disorder, suicidal ideation, and prior suicide attempt, using P<0.1 for inclusion and <0.15 for exclusion. P<0.05 was considered significant.
3. Results
3.1. Characteristics of participants
We obtained 250 questionnaires with valid responses for a 97.6% response rate. Transgender women participants were 27.9 years old (standard deviation [SD] 8.2) on average (Table 1). Over half (58.8%) of participants were born in Jiangsu province, including Nanjing (13.6%), Suzhou (7.2%), and other major cities (38.0%). Over one-third (39.2%) reported their sexual orientation as gay/lesbian, followed by straight/heterosexual (22.8%), and bisexual (16.4%); 7.2% were unsure of their sexual orientation. Most had a low level of education (71.2% with less than bachelor’s degree). One in five (20.0%) had been homeless before the age of 18 years, 27.2% had been homeless after the age of 18 years, 2.0% were homeless or lived in a shelter at the time of the survey. The majority had a monthly income of less than 5,000 yuan (approximately $700 USD) per month (74.4%).
Table 1.
Characteristics of transgender women surveyed, Jiangsu province, China, 2018–2019 (N=250).
| Demographic characteristics | Mean or N | SD or % |
|---|---|---|
| Age (years) | 27.9 | 8.2 |
| Official residency in Jiangsu province | 147 | 58.8 |
| Sex orientation | ||
| Gay/lesbian | 98 | 39.2 |
| Straight/heterosexual | 57 | 22.8 |
| Bisexual | 41 | 16.4 |
| Pansexual | 29 | 11.6 |
| Unsure | 18 | 7.2 |
| Other | 7 | 2.8 |
| Education | ||
| Primary school | 10 | 4.0 |
| Middle school or high school | 82 | 32.8 |
| Technical degree | 86 | 34.4 |
| Bachelor’s degree | 64 | 25.6 |
| Master’s degree or above | 8 | 3.2 |
| Homeless before age 18 years | 50 | 20.0 |
| Homeless after age 18 years | 68 | 27.2 |
| Living situation | ||
| Own a house or apartment | 71 | 28.4 |
| Rent a house or apartment | 143 | 57.2 |
| Couch surfing with friends or family | 13 | 5.2 |
| Homeless/Shelter | 5 | 2.0 |
| other | 18 | 7.2 |
| Marital status | ||
| Single | 215 | 86.0 |
| Married | 14 | 5.6 |
| Divorced or separated | 21 | 8.4 |
| Monthly income (yuan) | ||
| <1,000 | 22 | 8.8 |
| 1,000–3,000 | 65 | 26.0 |
| 3,000–5,000 | 99 | 39.6 |
| 5,000–10,000 | 50 | 20.0 |
| >=10,000 | 14 | 5.6 |
| Employment | ||
| Full-time job | 175 | 70.0 |
| Part-time job | 2 | 0.8 |
| Student | 19 | 7.6 |
| Unemployed | 42 | 16.8 |
| Retired | 12 | 4.8 |
| Alcohol and drug use in the past 12 months | ||
| Ever used alcohol | 164 | 65.6 |
| Ever used alcohol before or during sex | 94 | 37.6 |
| Ever used illicit substances | 13 | 5.2 |
| Ever used illicit substances before or during sex | 10 | 4.0 |
3.2. Experiences of discrimination and alcohol and drug use
A high percentage of participants experienced discrimination, including verbal abuse (56.0%), physical abuse (32.0%), and sexual violence (32.0%). Alcohol use before or during sex was reported by 37.6%%4.0% used illicit drugs before or during sex.
3.3. Mental health
The ten-item K10 scale had a Cronbach’s alpha of 0.95 in our survey sample. The mean K10 score among participants was 23.9 (standard deviation [SD] 9.0, range 10–48). Nearly one-third (32.4%) were classified as being well or of good mental health status. Proportions of participants who had a mild, moderate, or severe psychological distress were 24.0%, 16.8%, 26.8% respectively. Bivariate analysis revealed that poor mental health status was significantly more severe among participants with bisexual or unsure sexual orientation, homelessness before 18 years old, and experiencing verbal, physical, or sexual abuse, as well as alcohol use (all P<0.05, Table 2).
Table 2.
Classification of psychological distress (Kessler Psychological Distress Scale, K10), transgender women, Jiangsu province, China, 2018–2019(N=250).
| Variables | Good or Well | Mild Distress | Moderate Distress | Severe Distress | CMH-χ2 | P value | ||||
|---|---|---|---|---|---|---|---|---|---|---|
| n | % | n | % | n | % | n | % | |||
| Sex orientation | ||||||||||
| Gay/lesbian | 41 | 41.8 | 25 | 25.5 | 13 | 13.3 | 19 | 19.4 | 20.3 | <0.01 |
| Straight/heterosexual | 19 | 33.3 | 19 | 33.3 | 8 | 14.0 | 11 | 19.3 | ||
| Bisexual | 9 | 22.0 | 7 | 17.1 | 10 | 24.4 | 15 | 36.6 | ||
| Pansexual | 9 | 31.0 | 4 | 13.8 | 7 | 24.1 | 9 | 31.0 | ||
| Unsure | 2 | 11.1 | 3 | 16.7 | 3 | 16.7 | 10 | 55.6 | ||
| Other | 1 | 14.3 | 2 | 28.6 | 1 | 14.3 | 3 | 42.9 | ||
| Homeless before age 18 years | ||||||||||
| No | 72 | 36.0 | 47 | 23.5 | 32 | 16.0 | 49 | 24.5 | 5.7 | 0.02 |
| Yes | 9 | 18.0 | 13 | 26.0 | 10 | 20.0 | 18 | 36.0 | ||
| Verbally abused | ||||||||||
| No | 46 | 41.8 | 28 | 25.5 | 16 | 14.6 | 20 | 18.2 | 11.5 | <0.01 |
| Yes | 35 | 25.0 | 32 | 22.9 | 26 | 18.6 | 47 | 33.6 | ||
| Physically abused | ||||||||||
| No | 61 | 35.9 | 46 | 27.1 | 27 | 15.9 | 36 | 21.2 | 9.1 | <0.01 |
| Yes | 20 | 25.0 | 14 | 17.5 | 15 | 18.8 | 31 | 38.8 | ||
| Experienced sexual violence | ||||||||||
| No | 64 | 34.0 | 51 | 27.1 | 29 | 15.4 | 44 | 23.4 | 5.1 | 0.02 |
| Yes | 17 | 27.4 | 9 | 14.5 | 13 | 21.0 | 23 | 37.1 | ||
| Alcohol use | ||||||||||
| No | 23 | 26.7 | 18 | 20.9 | 16 | 18.6 | 29 | 33.7 | 4.2 | 0.04 |
| Yes | 58 | 35.4 | 42 | 25.6 | 26 | 15.9 | 38 | 23.2 | ||
Bold: Significant difference, P<0.05
Independent correlates of mental health status are shown in Table 3. The adjusted odds ratio (aOR) for increasing psychological stress was 2.9 (95% CI = 1.5–5.8) for transgender women with bisexual orientation, and 4.7 (95% CI = 1.8–12.8) for those with unsure sexual orientation compared to those identifying as gay/lesbian.
Table 3.
Correlates of psychological distress (Kessler Psychological Distress Scale, K10) by multivariate ordinal logistic regression, transgender women in Jiangsu province, China, 2018–2019 (N=250).
| Variables | Estimate | Standard error (SE) | Wald χ2 | P value | Adjusted OR (95%CI) |
|---|---|---|---|---|---|
| Intercept 1 | −1.8 | 0.3 | 31.8 | <0.01 | - |
| Intercept 2 | −1.0 | 0.3 | 9.7 | <0.01 | - |
| Intercept 3 | 0.2 | 0.3 | 0.4 | 0.55 | - |
| Sex orientation | |||||
| Gay/lesbian | - | - | - | - | 1.0 (referent) |
| Straight/heterosexual | 0.3 | 0.9 | 0.9 | 0.35 | 1.3 (0.7–2.4) |
| Bisexual | 0.4 | 9.1 | 9.1 | <0.01 | 2.9 (1.5–5.8) |
| Pansexual | 0.4 | 1.2 | 1.2 | 0.27 | 1.6 (0.7–3.4) |
| Unsure | 0.5 | 9.4 | 9.4 | <0.01 | 4.7 (1.8–12.8) |
| Other | 0.8 | 1.1 | 1.1 | 0.30 | 2.1 (0.5–9.1) |
| Homeless before age 18 years | 0.6 | 0.3 | 3.5 | 0.06 | 1.8 (0.9–3.2) |
| Verbally abused | 0.6 | 0.3 | 4.9 | 0.03 | 1.8 (1.1–3.1) |
| Physically abused | 0.5 | 0.3 | 3.2 | 0.07 | 1.7 (0.9–2.9) |
| Alcohol use | −0.6 | 0.3 | 4.2 | 0.04 | 0.6 (0.3–0.9) |
Adjusted for variables included in the table
Bold: Significant difference, P<0.05
Experiencing verbal abuse had higher odds of worse psychological distress compared to those not reporting such experiences (aOR = 1.8, 95% CI = 1.1–3.1). Transgender women reporting alcohol use had lower odds of psychological distress compared to those who did not drink (aOR = 0.6, 95% CI = 0.3–0.9).
3.4. Suicidal ideation and suicide attempts
Nearly one-quarter of the participants (22.0%) reported suicidal ideation and an additional 25.6% reported prior suicide attempt. In bivariate analysis, lack of official Jiangsu residency status, bisexual orientation, homelessness before age 18 years old, experiences of verbal, physical, sexual violence, alcohol use, and more severe mental health disorder were significantly associated with suicidal ideation or prior suicide attempt (Table 4).
Table 4.
Associations with suicidal ideation and prior suicide attempt, transgender women, Jiangsu province, China, 2018–2019(N=250).
| Variables | No suicidal ideation | Suicidal ideation only | Prior suicide attempt | CMH-χ2 | P value | |||
|---|---|---|---|---|---|---|---|---|
| n | % | n | % | n | % | |||
| Official residents in Jiangsu Province | ||||||||
| No | 43 | 41.8 | 23 | 22.3 | 37 | 35.9 | 11.1 | <0.01 |
| Yes | 88 | 59.9 | 32 | 21.8 | 27 | 18.4 | ||
| Sex orientation | ||||||||
| Gay/lesbian | 65 | 66.3 | 17 | 17.4 | 16 | 16.3 | 27.3 | <0.01 |
| Straight/heterosexual | 35 | 61.4 | 12 | 21.1 | 10 | 17.5 | ||
| Bisexual | 13 | 31.7 | 10 | 24.4 | 18 | 43.9 | ||
| Pansexual | 9 | 31.0 | 9 | 31.0 | 11 | 37.9 | ||
| Unsure | 7 | 38.9 | 5 | 27.8 | 6 | 33.3 | ||
| Other | 2 | 28.6 | 2 | 28.6 | 3 | 42.9 | ||
| Homeless before age 18 years | ||||||||
| No | 112 | 56.0 | 43 | 21.5 | 45 | 22.5 | 6.3 | 0.04 |
| Yes | 19 | 38.0 | 12 | 24.0 | 19 | 38.0 | ||
| Verbally abused | ||||||||
| No | 69 | 62.7 | 22 | 20.0 | 19 | 17.3 | 9.6 | <0.01 |
| Yes | 62 | 44.3 | 33 | 23.6 | 45 | 32.1 | ||
| Physically abused | ||||||||
| No | 100 | 58.8 | 35 | 20.6 | 35 | 20.6 | 9.8 | <0.01 |
| Yes | 31 | 38.8 | 20 | 25.0 | 29 | 36.3 | ||
| Experienced sexual violence | ||||||||
| No | 101 | 53.7 | 46 | 24.5 | 41 | 21.8 | 6.6 | 0.04 |
| Yes | 30 | 48.4 | 9 | 14.5 | 23 | 37.1 | ||
| Alcohol use | ||||||||
| No | 35 | 40.7 | 23 | 26.7 | 28 | 32.6 | 7.2 | 0.03 |
| Yes | 96 | 58.5 | 32 | 19.5 | 36 | 22.0 | ||
| Mental health | ||||||||
| Well | 63 | 77.8 | 11 | 13.6 | 7 | 8.6 | 65.8 | <0.01 |
| Mild disorder | 36 | 60.0 | 15 | 25.0 | 9 | 15.0 | ||
| Moderate disorder | 21 | 50.0 | 10 | 23.8 | 11 | 26.2 | ||
| Severe disorder | 11 | 16.4 | 19 | 28.4 | 37 | 55.2 | ||
Multivariate logistic regression analysis indicated that official Jiangsu residency status (aOR = 0.3, 95% CI = 0.1–0.6) and higher income (aOR = 0.6, 95% CI = 0.4–0.9) were independently associated with lower odds of suicide attempt (Table 5). Compared to no suicidal ideation, moderate (aOR = 4.9, 95% CI = 1.6–15.2) or severe psychological distress (aOR = 38.6, 95% CI = 12.8–111.2) were associated with prior suicide attempt. Suicidal ideation was also strongly associated with severe psychological distress score (aOR = 11.3, 95% CI = 4.1–31.3).
Table 5.
Associations with suicidal ideation and prior suicide attempt by multivariate ordinal logistic regression, transgender women, Jiangsu province, China, 2018–2019(N=250).
| Factors | Dependent variable | Wald x2 | P value | Adjusted OR(95%CI) |
|---|---|---|---|---|
| Official residency in Jiangsu province | 12.4 | <0.01 | ||
| Suicide ideation only | 2.9 | 0.09 | 0.6 (0.3–1.1) | |
| Suicide attempts | 11.5 | <0.01 | 0.3 (0.1–0.6) | |
| Monthly income (per income category) | 6.6 | 0.04 | 0.6 (0.4–0.9) | |
| Suicide ideation only | 3.6 | 0.06 | 0.7 (0.5–1.0) | |
| Suicide attempts | 6.1 | 0.01 | 0.6 (0.4–0.9) | |
| Mental health status | 50.8 | <0.01 | ||
| Well(referent) | - | - | - | 1.00 |
| Mild disorder | Suicide ideation only | 4.1 | 0.04 | 2.5 (1.0–6.2) |
| Suicide attempts | 2.8 | 0.10 | 2.6 (0.9–7.7) | |
| Moderate disorder | Suicide ideation only | 3.7 | 0.06 | 2.7 (0.9–7.5) |
| Suicide attempts | 7.6 | <0.01 | 4.9 (1.6–15.2) | |
| Severe disorder | Suicide ideation only | 21.6 | <0.01 | 11.3 (4.1–31.3) |
| Suicide attempts | 41.7 | <0.01 | 38.6 (12.8–111.2) |
Dependent variable: no suicide ideation as referent group; model adjusted for other variables shown in table.
Bold: Significant difference (P<0.05)
3.5. Mental health services received by participants
With respect to access to care, 44.8% of participants reported being diagnosed with mental health disorders including: depression (32.8%), PTSD (3.2%), anxiety (28.0%), and other mental health issues (6.0%). In our sample, the PTSD scale (Cronbach’s alpha of 0.85) screened 24.0% as positive for PTSD. In addition, 22.8%, 18.8%, and 3.2% of participants suffered from any one, two, and three different types of mental issues respectively. Fewer than one in four (22.8%) received professional mental health services in the past 12 months. Among those who did access mental health services, most (91.2%) sought gender-affirming health care services to support their gender identity and 68.4% reported the service was helpful.
4. Discussion
To our knowledge, this is the first and largest study of trans women in Jiangsu province, China. We found that suicidal ideation or suicide attempt were prevalent (together nearly half of trans women) among trans women in Jiangsu province. The estimated prevalence is greater than among the general Chinese population where 12–16% experienced suicidal ideation and 2–3% attempt suicide (Chen et al., 2019). The survey found that the proportion of good mental health in trans women (one in three) was substantially lower than in the general population (70.8%) of China (Li et al., 2017). We concur with other researchers that a main reason for mental health problems among trans women is their marginalization in society with accompanying discrimination, micro and macro aggressions, and late legal recognition and protection in China (UNDP and China Women’s University, 2018). Further isolation from support was evident in our finding as trans women who were bisexuals or unsure of their sexual orientation suffered more severe psychological distress compared to trans women whose sexual orientation was gay/lesbian. These findings support the body of literature demonstrating the strength of connections between discrimination, poor mental health status, suicide ideation, and suicide attempts across a global context (Mustanski and Liu, 2013; Mustanski et al., 2010; Robin et al., 2002; Saewyc et al., 2007).
We also found a significant protective effect for higher income on prior suicide attempts. This could be due to the fact that participants with high monthly incomes may have more social capital and freedom, which may buffer the effect of discrimination on mental health status (Virupaksha et al., 2016). Poverty, in addition to the negative effects of transphobia, may exacerbate mental health status. Additionally, income may be a proxy measure for one’s ability to contribute to society by having a skill, trade or profession that is desirable. Especially in cultures where collectivism is a dominant shared value over individualism, employment training and skills development may be a viable intervention for trans women to contribute to their families, communities, and society. Such contributions may buffer the effects of discrimination, build resiliency, and foster self-efficacy and self-confidence.
While many studies found that alcohol abuse may elevate the risk of suicidal ideation, attempt, and death (Darvishi et al., 2015; Miller et al., 2016; Salles et al., 2019), we found the opposite. We speculate that for some drinkers, alcohol may be a coping mechanism (Baker et al., 2004; Koob, 2003; Robinson et al., 2009) that, perhaps in the short-run, may reduce anxiety (Cox et al., 1993). However, we did not characterize specific alcohol use patterns. Future research should measure drinking patterns and quantities as well as reasons for use to reveal a greater understanding of how alcohol use and coping is related to suicidal ideation and suicide attempt among trans women in China.
5. Limitations
There are limitations to this study that bear on generalizability of our findings. First, we were unable to recruit many young trans women. We suspect that suicidal ideation and suicide attempt may be exacerbated among younger trans women in China, especially as they may not have developed coping and resiliency attributable to aging across the life course. Second, this study is limited by survivorship bias. Deaths of trans women by suicide are not represented in this study and this may have contributed to an underreporting of the prevalence of suicidal ideation and suicide attempts. Third, trans women recruited via shelters could be at a higher risk of mental health problems and suicidal ideation. Fourth, some trans women with severe mental health problems, such as anxiety and depression, may have received their peers’ invitation but declined to participate for a variety of reasons including feeling emotionally hostile toward research that asked about sexual behaviors. The consequences of this selection bias may have resulted in under estimation of the proportion of trans women with psychological distress and poor mental health. Finally, we acknowledge the limitation on our indicator of alcohol use. We did not distinguish problematic use of alcohol and social drinking, which is a commonplace in China. The potential linkages between alcohol use and mental health among Chinese trans women will need more thorough investigation.
6. Conclusions
Despite being the most populous country in the world, research on trans women in China is scant. This cross-sectional study contributes to our knowledge about the severe health issues facing the global communities of gender minorities. We found evidence that trans women experienced high levels of discrimination, poor mental health, suicidal ideation, and suicide attempt in Jiangsu province. Future research identifying potential interventions to improve mental health and prevent suicidal ideation and suicide attempts are needed especially among those that consider the cultural context of being transgender in China.
Acknowledgments
The author would like to thank National Institutes of Health (NIH) for providing financial support, Jiangsu Provincial Center for Disease Control and Prevention (Jiangsu CDC) for organizing the investigation and data analysis, and the Suzhou LESGO team and Nanjing transgender shelter for recruiting transgender women participants in this work.
Funding
This study was supported by the National Institute on Minority and Health Disparities (R01MD010678), the Lifting Program of Jiangsu Provincial Scientific and Technological Association, the Program of Jiangsu Preventive Medicine Association (Y2018075), and the Jiangsu Government Scholarship for Overseas Studies.
Footnotes
Declaration of Competing Interest
The authors have no conflicts of interest to declare.
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