Keep Trans Youth Alive: Considerations for Suicide Prevention of Gender Expansive Youth

Abstract

Objective

This article examines suicidality of gender expansive youth and identifies evidence-based, practical interventions for healthcare professionals and other adults who interact with gender expansive youth.

Methods

Research methods included an interview, literature review, articles from peer-reviewed journals, and application of clinical experience. Based on the interview, a case study is included, which describes one transgender man’s suicidal adolescence and early adulthood. Following the case study, statistics are presented, and then theories are applied for deeper understanding of the etiology. The population studied included gender expansive individuals age 24 and younger from the United States. Literature on adult transgender suicidality, as well as recommendations for general populations, was also taken into consideration due to limitations in the research.

Results

Gender expansive youth are at significantly heightened risk of suicide compared to their cisgender peers. Nonbinary youth are the most vulnerable of all subgroups.

Conclusion

Explicit recommendations for enhancing resilience for this population complete the article. More research is critical for this demographic, as current literature is severely limited.

This article is intended for professionals in the medical and mental health fields, as well as others interested in promoting the resilience of gender expansive youth (those age 24 and younger). It examines suicidality among this population and makes evidence-based, culturally informed recommendations for suicide prevention.

Eric: A Case Study

“Eric” (names and personal details have been changed to protect confidentiality) was twelve years old the first time he tried to commit suicide. He had just “come out” to his parents as a lesbian. He did not know what it was to be transgender. All he knew was that he was AFAB (assigned female at birth), he was socialized as a girl, and he did not realize he could even question his gender. By age 12, he knew that he was attracted to “other girls.” Eric believed that it was wrong to be gay, and he was deeply ashamed of his sexuality. When Eric finally gained the courage to come out to his friends at school, news spread rapidly and many of his peers became hostile toward him. Being gay made Eric an easy target.

Eric became very depressed. He started to have periods of dissociation. He would go into rage-fueled blackouts, unable to remember what had transpired when he settled back into reality. He began isolating himself because he was afraid he would hurt the people around him. Eric’s parents felt helpless. He developed severe anxiety including an intense fear of going outside, and his parents ultimately decided to homeschool him for the remainder of middle school.

Between the ages of 12 and 14, Eric attempted suicide two times. After the second attempt, Eric’s parents found him a therapist. They began to work on addressing the impact of the homophobia he experienced when he came out. Eric felt slightly better after a while, but his depression and suicidal thoughts persisted. When Eric was 14, he enrolled in the local public high school. Around the same time, he began to feel gender dysphoric (a type of distress caused by the misalignment of one’s sex assigned at birth and their gender identity) although he did not have the language to articulate the concept, nor did he know about gender variance.

What made a significant difference for Eric was being part of his local LGBTQ community center. Being there made Eric feel at home, gave him joy and put him at ease. Eric met other youth there, including some transgender teens. As he got to know them more, and realized how much he related to them, he developed an understanding of himself. Eric came out as transgender at the age of 16.

Upon gaining this insight, Eric felt excitement, relief, and terror. He knew that transitioning (the process some gender expansive people may undergo in order to align themselves with their gender identity through social and/or medical interventions) was an option he could explore, but he had no idea how to get started. He was terrified of being disowned by friends or family. The recent insufferable pain of being rejected and mistreated by many of his friends when he came out as gay was still present. On top of being worried about the social cost of transitioning, Eric was concerned about the financial aspect.

Eric’s fears were confirmed when he told his peers that he was considering medically transitioning. Responses ranged from telling him that he would not be attractive if he took steps toward masculinization, to others saying they would not like him anymore, to laughter. The deeper the connection, the more it hurt if someone was not supportive. Eric was let down repeatedly. He doubted that he could ever truly “become himself” and he internalized the belief that he would be unlovable.

During high school, Eric attempted suicide four more times. He was hospitalized for a period of time, and he began seeing a new mental health provider. Eric took antidepressant medication, but his symptoms persisted until he began medically transitioning. Finally, Eric’s mental health became manageable.

Eric is exceptionally lucky that his immediate family was always supportive. Attributable to the relationships with his parents, siblings, and friends from the community center, Eric felt a sense of connectedness that was tremendously fulfilling. Eric also began working with GLSEN (the Gay, Lesbian, Straight Education Network, a nonprofit organization that aims to improve school safety nationally), which made a positive impact on his mental health. GLSEN gave Eric a place to help other LGBTQ youth and to advocate for LGBTQ rights. His work instilled pride and empowered him; it gave him purpose. Eric graduated high school.

Without any regrets today, Eric has transitioned to an extent that feels comfortable to him. He sees being transgender as a cornerstone of his identity, connected to everything else about him and ever-present in his day-to-day life. He still manages symptoms of depression and has suicidal thoughts sporadically. Today, he acknowledges them, but he knows they will pass; they always do.

Devastatingly, in 2018, Eric’s best friend Cody died by suicide. Cody realized he was transgender and came out to Eric within a year of them meeting. Cody seemed so optimistic after he came out that Eric never expected Cody’s depression to reach such a lethal place. Cody also dealt with PTSD (Post-Traumatic Stress Disorder) and never received adequate care for his mental health. Cody made it clear that discovering he was transgender and then transitioning kept him living as long as he did. Before his death, Cody told Eric that, had he never transitioned, he would have killed himself years prior. However, as Eric summarizes,

“knowing who you really are and transitioning can save your life, but it’s not everything. It is a part of it, but you still have to make the rest of your life work. I miss [Cody] every day but when I think about him, it’s a reminder that I need to make the rest of my life work better so I don’t end up like that. I have been on testosterone for nine years. I had top surgery. I look the way I want to, sound the way I want to, but the rest of my life is still very far from perfect, and that’s the part I need to be focusing on.”

Prevalence

Current suicide rates of young people in general reflect a large public health problem. Sadly, suicide rates for individuals who are gender expansive are several times higher. Between 2015–2016, 7.2% of the general population of high school students in Delaware reported attempting suicide.¹ In contrast, over one-third (35%) of gender expansive high school students reported attempting suicide in 2018.² In Delaware, 1,100 youth are estimated to be gender expansive.³ Throughout the US, approximately 2% of high school students surveyed reported being transgender.² Even though the gender expansive community is a small minority, they are affected so disproportionately by suicide that specific consideration is warranted.

Etiology

Being gender expansive is not the cause of mental illness. On the other hand, experiencing regular hostility and discrimination, like so many who are gender expansive do, can be traumatic and increase the likelihood of having mental health problems as a result.⁴ Psychological distress for most people who are gender expansive is thus due to a lack of social acceptance and the pervasiveness of transphobia.

This response makes sense if considered from the perspective of the minority stress model.^5,6 This model explains that, because of differences between minority and dominant cultural values, minority group members may experience internal and environmental conflict as a result of having different belief systems from the majority. Each minority group has a unique set of relevant stressors associated with poorer health outcomes for members of that particular group. Hendricks and Testa identified minority stressors for this population by considering adverse experiences due to societal transphobia including: rejection, victimization, and/or internalized transphobia.⁷ Minority stress studies with gender expansive samples show that being disenfranchised, victimized or experiencing transphobia increases suicide risk.^8,9 Another stressor particular to this population is the experience of being referred to by a pronoun or name that is not affirming, especially when done maliciously or repetitively. To be misgendered (to have one’s gender identity misclassified) is an adverse experience uniquely damaging to those who are gender expansive.^10,11

Being gender expansive represents just one aspect of identity out of many that one might hold, and if other identities also have minority status, they too will come with their own set of stressors. A tremendous number of people are part of multiple minority groups. Gender expansive youth might also be: black or another racial minority, disabled, mentally ill, a member of a non-dominant religion, an immigrant, of low socioeconomic status, and so on. The greater the difference between one’s value system and that of the majority, the more distress one is likely to experience as a result.

One value that segments the gender expansive community is identification as either binary (male- or female-identified, as a majority of people in society), or not. Those who are nonbinary (people who identify as neither ‘male’ nor ‘female’) in particular, seems be most at risk of suicide.^12,13 This demonstrates another application of minority stress for this population.

Risk Factors

Suicidal Risk Factors are characteristics, internal or external, that make it more likely that one might consider, attempt, or die by suicide.¹⁴ According to the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Suicide Prevention Resource Center, they include^14,15:

Personal/psychological Factors

• Presence of mental health disorder(s) and/or alcohol/substance abuse

• Antisocial and/or maladaptive behaviors, including self-injury

• Previous suicide attempts

• Genes/neurobiology predisposing one to suicidality

• Impulsive, risk-taking, reckless tendencies

• Feeling hopeless, lonely/isolated/alienated, like a burden, and/or having low self-esteem

• Lacking adaptive coping skills

• Seeing oneself as severely overweight or underweight

• Risky sexual behavior, delinquency, and/or aggressive or violent behavior

Adverse Experiences

• Grief, loss, or other interpersonal challenges (risk is especially heightened for those exposed to a peer dying by suicide)

• Victimization (bullying, abuse, etc.)

• Legal or discipline problems

• Challenges at school or work

• Chronic illness or disability

Familial Factors

• Parental divorce, death, mental health problems, or relationship problems

• Relatives with suicidal behavior

Environmental Characteristics

• Lack of: community-wide acceptance of differences, common value of equality, positive relationships with school staff & students, pro-social beliefs, safety/security, and/or mental health care.

• Presence of: bullying, violence, other hostile behaviors, weapons (particularly if accessible within the home), peer suicide, stigma or discrimination based on gender/sexual identity, race, disability, or physical traits

Enhancing Resilience

Protective factors are personal or environmental characteristics that reduce the probability that someone will consider, attempt, or die by suicide. Protective factors can minimize the effects of risk factors. The capacity to cope adaptively with the effects of risk factors or adverse experiences is called resilience. Actions to enhance protective factors serve to boost resilience and are an essential element of an effective suicide prevention effort. Strengthening these factors also protects youth from other risks, including violence, substance abuse, and academic failure.¹⁴

Protective Factors suggested for the general population are listed below¹⁵:

Individual Characteristics and Behaviors

• Adequate self-esteem, self-efficacy, optimism, and an overall upbeat affect

• Emotional intelligence, easy-going temperament

• Coping skills including problem-solving abilities, conflict resolution, emotional regulation, and frustration tolerance

• Cultural and religious beliefs that respect and value life and discourage suicide

• Healthy relationship with one’s body to include: perception of body image, personal care/hygiene, regular physical activity, and overall concern for one’s physical self

Family and Other Social Support

• Connection to supportive parents and other family members, and parental involvement (especially as connected to school)

• Close friends or family members, a caring adult, and other social support(s)

• Pro-social norms within the household

School

• Positive relationship with school, including average or better academic achievement

• Real and perceived safety at school (especially relevant for this population)

• A school environment that promotes diversity and respect

Health

• Easy access to mental health services, physical healthcare, and treatment (if needed) for substance abuse disorders

• Positive relationship with providers

Environment

• Restricted access to means including guns, medications, alcohol, and firearms

• Safety barriers in place at dangerous locations in the community (such as bridges)

Specific Implications for Gender Expansive Youth

A swift and effective response to this crisis is urgently needed. Those with the ability to create impactful change, small or large, should consider taking action to enhance the resilience and wellbeing for the gender expansive community. Moody, Fuks, Peláez and Smith organize trans-specific protective factors into categories of social support, gender identity-related, transition-related, individual differences, and reasons for living.¹⁶ This article will utilize those categories and expand upon recommendations for suicide prevention specifically for gender expansive youth based on the literature.

As seen in most cultures and subcultures, those with multiple minority identities face a heightened risk of experiencing adversity. Thus, for those who are marginalized or oppressed in ways other than gender, meaningful, supportive relationships are vital to combatting minority stress. If social support is inadequate, strengthening it is an important goal. There is also great benefit from exploring and processing gender/identity, reviewing reasons for living, and for some, transitioning. Through affirming referrals to healthcare providers and community resources, gender expansive youth will have options available to increase their resilience.

Social Support

There is a positive correlation between perception of support and mental health for gender expansive youth.¹⁷ Those who report feeling accepted do not have disproportionately high rates of depression compared to cisgender peers.¹² In contrast, not feeling accepted is associated with higher rates of mental illness. This is part of the reason it is important to connect gender expansive youth with those they can relate to, as well as other community supports. It is helpful to have knowledge of resources for social and/or support groups, education, assistance, and other needs of this population, their families, and their communities.

If one seeks to be a support for those who are gender expansive, being affirming is the first step. When the name and pronoun that feel affirming are used, gender expansive youth feel accepted and safe. Incorrectly addressing or misgendering a gender expansive youth can be harmful and should be avoided. Modeling gender-affirming behavior helps to normalize it, which can be beneficial for families. However, not all families are going to be supportive – rejection is a reality for many of these youth. As mentioned, if family support is lacking, other positive relationships become a critically-important protective factor.¹⁸

Gender Identity-Related Factors

Gender education is essential. When gender expansive youth gain awareness and develop insight into their gender identity, their risk of suicide declines.¹⁶ It is also protective to increase acceptance (of self and gender), and to transition, if/as desired. It is a myth that everyone knows their gender identity by a young age.¹⁹ For many, gender evolves over time, and childhood gender experimentation is a part of typical development. It is important for all youth to feel safe to learn about and explore gender, so they can better understand themselves and the world. For those who are not cisgender, it is an essential prerequisite to developing a sense of self, and (ideally) of pride in one’s identity. Those who wish to make the world a safer place for gender variance can address environmental factors that might be harmful to this population, and do what is possible to increase inclusivity of spaces. It is also important to have current, accurate knowledge, including of gender-affirming resources, particularly those that promote identity development and provide community education.

Transition-Related Factors

Not everyone who is gender expansive decides to transition, but for those who do, each journey is unique. Risks and benefits of various options are examined, desired outcomes are considered, and accessibility is taken into account. For those who choose to transition, there are three aspects of the process that can be protective, including coming out/disclosing, hope of transitioning, and actively transitioning. When gender expansive youth are able to socially transition and use a name that is affirming, they are 65% less likely to attempt suicide compared to those who are not, and their suicidal thoughts decline by 35%.¹² Make it standard practice to ask about, rather than assume, pronouns as well. Direct advocacy might include asking about and respecting what is affirming, but there are endless other ways to make the world a safer place for those who are gender expansive. Some examples are improving school safety and inclusivity, building/sharing accurate education about this population, or donating time or money to gender-affirming programs or groups.

Individual Difference Factors

Some individual differences are unlikely to be influenced by external sources, such as the personality trait of being optimistic or one’s genetic capacity for resilience. However, effective therapeutic interventions can positively impact other protective factors including one’s use of effective coping strategies, problem solving skills, and ability to self-regulate. A qualified mental health provider can help clients acquire cognitive tools to negate problematic thinking and eliminate maladaptive behavior.

Reasons for Living

An effective therapist will encourage their suicidal client to explore reasons for living. Clients might be asked to share their beliefs about survival, and about suicide, allowing the clinician to search for embedded protective factors or areas that should be more protective. A client might also be asked to discuss negative aspects of suicide. If they are afraid of dying, fear can be protective and should be explored. Having a sense of responsibility toward meaningful individuals as well as being a role model to others are both protective. For some, spiritual/religious beliefs offset suicidality as well.

Conclusion

Suicide rates of gender expansive youth are devastatingly high and require attention. Societal transphobia is ultimately the cause of the disparity of the rates. While overcoming transgender discrimination might seem daunting, there are many steps that can be taken to positively impact health outcomes for this population. Everyone should ask and use gender-affirming name and pronouns. Families, schools, and communities need resources to become more informed and supportive. Gender expansive youth should be connected with affirming, competent medical providers. Participating in therapy can make a profound impact on resilience. It provides a meaningful relationship that might itself be protective, and often considered an essential part of a support system. Therapy helps clients learn coping skills, recognize reasons for living, correct problematic thinking, build hope, and improve relationships. Linking this population to mental health support, including crisis services should be prioritized. If suicidality is disclosed, find emergency help right away by calling 9-1-1 or your local crisis response department. For other times, there are two gender-affirming suicide helplines available throughout the US: The Trans Lifeline at (877) 565-8860, and the Trevor Project at (866) 488-7386 or online via instant message, chat or text at http://www.thetrevorproject.org/section/get-help.