Transgender and gender diverse (TGD) people are disproportionately impacted by suicide. Conversations in trans health research literature are trying to paint a picture of how widespread this issue is for TGD people. For example, McNeil et al. (2017) report in their systematic review on this issue that suicidal ideation rates across seventeen studies range from 37% to 83%. Suicide attempts were also shown to have wide prevalence rates ranging from 9.8% up to 44%.
The high rates of common mental health conditions (such as depression and anxiety) along with suicidality have been stable over quite some time in the TGD community. There are many possible reasons for this with evidence highlighting the role of minority stress and everyday discrimination actively harming TGD people’s mental wellbeing (Scandurra et al 2017; Zwickl et al 2021), but also psychological pain and a lack of social connectedness potentially explaining some of the relationships between being trans and suicide (Wolford-Clevenger et al 2018).
As already alluded to in the paper I am blogging about today (Wiepjes et al), small sample sizes and the relatively small number of papers in the field has made drawing conclusions on changes within TGD suicidality over time incredibly difficult. Thus, the authors’ aim is to explore suicide death rates in trans women and trans men using a large dataset from the Center of Expertise on Gender Dysphoria between 1972 and 2017.
This study draws on a retrospective cohort of all people who once visited the Center of Expertise on Gender Dysphoria of the Amsterdam University Medical Center in the Netherlands (n=8,263). All TGD adults, adolescents, and children had at least one appointment between the years of 1972 and 2017. Information regarding death occurrence, time, and cause of death was obtained through the National Civil Record Registry, as in the Netherlands this registry contains the date of birth and death of all civilians.
The study highlights the process by which TGD people navigate the service, with an initial visit to an endocrinologist (for adults) or a child psychiatrist (for children and adolescents). All TGD people were then referred to their psychology department for the diagnostic phase. It is at the diagnostic phase where a diagnosis of gender dysphoria is made, followed by a treatment plan, and preparation for medical intervention.
The statistical analyses took the form of a Cox regression in order to obtain hazard ratios. To establish a timeline, the authors used the date of the patients’ first appointment as the start of the follow-up, with the date of death or date of closing database (December 31st, 2017) as the end of the follow-up. To examine whether the incidence of suicide changed over time, the year of the appointment was included in the analyses. Analyses were adjusted for age at the first visit. The time between the date of suicide and the initial appointment and the time between the date of suicide and the initiation of hormonal therapy were also calculated. The analyses were stratified (i.e. separated) to trans women and trans men.
8,263 people attended the gender identity clinic (GIC), of which 5,107 were trans women and 3,156 were trans men. Trans women had a median age at the first visit of 28 years old, which ranged from 4 years old to 81 years old. Trans men had a median age at the first visit of 20 years old, which ranged from 4 years old to 73 years old. The median follow up time was 7.5 years and this ranged from 0 to 45.5 years. The follow-up time was longer for trans women compared to trans men (10.2 years compared to 4.8 years).
There was a total of 49 suicide deaths, of which 41 (0.8% of the total GIC population) were trans women and 8 (0.3%) were trans men. Both trans men and trans women had a median time of follow-up of 6.7 years. Trans women had a higher overall suicide death risk than trans men with a hazards ratio of 2.26, meaning that trans women were roughly two times more likely to die by suicide compared to trans men in this study.
Overall, there was no evidence that suicide risk changed over time. However, trans women’s suicide risk decreased slightly over time, while it did not change for trans men. There was also no difference for those who had their first appointment prior to 2011.
Of those who had died by suicide, 35 had face to face contact with the endocrinologist or psychologist in the previous two years. Sixteen of the 35 who recently visited the clinic used the service for check-ups only as they were post-surgery. Seventeen of the 35 were still in the diagnostic or hormone phase at the time of their suicide.
As this study is set in the Netherlands, the researchers had access to a national database that marks births and deaths for all civilians. The researchers used their GIC data to highlight that suicide rates were higher amongst the attendees of the GIC than in the general Dutch population. This translated to 40 per 100 000 person-years compared to 11 per 100 000 person-years, that is if there were 100 000 participants who were followed up for one year, 40 people attending the GIC would have died by suicide, and 11 would have died by suicide in the general population.
There was no observed increase in suicide death risk over time, and perhaps a slight decrease for trans women. However, the rate of suicide in TGD people was still much higher than the general population. The authors conclude that more attention is required on this risk within mental health services and a need to investigate the motives behind the suicide risk.
Strengths and limitations
Focusing first on the strengths of this work, there is a clear objective and need to examine suicide death risk over time for transgender and gender diverse (TGD) populations. The rather disparate prevalence rates of suicide may be reflected in what is being measured as suicidality and what is being counted, i.e. the inclusion (or exclusion) of suicidal ideation and self-harm, which may account for differences in prevalence. There is also the question of who is involved in the research, those selected from gender identity clinics (GICs) or broader mental health services may introduce bias towards a higher prevalence of suicidality. This work aimed to offer robust and strong evidence of suicide death risk using large sample size and adequate methodology, producing a result that adds credence to the growing body of work reflecting suicidality as commonplace within TGD communities.
Whilst this paper demonstrates what is commonly known in the literature on TGD suicide there are several issues that impact the implacability of this research:
- Firstly, the insistence on “treatment” and “transition-stage”; whilst I acknowledge these are times of both great promise and agonising fear and concern, the focus doesn’t appear to add anything useful clinically. Although this highlights areas of potential concern and possible risk assessment at particular stages of treatment, it removes the focus from causal risk factors that are commonplace in TGD people’s lives.
- The paper also offers no indication of demographic distributions in their findings. Humans are multifactorial beings and intersectionality tells us that experiences amongst the TGD community are not homogeneous. Therefore, information on ethnicity, social class, and disability, would have provided us with an initial understanding of who in the TGD community is at risk using this sample.
- Finally, there is also the issue of non-binary exclusion. Very frequently trans health research from large clinics tend to ignore or disregard gender diversity within their samples, therefore non-binary people’s risk of suicide is unknown for this Dutch population.
Implications for practice
The results of this paper pull our attention to the heightened suicide death risk amongst trans men and trans women, however as described above, it doesn’t offer any tangible insights into how we can reduce this risk. The authors highlight the need to explore the underlying motivations of suicide in transgender populations and I would agree that more work is required to examine wider structural and interpersonal factors that increase suicide risk for TGD people.
Statement of interests
Talen’s ongoing PhD is investigating the role of microaggressions and other social determinants, such as loneliness and social isolation, and their impact on TGD suicidality. She has an invested interest both as an academic and as a trans woman on how research is produced and what it can offer to marginalised and minoritised communities.
McNeil, J., Bailey, L., Ellis, S., Morton, J., & Regan, M. (2012). Trans mental health study 2012. Scottish Transgender Alliance. Available at: http://www. scottishtrans. org/wp-content/uploads/2013/03/trans_mh_study. pdf [accessed: 14 July 2016].
Scandurra, C., Amodeo, A. L., Valerio, P., Bochicchio, V., & Frost, D. M. (2017). Minority stress, resilience, and mental health: A study of Italian transgender people. Journal of Social Issues, 73(3), 563-585.
Wolford-Clevenger, C., Frantell, K., Smith, P. N., Flores, L. Y., & Stuart, G. L. (2018). Correlates of suicide ideation and behaviors among transgender people: A systematic review guided by ideation-to-action theory. Clinical psychology review, 63, 93-10
Zwickl, S., Wong, A. F. Q., Dowers, E., Leemaqz, S. Y. L., Bretherton, I., Cook, T., … & Cheung, A. S. (2021). Factors associated with suicide attempts among Australian transgender adults. BMC psychiatry, 21(1), 1-9.