Transgender Teens at Significant Risk for Suicide

George W. Citroner

September 27, 2018

Transgender male adolescents attempt suicide at a significantly higher rate than other transgender groups or teens whose gender identity matches their birth sex, a new study reports.

According to data from the Centers for Disease Control and Prevention, suicide is the second-leading cause of death among young people aged 15 to 19 years.

"We found that transgender youth — those whose gender identity does not align with their sex assigned at birth — were more likely to report a suicide attempt compared to cisgender youth — those whose gender identity does align with one's sex assigned at birth," lead author Russell B. Toomey, PhD, University of Arizona, Tucson, told Medscape Medical News.

"Across all groups, transgender youth who reported identification as male or as nonbinary reported the highest levels of suicide attempts," he added. "We also found that a nonheterosexual identity was also associated with greater risk for suicide attempts for all youth, except for those who identified as nonbinary."

The study was published online September 11 in Pediatrics.

First to Examine Within-Group Differences

This isn't the first study of suicidality in teens experiencing gender dysphoria. Research published August 2016 in Suicide and Life-Threatening Behavior, the official journal of the American Association of Suicidology, also reported higher rates of suicide and self-harm in transgender teens.

In that study, researchers analyzed data from the medical records of 96 transgender patients (aged 12 to 22 years) with gender dysphoria who visited the Transgender Health Clinic at Cincinnati Children's Hospital.

Besides an increased risk for suicide, results showed that 58% of participants had received at least one psychiatric diagnosis in addition to gender dysphoria.

"While prior research has shown that transgender youth are at a heightened risk for suicide behaviors, ours is the first to examine the possibility of within-group differences among transgender youths," said Toomey.

His investigative team analyzed data from 2012 to 2015 drawn from the Profiles of Student Life: Attitudes and Behaviors survey, which collected information from 120,617 persons between the ages of 11 and 19 years.

Of these participants, 60,973 respondents identified as female, and 57,871 identified as male. Fewer than 1% of the teens surveyed identified as transgender.

Of those identifying as transgender, 1052 adolescents identified as questioning, 344 identified as nonbinary transgender, 202 identified as male to female transgender, and 175 identified as female to male transgender.

About 14% of the overall respondents said they had attempted suicide.

Transmasculine Teens at Greatest Risk

The investigators found that 50.8% of transmasculine adolescents, who were female at birth but who identified as male, attempted suicide.

In addition, 42% of teens who identified as nonbinary, defined as not identifying exclusively as being of either sex, reported a suicide attempt — as did 30% of transgender female adolescents.

By comparison, only 18% of females and 10% of males whose gender identity matched their birth sex had attempted suicide.

Toomey explained that "given our large sample size, we were able to examine whether these differences emerged or not. An understanding of this difference is important knowledge for suicide prevention and intervention efforts, particularly those tailored to the experiences of transgender youth."

He added that there may be two reasons why this difference exists.

"First, it may be that we have already lost male to female transgender teens to death by suicide. We did not capture this is in the data, and in the US, we have no systematic data collection of gender identity in death records," he said.

"Second, it may be that transmasculine and nonbinary youth simply lack a community or visibility."

Toomey emphasized that one key finding across populations is that a major predictor of suicidal behavior is experiencing a lack of belonging or feeling disconnected with others.

"Given that much of the mainstream media focuses on the experiences of transfeminine youth, transmasculine youth or youth who identify as nonbinary may not see themselves represented or feel like they belong to a greater community," said Toomey.

"Invalidation and Marginalization"

Commenting on the findings for Medscape Medical News, John B. Steever, MD, assistant professor of pediatrics at the Mount Sinai Adolescent Health Center, New York City, noted that transgender youth are also more likely than their cisgender peers to be diagnosed with an eating disorder, to engage in nonsuicidal self-harm, such as cutting, and to abuse substances.

"This usually arises as a response to a lifetime of invalidation and marginalization," said Steever, who was not associated with the study.

He also noted that hormone therapy may play a valuable role in reducing risk for suicide.

"Although it hasn't been formally studied, starting trans teens on gender congruent hormones may reduce suicide risk, because we know their mental health improves significantly when they start hormones," he said.

Steever emphasized that the higher rates of negative mental health outcomes for most transgender youth stem from "society's marginalization of and violence toward trans and gender nonconforming folk, not directly from being transgender.

"When a young trans person's family accepts and supports them, their mental health outcomes are much better than when their family rejects them," he added.

However, Toomey isn't so sure about that. "Empirically, we know too little about factors that can lower the odds of suicide behavior among transgender youth. This study, in particular, did not examine how families/schools/community groups should or could treat people who identify as transgender."

Overall, "these findings only indicate that we should focus greater prevention and intervention efforts for suicide prevention on transgender youth and ensure that we are paying attention to the particularly heightened risk that transmasculine and nonbinary youth experience," he concluded.

The study authors have reported no relevant financial relationships.

Pediatrics. Published online September 11, 2018. Abstract

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