What you need to know
In North America, research has consistently shown that transgender (trans) individuals experience higher rates of physical and mental health burden compared to the general population. Furthermore, trans youth experience even higher rates of suicidality and non-suicidal self-injury (NSSI) compared to trans adults. Researchers conducted a systematic review to identify risk and protective factors (e.g., transition status, comorbidities, discrimination, social support, community-related factors and social policy) for suicidality and NSSI.
What is this research about?
In North America, trans youth experience higher rates of suicidality and NSSI compared to trans adults. Researchers conducted a systematic review to synthesize research on risk and protective factors for suicidality and NSSI among trans populations, and to determine the differences between trans youth and trans adults.
The researchers defined several terms:
- Transgender (trans) refers to “individuals who do not identify with the sex they were assigned at birth (e.g., a person who was assigned male at birth but identifies as a woman is a transgender woman).”
- Gender expansive refers to “a wide range of gender identities that broaden gender-normative definitions and are neither male nor female (e.g., non-binary, gender-fluid, genderqueer).”
- Cisgender refers to “individuals who identify with the sex they were assigned at birth (e.g., a person who was assigned female at birth and identifies as a woman is a cisgender woman).”
- Suicidal ideation encompasses “all instances where an individual had thoughts of ending their life, whether this included having an active plan or not.”
- Suicide attempt encompasses “all instances where an individual attempted to put an end to their life, irrespective of the lethality of the attempt or of hospitalization as a consequence of the attempt.”
- Non-suicidal self-injury (NSSI) encompasses “all instances where an individual intentionally hurts themselves (e.g., cutting, burning, bruising) without intent to end their life.”
What did the researchers do?
The researchers conducted a systematic review where they synthesized the research on risk and protective factors for suicidality and NSSI among trans populations and determined the differences between trans youth and trans adults. The risk and protective factors that the researchers focused on were transition status, comorbidities, discrimination, social support, community-related factors and social policy. They also looked at outcomes such as NSSI, suicidal ideation and suicide attempts. The outcome measures captured included prevalence and/or risk and/or protective factors associated with NSSI and/or suicidality.
The systematic review excluded all reviews (systematic reviews, scoping reviews, literature reviews, etc.), non-peer-reviewed reports, gray literature, guidelines, recommendations, editorials, letters to the editor, commentaries, theses and dissertations.
What did the researchers find?
The researchers selected 52 studies. Most of the data in the studies came from the United States, Canada, the United Kingdom, Australia and Sweden. The groups represented in this systematic review included trans adults and trans youth.
The researchers summarized the findings of the systematic review into two outcomes: suicidality and NSSI. They further discussed risk and protective factor for trans adults and trans youth under the age of 25.
Suicidality
Medical transition status
Adults: Studies showed a significant association between suicidal ideation and the desire to medically transition. The completion of the desired medical transition and accessing gender-affirming care were protective factors for suicidal ideation. Additional studies mentioned that medically transitioning and the prospect of doing so in the future had also decreased suicidal ideation and were significant protective factors.
Youth (under 25): Similar to the trans adult population, accessing gender-affirming care was associated with reduced suicidality.
Comorbidities
Adults: Major depressive disorder and/or having previously engaged in NSSI were risk factors for suicidal ideation. Having a mental health disorder such as a major depressive disorder diagnosis significantly increased the odds of experiencing a suicide attempt. Studies also highlighted treated substance use disorders, which were associated with twice the odds of experiencing a lifetime suicide attempt. In contrast, receiving counselling for mental illness was associated with significantly lower levels of lifetime suicidal ideation.
Youth (under 25): Studies found that depressive symptoms rather than the diagnosis of major depressive disorder were associated with increased suicidal ideation and suicide attempts. Furthermore, in Australia and the United States, body dysphoria, body esteem and level of satisfaction with weight and appearance were factors associated with increased suicidal ideation.
Discrimination
Adults: Gender-related discrimination and experiencing gender-based violence were both associated with suicidal ideation and suicidal attempts. Furthermore, experiencing gender identity conversion efforts before the age of 10 and internalizing transphobia were also found to be associated with increased suicidal ideation and suicide attempts.
Youth (under 25): The studies on youth focused more on school-based factors. In Australia and the United States, gender-related bullying, victimization and rejection by peers were associated with increased suicidal ideation and attempts. Feeling safe at school was identified as a protective factor for suicidality.
Social support
Adults: Studies found social support to be a protective factor, with family being the most important support system. Therefore, family rejection and not being able to reach out to someone for help were associated with increased suicide attempts.
Youth (under 25): Similar to trans adults, family, especially parental support, was identified as the most important protective factor for suicidality.
Community and social policy factors
Adults: Social factors, including being a non-White race or ethnicity, identifying as multiracial, having a lower level of education and income, being unemployed and living in a rural environment instead of an urban environment, were associated with increased suicide attempts due to stigma and racism.
Youth (under 25): One study found that socioeconomic factors associated with suicidality included accommodation issues, employment issues, school issues and feeling isolated from services.
Non-suicidal self-injury
Comorbidities
Adults: Gender dysphoria, body dissatisfaction, lower levels of self-esteem and a formal diagnosis of mental illness were associated with engagement in NSSI.
Youth (under 25): Major depressive disorder, eating disorders and general psychopathologies were important risk factors for engaging in NSSI.
Discrimination
Adults: Discrimination, unstable housing and stigma were all associated with increased odds of engagement in NSSI.
Youth (under 25): Peer rejection, bullying, physical bullying, gender-based bullying and exposure to gender-based discrimination were associated with increased odds of engagement in NSSI.
Social support
Youth (under 25): Familial support, especially parental connectedness, was an important protective factor against engagement in NSSI.
Community and social policy factors
Youth (under 25): Socioeconomic factors such as employment issues, school issues and feeling isolated from services were associated with increased odds of engaging in NSSI. Furthermore, rural trans youth had significantly higher odds of engaging in NSSI than urban trans youth.
Limitations of the research
The researchers identified several limitations from the studies reviewed. First, because the sample sizes and selection strategy varied between studies, it was difficult to compare them. Second, no studies were included from the gray literature or in languages other than English. Third, all the data was collected at one specific point in time. Therefore, it was hard to determine whether a risk or protective factor caused the outcomes (e.g., NSSI, suicidal ideation or suicide attempts). Fourth, because the studies were from different geographical locations, it is hard to generalize the findings. Fifth, the studies did not differentiate between trans and gender expansive individuals. Last, there was sampling bias and survival bias.
How can you use this research?
The researchers suggest that in order to reduce stigma felt by trans individuals, it is important to educate healthcare providers in all settings, including the emergency department, and the general population. Furthermore, more research is needed to better understand how risk and protective factors affect suicidality and NSSI.
About the researchers
Myriam Vigny-Pau1, Nelson Pang2, Hamad Alkhenaini1, and Alex Abramovich2,3
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Institute of Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada