SUICIDE DATA OVERVIEW
HOW EFFECTIVE IS MEDICAL TRANSITION IN REDUCING SUICIDE RISK IN INDIVIDUALS WITH GENDER DYSPHORIA?
It is difficult to know the extent medical transition has on reducing suicide risk (ideation and attempts) for these reasons:
Follow up studies on trans people are usually low-quality due to a short time span after follow-up, loss to follow-ups, lack of control groups, and failing to ask if the suicide attempt/ideation took place before or after medical transition.
To truly measure this, it would be necessary to compare individuals who have medically transitioned to control groups of dysphoric people in similar cultures where transition wasn’t available. Cultural comparison studies would further be needed to determine the effect of the environment on gender nonconforming people in places that are tolerant versus intolerant of them.
There are factors related to the timeline of a trans person’s medical transition. Some studies show suicide risk goes up right before and during transition due to it being a tumultuous time. Trans people also often discuss that there are often honeymoon periods right after transition. If a person such as this is interviewed right before and right after transition, it may fail to provide a more realistic picture of the dynamic that is happening over the long run.
Gender dysphoric youth are currently coming out in an environment where they hear a constant narrative that they will kill themselves if they don’t transition. Trans people and even one doctor (Dr. Wong) are coaching them to say they will commit suicide if they don’t get immediate access to medical transition.
Measuring subjective outcomes and objective outcomes can be two different categories. Self-reporting may be inaccurate.
Given suicide ideation is well-known to be socially contagious, and this narrative is being used to get compliance to go along with transition, these factors may affect studies on suicide risk in youth.
NY Times article:
SOME STUDIES THAT CONFIRM HIGHER SUICIDE IDEATION & ATTEMPTS IN TRANS-IDENTIFIED YOUTH
Below are just some of the many studies confirming higher mental health issues and suicide risk in trans youth.
Aitken et al., 2016
Dean, et al., 2000
Fitzpatrick, Jones, & Schmidt, 2005
Gibson & Catlin, 2011
Grossman & D’Augelli, 2007
Hass, et. al., 2010
Spack et al., 2012
Tishelman et al., 2015
Actual suicides in youth are very rare and almost non-existent in pre-pubescent children. See Centers for Disease Control.
INCREASE RISK IN FEMALE YOUTH?
Some studies on adults (not all) show better mental health outcomes for FtMs than MtFs. More recent studies seem to show female minors have a higher suicide risk.
“More of the girls reported self-mutilation in the past or present.
More of the girls reported suicidal thoughts and/or attempts.”
Cincinnati Children's Hospital Medical Center (2016)
More patients transitioning from female to male reported a history of suicide attempts and self-injury than those transitioning from male to female.
Rates may be higher for all female LGBT youth in this study.
Stonewall UK School Report (2017)
To understand how this study probably shows more females with suicide risk read the Transgendertrend review:
“The ‘transgender’ category may just serve to cover up the scale of suicide attempts and self-harm rates of girls and young women.”
STUDIES THAT SHOW POSITIVE RESULTS THAT TRANSITION REDUCES SUICIDE RISK
Cornell University did a review of research studies on gender transition and found 4 negative studies, but 52 studies showed overall low regret rates, improved mental health, and reduced suicide risk.
Only 2 studies specifically addressed suicide. But one may deduce the overall positive mental health data would improve suicide risk.
Issues: Many of these studies are poor quality, with small sample sizes, short term outcomes, and high rates of “lost to follow-ups.” They oddly put Dhejne in the positive outcome category despite it painting a negative view of long term physical and mental health outcomes. They also left off Adams, Marshall, Asscheman, and Rauchfleisch that indicate negative mental health outcomes.
Cuypere is one of the studies in the Cornell Review that shows a significant reduction in suicide risk. It is one of the few that compares pre and post-transition statistics on suicide and shows a very significant reduction in suicide, post-transition, for a small group of Belgian transsexuals.
“Results: On the GAF (DSM-IV) scale the female-to-male transsexuals scored significantly higher than the male-to-females (85.2 versus 76.2). While no difference in psychological functioning (SCL-90) was observed between the study group and a normal population, subjects with a pre-existing psychopathology were found to have retained more psychological symptoms. The subjects proclaimed an overall positive change in their family and social life. None of them showed any regrets about the SRS. A homosexual orientation, a younger age when applying for SRS, and an attractive physical appearance were positive prognostic factors. Conclusion: While sex reassignment treatment is an effective therapy for transsexuals, also in the long term, the postoperative transsexual remains a fragile person in some respects.”
“Suicide attempt rate
Although the suicide attempt-rate dropped significantly from 29.3% to 5.1% (McNemar test, N = 58, P = 0.004), it was definitively higher than in the average population (0.15%) (Van Heeringen et al., 2002).”
Issues: A large percentage of their cohort was lost to follow-up or were individuals who refused to participate.
Bailey is also included in the Cornell and included in the list of positive studies.
The study shows overall the suicide risk was reduced for a majority of trans people:
Issues: The study is interesting because while yes, suicide risk was reduced for most, it indicates a few got worse and a significant amount did not improve at all. The picture seems to be that many people are helped, but a significant minority still have major mental health issues not solved by transition, and comorbid conditions are a factor.
Travers (2012) (the Trans Pulse Survey)
The charts below show a strong association of a reduction of suicide risk with parental support. Affirmative model advocates like Ehrensaft often cite this study.
Issues: The unsupportive families in this study appear very unsupportive. Notice the high rates of lack of adequate housing. This indicates major falling outs with parents. They may be transphobic or have other conflicts unrelated to the trans identity (possibly even issues with the trans person themselves). These parents may not be a proper comparison to a supportive parent who supports a minor but supports them in waiting to make permanent changes. Also, some of these youths were young adults (22-24) where their trans identity may be more certain if they have been struggling with GD for a long time. Parental rejection at this point would be harmful to an adult who knows what they want.
Bauer (2015) (the Trans Pulse Survey)
The Trans PULSE survey in Canada is one of the few studies that measures pre-transition individuals and post-transition individuals and found a positive effect of access to medical transition.
It shows an increase in suicide risk mid-transition (possibly due to that being at a tumultuous time as the UK survey seems to show).
Most relevant quotes below:
Social support, reduced transphobia, and having any personal identification documents changed to an appropriate sex designation were associated with large relative and absolute reductions in suicide risk, as was completing a medical transition through hormones and/or surgeries (when needed)…
Medical transition variables, but not social transition or being perceived as cisgender, were associated with suicidality. Among those who desired medical transition, those on hormone therapy were about half as likely to have seriously considered suicide (RR = 0.52; 95 % CI: 0.37, 0.75). The process of medically transitioning overall was more complex, with a monotonic reduction in suicide ideation from planning to transition vs. being in process, vs. completing. However, among the sub-group with ideation, being in the process of transitioning was significantly associated with increased risk of an attempt (RR = 2.91; 95 % CI: 1.48, 5.76) in comparison with those who were planning to transition but had not yet begun. We did not observe an increased risk in this sub-group among those who completed a medical transition (RR = 0.51; 0.07, 3.74). Completing a medical transition had beneficial individual and population effects. It was associated with a 62 % relative risk reduction (RR = 0.38; 95 % CI: 0.22, 0.66) in ideation. On a trans population level, to facilitate completion of medical transition (when desired) would correspond to preventing 170 cases of ideation per year per 1,000 trans persons (cPAR = 0.17), representing 44 % of ideation (c%PAR = 0.44), and further preventing 240 attempts per 1,000 with ideation (cPAR = 0.24) or 69 % of attempts in this group (c%PAR = 0.69).
Our use of past-year suicide-related measures represents an improvement over studies that used lifetime measures, as we are able to analyse impact on recent or current risk, which is most relevant to prevention. However, temporality remains a concern.
This study on minors shows a significant reduction in suicide risk and improved mental health after initiating hormone treatment. The researchers say their results can be used to help get parents to support these protocols.
“Our findings demonstrate that levels of suicidality decrease, while general well-being increases, among adolescents diagnosed with GD after receiving GAH. The findings contribute to a growing literature supporting the hypothesis that transgender adolescents and adults benefit from GAH in terms of quality of life and psychological functioning (de Vries et al., 2014; Keo-Meier et al., 2015). Clinicians and advocates working with transgender youth and their families can cite these data as support that GAH is associated with improved psychological outcomes among transgender youth. Our study, specifically, speaks to reduced risk for suicidality and improved wellbeing, both of which are prominent worries of parents. Parents often struggle with the decision about whether to provide permission for irreversible steps in medical transition, such as initiation of GAH. Their fears may be alleviated to some extent as the emerging evidence supports use GAH among transgender youth.”
This study shows a link between lack of support and validation to an increase in suicide risk.
Issues: While this study shows a link with trying to change gender identity and suicide risk, perhaps it should be alarming that 1/3 of the LGBT community now identifies as trans. It was nowhere near these numbers just 15 years ago. This is only positive if you think the cost and health consequences to medical transition are irrelevant (many affirmative model advocates do). There are also over 100 genders now.
“After adjusting for personal characteristics and social support, chosen name use in more contexts was associated with lower depression, suicidal ideation, and suicidal behavior. Depression, suicidal ideation, and suicidal behavior were lowest when chosen names could be used in all four contexts.”
The one strength of this study is a very large sample size.
“Findings In a cross-sectional study of 27 715 US transgender adults, recalled exposure to gender identity conversion efforts was significantly associated with increased odds of severe psychological distress during the previous month and lifetime suicide attempts compared with transgender adults who had discussed gender identity with a professional but who were not exposed to conversion efforts. For transgender adults who recalled gender identity conversion efforts before age 10 years, exposure was significantly associated with an increase in the lifetime odds of suicide attempts.”
Issues: This study has multiple weaknesses: based on recall, how are conversion efforts defined?, no control group of people who resolved gender dysphoria.
This isn’t a study on suicide specifically, but affirmative model advocates always use this study to justify social and medical transition. It shows comparable mental health to controls who aren’t trans in socially transitioned youth. Wong, a recent study, does not show the same stellar results.
Issues: Olson herself admits her cohort may be biased due to recruitment over the internet attracting parents with certain personality traits and economic standing. There is no control group of children loved and supported but encouraged to wait.
STUDIES THAT SHOW NEGATIVE RESULTS THAT TRANSITION REDUCES SUICIDE RISK
“The authors found that the overall mortality rate for sex-reassignees was higher than for controls of the same birth sex, particularly death from suicide. They also reported that sex reassignees had an increased risk for suicide attempts, suggesting that the suicide risk for the trans population may not be reduced after treatment and transition.”
Issues: Marshall can’t necessarily be considered proof transition doesn’t reduce risk due to the quality of the studies reviewed, lack of consistency, and lack of control groups. But it is included because the authors of the study are willing to consider if transition may not reduce suicide risk as per the quote above.
This study, a meta-synthesis analysis, indicates transition is ineffective in reducing suicide risk. When combining averages across 42 of the more recent studies (relevant because being trans was likely more difficult and unaccepted in the past), they found very high suicide ideation rates, even within the last year. Past year’s stats also are not much better than lifetime stats in this review. And these are individuals accessing “gender affirming” medical care.
Most studies in this review don’t have clear comparisons between pre-transition averages and post-transition averages. But it is interesting to note that the two studies that focused on pre-transition suicide ideation show lower averages than past year study data averages (indicating worsening).
Issues: The biggest problem with this study is the design, as they are combining averages from studies with differing methodologies.
Haas (2014) (Williams Institute Study)
The survey found a high incidence of suicide attempts, 41%.
This is the study that is quoted to scare everyone to support the affirmative model. The results, in reality, call into question the effectiveness of transition (quotes from 4thwavenow):
“-People who had either sought or received transition-related services had a higher suicide attempt rate than people who have not. And the survey did not ask whether suicide attempts occurred before or after services were sought or received.
-The data suggest that natal females seem not to be helped at all, in terms of self harm, by being either “stealth” trans or passing as male. (This is the opposite finding from that of natal males.)”
“Importantly, our analyses suggest that the protective effect of non-recognition is especially significant for those on the trans feminine spectrum. For people on the trans masculine spectrum, however, our data suggest that this protective effect may not exist or, in some cases, may work in the opposite direction.” -researchers quote
The suicide attempt rate is still very high among trans people who do not view their trans status as negative. This indicates comorbid conditions, found to be high in all trans studies.
Issues: The Williams Institute reported some data for suicide attempts but did not distinguish if they took place pre or post-transition. The researchers themselves pointed out that without individual follow up, suicide stats can be significantly inflated in studies like this.
This is an odd study that shows improved mental health but not suicide risk. In this study one person committed suicide, and suicide ideation remained high, even though patients reported less dysphoria and depression.
This study has mixed results. The study is contradictory because patients aren’t reporting anxiety and depression, but there are high suicide rates and rates of self-harm post-transition.
THE REGISTRY STUDIES
Registry studies are valuable because they avoid problems of loss to follow-ups. They show high rates of poor transition outcomes.
Large sample size (1331)
Longer follow-up periods may paint a picture of worse suicide outcomes.
High suicide rates exist even in a liberal country like Sweden
Issues: Dhejne shows poor overall outcomes, but there is no pre-transition control group of people denied medical transition in a similar culture. This may or may not have shown worse mental health without transition. In the interest of accurate analysis, it is very important to note that a longer study may have a cohort of older individuals who transitioned at a time when coming out and being trans was more difficult than it is today.
Relatively large sample size (324)
“The above study involved over 1300 individuals. The external causes of death were increased almost eight times controls. There were 18 suicides, a 6-fold increased suicide rate for MtFs (but not FtMs). Like several of the other studies (Dhejne 2011, Lindqvist 2017) outcomes may get worse over time. Suicides start happening two to five years after transition. This indicates that there is a honeymoon period.
We suspect that our negative finding are due to a long follow up time.”
Issues: Outcomes are shown to worsen over time, but with no control groups of people who don’t transition with GD one can’t know for sure the effectiveness of medical transition.
This is a very useful study because they show pre and post data, showing no overall improvement in a very liberal country.
Overall, 27.9% of the sample were registered with psychiatric morbidity before SRS and 22.1% after SRS (p = not significant)…These results indicate that overall individuals undergoing sex reassignment in the Danish public health system hold considerable psychiatric morbidity besides gender identity disorder both pre-and post SRS.
OTHER PERTINENT OBSERVATIONS
1) Dr. Zucker has noted (timestamp 1:05:30) that suicide ideation in trans youth should be a concern of parents and mental and medical health professionals involved in treating dysphoric youth. However, suicide risk is no different than the elevated suicide risk for all youth seeking mental health treatment.
2) Dr. Polly Carmichael at Tavistock in Britain has indicated the same thing. Young people referred to the mental health service (CAMHS) have similar rates of suicide risk as youths with other mental health issues overall.
The Gender Identity Development Service portion of the NIH in Britain, their public medical health system:
“Similarly, suicide is extremely rare.”
3) ASD people are over-represented in gender dysphoria clinics (see here and here and here). There may be much higher suicide risk in autistic youth in general. Suicide risk may be strongly related to autism, not just GD:
Nor does the study consider the significance of autism it found in 12.2 to 17.1 percent of its children. Elsewhere, 14 percent of children with autism aged from one to sixteen have been reported to experience suicidal ideation or attempts, suggesting a rate twenty-eight times greater than that for typical children (0.5 percent) [22].
4) Multiple stories promoted in the media to encourage the affirmative model involve teens/YA’s who were fully affirmed which actually contradicts their narrative. See links here.
5) Similarly, a recent study of college students, Lipson (2019), shows very high rates of suicide risk, self-harm, and depression. Many universities are very affirming environments with many offering medical transition on student healthcare plans. So, there may still be high rates of mental health problems in changing demographics, even in affirming environments. This wasn’t included in negative studies due to not knowing anything about the students’ access to transition or current transition status for sure.
6) Parents of trans youth, LGBT organizations, media, and affirmative model advocates (including doctors and psychologists) all are involved in promoting the “transition or die” narrative. This contradicts advice from every suicide prevention advocacy organization out there.
7) Youth are being encouraged to threaten suicide by the trans community to facilitate transition. One doctor (Dr. Wong) has advised this.
8) Due to 5 and 6 and the fact suicide and negative rumination are both socially contagious, it is worth considering more youth are ruminating about suicide now more than ever.
9) There may be problems analyzing true overall efficacy by weighting subjective feelings about transition versus the reality of serious health issues, social costs, financial costs, and high suicide rates. That’s not to say anyone should discount a person’s self-report of feeling better and there are psychological surveys designed to measure improved real-world functioning. It just isn’t the only criteria. Asschemen addresses this as well as researcher bias:
*I suggest that one way to better validate subjective data in future research might be to use the “Veiled Report” method which makes it nearly impossible to associate a particular respondent with her answers to test questions.
An interest discussing on this is on sexnotgender.com.
SUMMARY
1) Trans youth are at increased risk for suicide. The risk should be taken very seriously and not brushed aside by pediatric-transition critical people.
2) Haas acknowledges that studies on suicide may exaggerate risk due to inflated self-report. Also, ideation, suicide threats, and self-harm are not always the same thing as an immediate danger of a life-threatening suicide attempt.
3) Suicide risk in trans-identified youth is likely the same as youth with other mental health problems. Claims of astronomically high suicide risk may be very inflated.
4) Recent studies show the highest risk may be more related to being a gender nonconforming female in these changing demographics.
5) Many studies on adults show extremely low regret rates, an improvement in mental health, and a reduction in gender dysphoria. While most don’t address suicide risk, these improvements theoretically would help suicide ideation and attempts, and these studies (Cornell review list) support the argument transition improves QOL.
6) Several studies strongly support the affirmative model argument that affirmation and support for trans identity reduce suicide risk.
7) Other studies complicate the issue by showing no improvement or worsening outcomes over time. They tend to be the better review, long range, and/or registry studies.
8) Suicide risk is used to manipulate the public and parents to enthusiastically affirm a minor’s trans identity. This closes off all other mental health exploration and violates every guideline around how to talk about suicide in young people. Suicide is known to be socially contagious and promoting a suicide panic narrative risks exasperating the issue.
9) Several high-profile anecdotal examples indicate affirmation does not solve all of these youth’s problems as they were affirmed by family and had access to medical treatment. Ironically, they are used to promote the affirmative model.
10) There may be problems analyzing efficacy concerning objective versus subjective reports of benefits.
11) Without a control group of people experiencing what it was like before medical transition was made available it is impossible to truly know the failures or benefits of coping without medical transition in the long run. Dysphoric people may have been very depressed and worse off. More individuals may be truly living their happiest selves. They indeed claim they are and have studies to back up this assertion. Conversely, GD appears to have socially contagious and iatrogenic aspects. It is possible that in this climate more youths are experiencing depression and suicide ideation around gender, not less, despite the plethora of attention and support. The dearth of reports of a suicide crisis around gender in minors in the past should raise questions. For example, why wasn’t PFLAG reporting extremely distressed, suicidal gender nonconforming children twenty years ago as the only organization helping families with the most obviously LGBT young people? Other cultures have accepted gnc males with seeming success when no medical transition was available (see Paul Vasey’s work). This is a very complex issue where many individuals will be happier transitioning with increased tolerance and access. The harm transitioning cognitively immature minors/YAs could do is becoming a complicated question with changing demographics, more young people medically transitioning, and an appearance of more stories of regret. Balancing concern for suicide risk with who could be damaged is central to the discussion of transitioning minors.
*Use freely with accreditation to Gender Health Query.
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