Trans (transgender or transsexual) people, who may represent up to 0.5 % of the adult population, have an extremely high prevalence of suicide ideation and attempts. Studies in Canada, Europe, and the United States have reported suicide attempt prevalences within the trans population that range from 22 to 43 % over the lifetime and 9 to 10 % for the past year. In contrast, 3.7 % of all Canadians had seriously considered, and 0.6 % attempted, suicide in the past year. While completed suicide rates among trans people are unknown, a history of attempted suicide is the strongest predictor of completed suicide across multiple populations. Demographic factors predictive of suicide attempts in the Canadian population overall include female sex, youth, chronic illness, lack of religiosity, and being unmarried. These predictors may not hold within trans populations; for instance, among trans Ontarians, ideation and attempts did not differ by gender identity. Moreover, while identification of demographic risk factors is helpful for targeting interventions, they are largely non-modifiable. There is an urgent need to identify intervenable risk and protective factors.
To date, most trans suicide research has been descriptive, or has assessed predictors of any lifetime suicide attempts. This limits applicability of results to suicide prevention, because predictors of lifetime versus recent suicide risk, and of ideation versus attempts, may differ. Other studies have focused on patients seeking care for medical transition, who are not representative of the entire trans population. Recent longitudinal studies demonstrate reductions in psychological distress following medical transition. Therefore, barriers to accessing transition-related care may contribute to increased suicide ideation and attempts. However, among those who have had hormonal treatment and/or sex reassignment surgery, suicide attempts and deaths remain elevated relative to the broader population. Thus, it appears that factors other than gender dysphoria (distress or discomfort with one's natal sex) contribute to increased suicide risk in trans populations.
While not all trans people experience profound distress regarding their embodiment, they nearly universally report some degree of social exclusion and transphobia. Trans people are subjected to invisibility in institutional settings, high levels of discrimination and rejection, harassment and violence, and poverty. Trans-related social exclusion has been associated with increased lifetime and past-year suicide attempts, while social and family support appear to be protective. Determinants of suicide risk in the broader population, including depression, substance misuse, and poverty are also elevated among trans persons, but are consistently attributed to social exclusion and victimization. Social exclusion, victimization, and trauma have been identified as key contributors to suicide disparities across marginalized populations, including sexual minorities and Indigenous peoples.
The current study sought to identify intervenable social factors associated with suicide risk reduction for trans people.
We present a conceptual model (Fig. 1) for two outcomes: past-year serious consideration of suicide, and – among those considering – past-year attempt. This approach reflected the possibility that factors impacting ideation and attempts may differ, as well as the pragmatic desire to both prevent suicidal ideation and to inform crisis interventions among those who are suicidal.
Conceptual model of intervenable social inclusion, transphobia and transition-related factors for suicide prevention among transgender people in Ontario, Canada
Variables were included as socio-demographic or background factors for the following reasons: 1) they are not amenable to change through intervention in our study population, either because they are unchangeable or because they occurred prior to age 16; 2) they are unlikely to be a result of the intervenable factors in the model, and 3) they are known or hypothesized to be associated with suicide ideation or attempts. Background factors must be controlled for as confounders in order to explore the impact of intervenable factors, so that differences observed for other factors are not based simply on differences in socio-demographic composition, illness, or history of childhood abuse.
Variables representing modifiable factors that may be targeted by potential interventions for suicide prevention within trans populations fell within three major constructs: social inclusion, transphobia (including enacted and internalized stigma, as well as violent victimization), and sex/gender transition. Their roles reflect minority stress, as they represent discrimination or acceptance, inclusion or exclusion, and barriers to full social participation. Moreover, all thirteen intervenable factors are social or medical determinants of health that are potentially intervenable through policy, social and/or medical intervention, but suggest different strategies. Thus, they are considered individually in this analysis rather than as overall constructs. For example, within the construct of social inclusion, interventions designed to increase parental support for gender identity or expression (e.g., family therapy, social media campaigns) would differ from those to increase identity document concordance (e.g., policy change on requirements for sex designation changes (or removal of sex designations altogether) at the federal and state/provincial levels).
Interventions on these factors have the potential to impact suicide ideation and attempts through multiple pathways. Suicide researchers have proposed models of suicidal behaviour, which focus on proximal determinants of ideation and attempts. Prominent among them is Joiner's Interpersonal Theory of Suicide, which accounts for a wide range of known risk factors for suicidal behaviour via three primary constructs. Suicide ideation is attributed to thwarted belongingness (resulting from social isolation) and perceived burdensomeness (e.g., resulting from family conflict or illness), and acquired capability is required for suicidal ideation to engender suicidal intent and attempts. The capability to overcome the natural disinclination to physical pain and death is acquired through previous exposure to fear and/or pain. Distal factors are posited to increase suicide risk by contributing to these proximal constructs. Such distal factors are the focus of our analysis, but we include proximal factors in Fig. 1 to explicate this conceptualization. Similarly, given the frequency of transphobic experiences and their profound effects on depression, housing, and access to services, we also included most of the variables traditionally defined as psychosocial risk factors as proximal factors. Together, these may mediate the effects of transphobia and other intervenable variables on ideation and/or attempts through a multitude of possible pathways that may be explored in future research.