Suicidal thoughts and behaviors (STBs) remain a pressing public health problem for transgender and gender diverse (TGD) persons. The goal of this study was to apply social-ecological and minority stress frameworks to identify individual and interpersonal-level TGD-specific STB risk and protective factors.
This is a secondary analysis of the 2015 United States Transgender Health Survey, a comprehensive cross-sectional health assessment of a national sample of TGD adults (N = 27,658). Chi-square and Analysis of Variance (ANOVA) were used to identify bivariate correlates of 12-month and lifetime suicidal ideation (SI) and suicide attempt (SA). Logistic regression was employed to identify the strongest STB risk and protective factors across levels.
Sexual minority identification, racial minority identification, and having a disability were lifetime STB risk factors. TGD identity, sexual minority identification, racial minority identification (SA only), lower education, lower income, military experience, having a disability, and being uninsured were 12-month STB risk factors. Psychological distress was the most robust STB risk factor. Workplace discrimination, family rejection, healthcare discrimination, and childhood bias-based victimization were lifetime STB risk factors. All forms of discrimination and victimization (with the exception of family rejection for SI) were 12-month STB risk factors. Family and coworker support were protective factors for lifetime SA (but not SI) and all 12-month STBs. Being less out about TGD identity was a protective factor for STBs (except for 12-month SI).
Findings support social-ecological and minority stress STB risk frameworks. Recommendations are provided for a comprehensive approach to TGD suicide prevention.
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The United States Transgender Health Survey is available from http://www.ustranssurvey.org/.
World Health Organization [WHO] (2014) Preventing suicide: A global imperative. WHO Press, Luxembourg https://www.who.int/mental_health/suicide-prevention/world_report_2014/en/ Accessed 2 Nov 2020
Drapeau CW, McIntosh JL (for the American Association of Suicidology) (2020) U.S.A. suicide: 2018 official final data. Washington, DC: American Association of Suicidology, downloaded from http://www.suicidology.org. Accessed 12 Feb 2020
Shepard DS, Gurewich D, Lwin AK, Reed GA Jr, Silverman MM (2016) Suicide and suicidal attempts in the United States: costs and policy implications. Suicide Life Threat Behav 46(3):352–362. https://doi.org/10.1111/sltb.12225
Klonsky ED, Saffer BY, Bryan CJ (2018) Ideation-to-action theories of suicide: a conceptual and empirical update. Curr Opin Psychol 22:38–43. https://doi.org/10.1016/j.copsyc.2017.07.020
Joiner TE (2005) Why people die by suicide. Harvard University Press, Cambridge, MA
Klonsky ED, May AM (2015) The three-step theory (3ST): a new theory of suicide rooted in the “ideation-to-action” framework. Int J Cogn Ther 8(2):114–129. https://doi.org/10.1521/ijct.2015.8.2.114
O’Connor RC (2011) The integrated motivational-volitional model of suicidal behavior. Crisis 32(6):295–298. https://doi.org/10.1027/0227-5910/a000120
Van Orden KA, Witte TK, Cukrowicz KC, Braithwaite SR, Selby EA, Joiner TE (2010) The interpersonal theory of suicide. Psychol Rev 117(2):575–600. https://doi.org/10.1037/a0018697
Bryan CJ, Rudd MD (2006) Advances in the assessment of suicide risk. J Clin Psychol 62(2):185–200. https://doi.org/10.1002/jclp.20222
Franklin JC, Ribeiro JD, Fox KR et al (2017) Risk factors for suicidal thoughts and behaviors: a meta-analysis of 50 years of research. Psychol Bull 143(2):187–232. https://doi.org/10.1037/bul0000084
Batterham PJ, Ftanou M, Pirkis J et al (2015) A systematic review and evaluation of measures for suicidal ideation and behaviors in population-based research. Psychol Assess 27(2):501–512. https://doi.org/10.1037/pas0000053
Bryan CJ, Stone SL, Rudd MD (2011) A practical, evidence-based approach for means-restriction counseling with suicidal patients. Prof Psychol Res Pr 42(5):339–346. https://doi.org/10.1037/a0025051
Jobes DA (2012) The Collaborative Assessment and Management of Suicidality (CAMS): an evolving evidence-based clinical approach to suicidal risk. Suicide Life Threat Behav 42(6):640–653. https://doi.org/10.1111/j.1943-278X.2012.00119.x
Standley CJ (2020) Expanding our paradigms: Intersectional and socioecological approaches to suicide prevention. Death Stud. https://doi.org/10.1080/07481187.2020.1725934 (published online ahead of print, 2020 Feb 12)
Brodsky BS, Spruch-Feiner A, Stanley B (2018) The zero suicide model: applying evidence-based suicide prevention practices to clinical care. Front Psychiatry 9:33. https://doi.org/10.3389/fpsyt.2018.00033
Cramer RJ, Kapusta ND (2017) A social-ecological framework of theory, assessment, and prevention of suicide. Front Psychol 8:1756. https://doi.org/10.3389/fpsyg.2017.01756
Allchin A, Chaplin V, Horwitz J (2019) Limiting access to lethal means: applying the social ecological model for firearm suicide prevention. Inj Prev 25(Suppl 1):i44–i48. https://doi.org/10.1136/injuryprev-2018-042809
Caine E (2019) Building the foundation for comprehensive suicide prevention—based on intention and planning in a social-ecological context. Epidemiol Psychiatr Sci 29:e69. https://doi.org/10.1017/S2045796019000659
Cerulli C, Winterfeld A, Younger M, Krueger J (2019) Public health law strategies for suicide prevention using the socioecological model. J Law Med Ethics 47(2_suppl):31–35. https://doi.org/10.1177/1073110519857312
Wilkins N, Myers L, Kuehl T, Bauman A, Hertz M (2018) Connecting the dots: state health department approaches to addressing shared risk and protective factors across multiple forms of violence. J Public Health Manag Pract 24(Suppl 1):S32–S41. https://doi.org/10.1097/PHH.0000000000000669
Cramer RJ, Judah MR, Badger NL et al (2020) Suicide on college campuses: a public health framework and case illustration. J Am Coll Health. https://doi.org/10.1080/07448481.2020.1739053 (published online ahead of print, 2020 Mar 24)
James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M (2016) The report of the 2015 U.S. Transgender Survey. National Center for Transgender Equality, Washington, DC
Baca-Garcia E, Perez-Rodriguez MM, Keyes KM et al (2010) Suicidal ideation and suicide attempts in the United States: 1991–1992 and 2001–2002. Mol Psychiatry 15(3):250–259. https://doi.org/10.1038/mp.2008.98
Kessler RC, Borges G, Walters EE (1999) Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Arch Gen Psychiatry 56(7):617–626. https://doi.org/10.1001/archpsyc.56.7.617
Kaniuka AR, Bowling J (2021) Suicidal self-directed violence among gender minority individuals: a systematic review. Sui Life-Threat Behav 51:212–219. https://doi.org/10.1111/sltb.12696
Wolford-Clevenger C, Frantell K, Smith PN, Flores LY, Stuart GL (2018) Correlates of suicide ideation and behaviors among transgender people: a systematic review guided by ideation-to-action theory. Clin Psychol Rev 63:93–105. https://doi.org/10.1016/j.cpr.2018.06.009
Rabaso A, Andover M (2020) Suicidal ideation among transgender and gender diverse adults: a longitudinal study of risk and protective factors. J Affect Disord 278:136–143. https://doi.org/10.1016/j.jad.2020.09.052
Meyer IH (2003) Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull 129(5):674–697. https://doi.org/10.1037/0033-2909.129.5.674
Hatzenbuehler ML (2009) How does sexual minority stigma “get under the skin”? A psychological mediation framework. Psychol Bull 135(5):707–730. https://doi.org/10.1037/a0016441
Testa RJ, Michaels MS, Bliss W, Rogers ML, Balsam KF, Joiner T (2017) Suicidal ideation in transgender people: gender minority stress and interpersonal theory factors. J Abnorm Psychol 126(1):125. https://doi.org/10.1037/abn0000234
Tucker RP, Testa RJ, Reger MA, Simpson TL, Shipherd JC, Lehavot K (2019) Current and military-specific gender minority stress factors and their relationship with suicide ideation in transgender veterans. Suicide Life Threat Behav 49(1):155–166. https://doi.org/10.1111/sltb.12432
Testa RJ, Habarth J, Peta J, Balsam K, Bockting W (2015) Development of the gender minority stress and resilience measure. Psychol Sex Orientat Gend Divers 2(1):65–77. https://doi.org/10.1037/sgd0000081
White Hughto JM, Reisner SL, Pachankis JE (2015) Transgender stigma and health: a critical review of stigma determinants, mechanisms, and interventions. Soc Sci Med 147:222–231. https://doi.org/10.1016/j.socscimed.2015.11.010
Kessler RC, Andrews G, Colpe LJ, Hiripi E, Mroczek DK, Normand SL et al (2002) Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychol Med 32(6):959–976. https://doi.org/10.1017/s0033291702006074
Hosmer DW, Lemeshow S, Sturdivant RX (2013) Applied logistic regression, 3rd edn. Wiley, New York
Chen H, Cohen P, Chen S (2010) How big is a big odds ratio? Interpreting the magnitudes of odds ratios in epidemiological studies. Commun Stat-Simul C 39(4):860–864. https://doi.org/10.1080/03610911003650383
Cohen J (1988) Statistical power analysis for the behavioral sciences. Routledge Academic, New York
Hewitt J (2013) Why are people with mental illness excluded from the rational suicide debate? Int J Law Psychiatry 36(5–6):358–365. https://doi.org/10.1016/j.ijlp.2013.06.006
Wortzel HS, Nazem S, Bahraini NH, Matarazzo BB, Silverman MM (2018) The potential perils of a suicide-specific diagnosis. J Psychiatr Pract 24(5):354–358. https://doi.org/10.1097/PRA.0000000000000333
Mohr JJ, Kendra MS (2011) Revision and extension of a multidimensional measure of sexual minority identity: the lesbian, gay, and bisexual identity scale. J Couns Psychol 58(2):234–245. https://doi.org/10.1037/a0022858
Hatzenbuehler ML, Pachankis JE (2016) Stigma and minority stress as social determinants of health among lesbian, gay, bisexual, and transgender youth: research evidence and clinical implications. Pediatr Clin North Am 63(6):985–997. https://doi.org/10.1016/j.pcl.2016.07.003
Jameson JP (2020) Responding to adolescents at risk of suicide: Implications of the ideation-to-action framework. N C Med J 81(2):106–110. https://doi.org/10.18043/ncm.81.2.106
Lange TM (2020) Trans-affirmative narrative exposure therapy (TA-NET): A therapeutic approach for targeting minority stress, internalized stigma, and trauma reactions among gender diverse adults. Pract Innov 5(3):230–245. https://doi.org/10.1037/pri0000126
Lange TM, Hilgeman MM, Portz KJ, Intoccia VA, Cramer RJ (2020) Pride in all who served: development, feasibility, and initial efficacy of a health education group For LGBT veterans. J Trauma Dissociation 21(4):484–504. https://doi.org/10.1080/15299732.2020.1770147
Millner AJ, Lee MD, Nock MK (2015) Single-item measurement of suicidal behaviors; validity and consequences of misclassification. PLoS ONE. https://doi.org/10.1371/journal.pone.0141606
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The authors declare not conflicts of or competing interests.
All human and animal studies have been approved by the appropriate ethics committee and have, therefore, been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.
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Cramer, R.J., Kaniuka, A.R., Yada, F.N. et al. An analysis of suicidal thoughts and behaviors among transgender and gender diverse adults. Soc Psychiatry Psychiatr Epidemiol 57, 195–205 (2022). https://doi.org/10.1007/s00127-021-02115-8
- Gender identity
- Social-ecological model
- Social support