Our understanding of how gender affects suicidality was developed when most scholars viewed gender as a male/female binary. However, over the last decade scholars have begun investigating suicide in those whose gender identity do not match their sex assigned at birth.

For example, studies1 show that many risk factors for suicide in transgender/gender-diverse (TGD) adults mirror those from the general population, such as mental health concerns, substance abuse, and life stressors. However, through recent research, unique risk factors for TGD individuals are becoming more apparent. Much of this research has attempted to understand the factors that relate differently to suicidal thoughts (e.g., symptoms of depression) and suicidal behaviors (e.g., access to a firearm). This way of understanding suicide is often referred to as the ideation-to-action framework.2

Why do Transgender People Die by Suicide?

The following are six risk factors that providers should be aware of and assess in order to better understand suicide risk in their TGD patients.

Risk Factor #1:  External minority stress

Factors studied under this category include various types of violence, discrimination, harassment, and rejection based on one’s minority gender identity. These factors are consistently positively related to suicidal thoughts but less so to suicidal behaviors. Factors most highly related to suicidal thoughts include harassment, discrimination, social stressors such as rejection, and non-affirmation in one’s identity. The experiences of physical and sexual violence are related to both suicidal thoughts and behaviors.

Risk Factor #2:  Internal minority stress

These factors are unique to TGD individuals and are experienced more internally compared to the experience of discrimination or violence. These factors include internalized stigma/transphobia (e.g., shame about being transgender), concealment of identity/nondisclosure, expectations of social rejection, an inability to express gender, negative self-concept, and an unclear gender identity. These factors appear to be particularly implicated in the vulnerability for suicidal thoughts but less so for suicidal behavior once suicidal thoughts have developed.

Risk Factor #3:  Psychiatric morbidity

As to be expected, mental health problems relate to suicidal thoughts and behaviors within this population. These include depression, loneliness and isolation, emotional instability, anxiety, PTSD, alcohol and drug abuse, physical and mental disabilities, and learning disabilities. Some risk factors are more strongly related to suicide attempts than others. For example, factors such as substance abuse and PTSD are slightly more closely related to suicidal behavior compared to internal factors such as loneliness.

Risk Factor #4:  Transition and healthcare

Gender transition is a unique experience for each individual who chooses to, or chooses not to, go through the process. There are many steps in the transition process ranging from social transition (e.g., dressing as one’s gender) to medical interventions (e.g., hormone therapy or surgical interventions). The following factors fall into the transition and healthcare risk category, and relate to suicidal thoughts and behaviors in TGD adults:  not completing hormone therapy, lack of medical interventions such as breast or genital surgery, lack of social transition or living every day in one’s real gender, lack of identity documents that align with identified gender, health care coverage for gender-related interventions, lack of psychotherapy for gender dysphoria, and visual nonconformity.

Risk Factor #5:  Reasons for living

Reasons for living are often protective against suicidal thoughts and include religiosity, optimism, survival coping beliefs, concerns about how loved ones will react to one’s suicide, fear of suicide, fear of social disapproval if one attempts suicide, and moral objections to suicide.

Risk Factor #6:  Demographics

The more static/demographic risk factors for suicide among TGD individuals include assigned female sex at birth, gender self-identification as male, and childhood gender nonconformity. Other demographic factors related to suicidal thoughts include younger age, being a racial or ethnic minority (though there are mixed findings on this), education, income, employment, socioeconomic status, sexual orientation as gay, lesbian, bisexual, or unsure sexual orientation.

Awareness and inclusion of these risk factors in patient assessments can increase the effectiveness of suicide prevention efforts within TGD individuals.