Previous studies have documented high rates of suicidal ideation and increased risk of suicide in transgender and gender diverse (TGD) compared to cisgender individuals. However, much of the current literature consists of small-sample studies that have not assessed subgroup differences. Using data from the electronic health records of patients receiving care at the Fenway Health Center, a community health center specializing in sexual and gender minority health in the Boston area, Norik Kirakosian and colleagues, including Abigail Batchelder, PhD, MPH and Conall O’Cleirigh, PhD from the Department of Psychiatry at Mass General examined the relationship between gender identity and suicidal ideation.
In this study, data were extracted from the 29,988 patients receiving care between 2015 and 2018. The researchers found that younger age, sexual and gender minority identity, and public/grants-based insurance were associated with significantly higher odds of suicidal ideation. Compared to cisgender men (6.1% reported suicidal ideation), the researchers noted greater likelihood of suicidal ideation in transgender men (OR=2.08; 95% CI=1.29-3.36), transgender women (OR=3.08; 95% CI=2.05-4.63), nonbinary (NB) individuals assigned male at birth (AMAB; OR=3.55; 95% CI=1.86-6.77), and NB individuals assigned female at birth (AFAB; OR=2.49; 95% CI=1.52-4.07) even after controlling for age, race, ethnicity, sexual orientation, and insurance status.
Risk profiles differed according to assigned sex at birth. Larger proportions of transgender women (23.6%) and NB AMAB individuals (26.7%) reported suicidal ideation, not only when compared to cisgender men (6.1%) and women (6.6%), but also when compared to transgender men (17.4%).
Recommendations
The current study indicates that TGD patients were significantly more likely to report suicidal ideation compared to cisgender individuals, even after accounting for age, race, ethnicity, sexual orientation, and insurance status. Particularly at high risk for suicidal ideation were TGD individuals assigned male at birth.
It is noteworthy that this study was carried out not in the general population, but in a group of patients seeking care at a clinic offering gender-affirming care. Given that previous studies have indicated that psychological distress and suicidal ideation are more common among individuals who are denied or unable to access gender-affirming care, we might expect even higher rates of suicidal ideation in certain communities – for example, among TGD individuals living in states which have legislation restricting access to gender-affirming care. Furthermore, TGD youth may be particularly vulnerable; according to this study, they are more likely to report suicidal ideation than older individuals, which may be attributable to legislation limiting gender-affirming care being the most restrictive for youth.
Given such striking disparities in suicidal ideation between cisgender and TGD individuals, the authors state that, “Clinical assessment of suicidal ideation and risk among TGD populations should be consistent, comprehensive, and directed, rather than relying on spontaneous patient report.” While this study indicates a two- to threefold higher risk of suicidal ideation in TGD individuals, efforts to screen this high-priority population in traditional clinical settings may be hampered by the fact that gender identity demographic data is not consistently collected by clinicians.
Furthermore, the authors note that screening instruments such as the Patient Health Questionnaire (PHQ) which is commonly used to screen for depression may not be adequate. Tools like the Columbia Suicide Severity Rating Scale (C-SSRS) may be more appropriate for use among groups that have high rates of suicidal risk. Additionally, efforts are needed to reduce the systemic bias and discrimination perpetuated against the TGD population, which are critical root causes of these disparities.
Lead author Norik Kirakosian, B.S. is now pursuing a Ph.D. in clinical psychology at the University of Miami and is a member of the Health Promotion and Care (HPAC) Research Lab.
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Kirakosian N, Stanton AM, McKetchnie SM, King D, Dolotina B, O’Cleirigh C, Grasso C, Potter J, Mayer KH, Batchelder AW. Suicidal Ideation Disparities Among Transgender and Gender Diverse Compared to Cisgender Community Health Patients. J Gen Intern Med. 2023 Jan 17:1–9.
