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(p. 121) Suicide Risk Among Transgender and Gender-Nonconforming Youth 

(p. 121) Suicide Risk Among Transgender and Gender-Nonconforming Youth
Chapter:
(p. 121) Suicide Risk Among Transgender and Gender-Nonconforming Youth
Author(s):

Rylan J. Testa

and Michael L. Hendricks

DOI:
10.1093/med:psych/9780199950706.003.0011
Page of

date: 24 September 2018

As young people develop, they face pressures to exhibit socially desirable traits, behaviors, and identities in multiple domains, including gender. Youth who do not fit these expectations regarding gender are often subjected to negative social consequences, including bullying. In this chapter, we examine the prevalence of bullying experiences in transgender and gender-nonconforming (TGNC) youth, the prevalence of suicidality in these youth, and what the extant research says about the association between bullying and suicide in this population. We also examine how to address these patterns and support the development of healthy youth regardless of their gender identity or expression.

Who Are Transgender and Gender-Nonconforming Youth?

Essentially, TGNC youth comprise a fairly wide range of children and adolescents whose gender identity and/or expression of gender does not match the cultural expectation for the sex that was assigned to them at birth (Conron, Scout, & Austin, 2008; Meier & Labuski, 2013). While most individuals define their gender identity consistently with their assigned birth sex within the binary structure of male or female (Tobin et al., 2010), for some, gender identity and/or expression falls outside the gender binary (e.g., genderqueer, bigender, gender neutral; Kuper, Nussbaum & Mustanski, 2012). The amount of deviation tolerated varies by subculture and by sex assigned at birth, with some cultures evidencing societal acceptance and even reverence of diversity in gender identity and gender expression (Coleman, Colgan, & Gooren, 1992; Feinberg, 1996; Miller & Nichols, 2012; Schmidt, 2003). Among TGNC youth are those whose gender identity does not match their sex assigned at birth, referred to here as “transgender youth.” For example, a person who was assigned male at birth might instead identify as a girl or trans woman or as a gender that is other than boy or man. For other TGNC youth, the primary deviation from (p. 122) the cultural norm may be in their expression of gender, rather than their gender identity. They might have interests or present themselves in appearance in ways that do not conform to cultural expectations for their sex assigned at birth. For example, a person who was assigned female at birth might dress and behave in ways considered masculine while still identifying as a girl.

While research on TGNC youth is currently in its infancy, it is evolving quickly (Coleman et al., 2011). The primary body of research falling into this domain is that focusing on transgender adolescents. Some literature also exists looking at gender-related victimization in lesbian, gay, and bisexual (LGB) adolescents. However, many of these studies unfortunately conflate sexual orientation with gender identity and expression. In addition, while research clearly shows that gender-nonconformity exists among heterosexual youth as well, this population of youth is very rarely studied with respect to their potential victimization. We will therefore focus much of our analysis and discussion on understanding how gender-nonconformity influences bullying and suicide, primarily for adolescents who identify as transgender (trans) or LGB, with recognition that our knowledge and recommendations are based on a currently limited and quickly evolving body of literature.

Victimization of Transgender and Gender-Nonconforming Youth

Young people do not always react negatively to a peer’s gender-nonconformity. In many cases, their reactions may depend on just how far from the cultural expectation gender-presentation strays, along with other factors, such as the youth’s sex assigned at birth, race/ethnicity, and age (Beemyn & Rankin, 2011). Nonetheless, studies suggest that, overall, TGNC youth face high rates of rejection and victimization, sometimes to serious degrees and with serious consequences. In their 2009 survey of 7,261 LGBT students (ages 13 through 18), the Gay, Lesbian, and Straight Education Network (GLSEN) found that 62.7% of respondents heard negative remarks about gender expression, 56.7% heard negative remarks about “not being masculine enough,” and 39.7% heard negative remarks about “not being feminine enough” (Kosciw, Greytak, Diaz, & Bartkiewicz, 2010). This report also showed that trans students were more likely (76.3%) than LGB students (52.9%) to report feeling “unsafe at school because of their sexual or gender orientation” (Kosciw et al., 2010, p. 87). Goldblum and colleagues (2012) found that 44.8% of trans respondents reported having experienced hostility or insensitivity as a result of their gender identity or expression during high school, with 14.8% of these students reporting that the victimization was severe enough to prevent them from completing high school. Recent work by Nadal, Skolnik, and Wong (2012) noted that LGBT youth also reported being subjected to microaggressions—subtle forms of discrimination directed at members of minority groups.

Recent research has found that not all youth are at equal risk for victimization. Goldblum and colleagues (2012) found that in-school gender-based victimization was reported significantly more prevalently among the trans men (60.5%) than among trans women (38.8%). In addition, in this study, multiracial individuals (71.4%), African-Americans (53.1%), and those who classified their race as “other” (p. 123) (50.0%) reported higher rates, compared to 38.2% of white respondents. Finally, Goldblum and colleagues (2012) found that a significantly higher percentage of individuals under age 45 (at the time of their participation in the study) reported having experienced gender-based victimization, compared to respondents ages 45 and older.

Suicidality Among Transgender and Gender-Nonconforming Youth

Few studies have examined any association between gender-nonconformity itself and suicidality in youth or adults. Among these studies, findings have been mixed (D’Augelli et al., 2005; Fitzpatrick, Euton, Jones, & Schmidt, 2005; Friedman, Koeske, Silvestre, Korr, & Sites, 2006; Grossman & D’Augelli, 2007; Liu & Mustanski, 2012; Mustanski & Liu, 2013; Ploderl & Fartacek, 2009). What is clear is that trans people, and trans youth in particular, report alarming rates of suicidality. Recent research has revealed that between 38% and 83% of trans individuals have reported suicidal ideation (Goldblum et al., 2012; Grossman & D’Augelli, 2007; Testa et al., 2012; Xavier, Bobbin, Singer, & Budd, 2005), and approximately one-third of participants indicated a history of suicide attempts (Goldblum et al., 2012; Haas et al., 2011, Risser et al., 2005; Testa et al., 2012). Furthermore, among those who attempted suicide, the majority reported a history of multiple attempts across their lifespan (Goldblum et al., 2012; Testa et al., 2012). While multiple attempts have been associated with completed suicide in the general population, none of these studies on TGNC youth has evaluated completed suicide.1

Like victimization, suicidality has also been shown to vary based on demographics. Goldblum and colleagues (2012) found that suicide-attempt rates varied significantly by gender group, with trans men reporting the highest rates of suicide attempts, at 32.1%, while trans women reported a suicide-attempt rate of 26.5%. In addition, those in multiracial and “other” race categories reported the highest rates of attempt (57.1% and 60.0%, respectively), though Caucasian, African-American, and Latino/Latina respondents also reported high rates of suicide attempts (23.0%, 25.0%, and 28.6%, respectively). The Washington, D.C., Transgender Needs Assessment Survey (WTNAS), conducted by Xavier and colleagues (2005), also revealed that trans people of color are at increased risk for suicidality. Finally, both Goldblum and colleagues (2012) and Xavier and colleagues (2005) found that rates of suicidal ideation were highest among younger trans participants. Finally, while trans people of low and middle socioeconomic status (SES) had similar attempt rates (30.5% and 29.0%, respectively), those with high SES had a relatively much lower rate (9.1%; Goldblum et al., 2012).

Theories Linking Victimization and Suicidality Among Transgender and Gender- Nonconforming Youth

To better understand and explain the relationship between gender-based victimization and suicidality, Hendricks and Testa (2012) adapted Meyer’s Minority Stress Model (2003) to specifically apply to the experiences of trans individuals, and wove (p. 124) into it key aspects of the Interpersonal Theory of Suicide developed by Joiner (2010). In this work, Hendricks and Testa described the primary pathways through which victimization of TGNC youth might lead to suicidality.

Drawing on Meyer’s model, which was originally formulated to explain both the increased incidence of mental health symptoms and disorders found among lesbian, gay, and bisexual (LGB) people, several processes through which trans individuals are subjected to minority stress are delineated. First are the environmental and other external events that occur in the individual’s life as a result of that person’s minority status that create overt stress in the person’s life. Examples would include discrimination and threats to the person’s safety or security, such as bullying. The second set of processes involves the anticipation and expectation that the individual develops that external stressful events will occur. Anticipation of these events results in a heightened level of vigilance and further distress. As a result of this vigilance, trans people who are able to conceal their minority status may do so in order to protect themselves from psychological or physical harm. When this occurs, efforts to conceal their identity create additional distress. Third are the processes in which negative attitudes and prejudices from society are internalized. For LGB people, the epitome of this is internalized homophobia; for trans people, the epitome of this is internalized transphobia. This internalized sense of stigma can have direct negative effects on the individual’s ability to cope with external stressful events and ultimately reduces the individual’s resilience. Thus, when gender-based victimization occurs to self or others of one’s minority identity status, one faces multiple processes of stress that increase the risk for mental health difficulties, including suicidality.

Hendricks and Testa (2012) incorporated the Interpersonal Theory of Suicide, developed by Joiner (2010), to offer a further explanation for the connection between gender-based victimization and suicide risk among trans people. Joiner’s theory posits that completed suicide requires three components: perceived burdensomeness, thwarted belongingness, and the capability to enact lethal self-injury. “Burdensomeness” comprises liability (thinking that one would be more valuable dead than alive) and self-hate (Van Orden et al., 2010). Factors that contribute to self-hate include self-blame and low self-esteem. Hendricks and Testa (2012) highlighted how gender-related minority stress, including internalized transphobia and the anticipation of negative events, can lead to thoughts of self-hate and a related understanding of oneself as a burden to one’s family or society. Thwarted belongingness is composed of two primary dimensions: loneliness or social disconnectedness, and an absence of reciprocal care or the lack of social support (Van Orden et al., 2010). Hendricks and Testa (2012) described how, for trans youth, loneliness may result from rejection by family members, friends, or peers who are unwilling to accept their trans status, and may be compounded by existing in a society that is generally not accepting of gender-nonconformity. In addition, even without exposure to overt rejection, discrimination, or violence, individuals who do not see people like themselves represented in their community or society may develop a sense of not belonging. Finally, Hendricks and Testa (2012) described how the capability for lethal self-harm may be acquired by many trans people, as this capability can develop as a result of repeated acts of abuse or assaults, or from any other repeated exposure to pain (Van Orden et al., 2010), such as exposure that has been shown to be experienced as a result of gender-based victimization.

(p. 125) The models developed by Meyer (2003) and Hendricks and Testa (2012) also address factors that lead to resilience in, respectively, LGB and trans populations. Specifically, these models name pride and participation in one’s minority community as protective factors that buffer the individual against both external and internal minority stress factors. For example, trans individuals who identify with and engage with a trans community gain valuable social support to address minority stress while also developing a more positive concept of what it means to be a trans person.

Research Linking Victimization and Suicidality Among Gender-Nonconforming Youth

Research has provided some preliminary support for these theories’ implications that gender-related bullying would increase risk for suicide among TGNC youth. A study by Friedman and colleagues (2006) demonstrated that, among young adult gay men, there was an association between childhood femininity and suicidality, and that this relationship was mediated by experiences of bullying. In a sample of trans respondents, Goldblum and colleagues (2012) examined the relationship between having been subjected to hostility or insensitivity based on their gender identity or expression in school, and suicide attempts. They found that those in the overall sample who reported having been the victim of such gender-based hostility were approximately four times more likely to have made a suicide attempt than those who did not report being so victimized. Individuals who faced hostility had also made significantly more suicide attempts. This relationship was true for both trans men and trans women. A history of victimization and suicide attempts were both significantly more common among multiracial individuals. This highlights the crucial importance of the intersectionality of identities in understanding the experiences of TGNC youth. While no data have been collected on suicide completions in trans youth, in general, those who attempt suicide are at markedly higher risk for suicide completion than those who think about suicide but do not attempt it (Joiner, 2010; Van Orden et al., 2010).

Together, these studies add some support to the idea that bullying related to gender-nonconformity may increase the risk for suicide, and more clearly support a relationship between gender-related bullying and suicidal ideation and suicide attempt. However, since these studies were based on retrospective self-reports, causality could not be determined. Several other variables could explain the relationships found between victimization and suicidality. For instance, it is possible that individuals who were raised in social environments where they were exposed to bullying may also have been more likely to be rejected by parents and facing homelessness, or to face job discrimination and unemployment, and that these stressors were more predictive of suicidality than the experiences of bullying themselves. Another alternative explanation could be that study respondents experiencing long-standing depression or other mental health conditions have selective recall for prior negative events or a tendency to interpret experiences as more negative, as well as a higher incidence of suicidality. However, it is important to note that several studies have ruled out that gender-nonconformity itself is associated with suicidal ideation or suicide attempt among LGBT youth (Liu & Mustanski, 2012; Grossman & D’Augelli, 2007; Mustanski & Liu, 2013).

(p. 126) Finally, research has supported the idea that trans people’s resilience is supported by identification and engagement with a trans community. A large survey of trans adults demonstrated that mere exposure to information that others like themselves exist has a strongly protective effect on TGNC youth, with those exposed to such knowledge before their own transition significantly less likely to report feeling suicidal when first identifying as trans, compared to those who did not have this prior awareness (Testa, Jimenez, & Rankin, in press). In two qualitative surveys, Singh, Hays, and Watson (2011) and Singh and McKleroy (2011) found that connecting with others like themselves was identified by TGNC participants as a resilience factor. Furthermore, Sánchez and Vilain (2009) found that “collective self-esteem,” a concept defined as positive identification with one’s social group, was a buffer against experiences of discrimination among self-identified male-to-female transsexuals. In youth specifically, Heck, Flentje, and Cochran (2011) found that LGBTQ adolescents who attend high schools with gay-straight alliance clubs had better mental health outcomes. Finally, Davis, Saltzburg, and Locke (2009) found that LGBT youth explicitly stated a desire for increased opportunities for interaction and support within the LGBT community, both from their LGBT-identified peers and older LGBT-identified adult role models. This factor was seen as beneficial and necessary for psychological and emotional well-being by the participants.

Research-Based Recommendations

What Can Be Done in Schools?

With increased public attention to bullying and suicide over the past decade, interventions have been developed and evaluated and suggestions have been provided to schools, parents, and communities to attempt to address this problem. None of the programs or research found was designed primarily to address gender-related victimization. Among the several interventions that do include an LGBTQ focus, curricula often focus almost solely on sexuality and sexual identity. However, certain lessons from the research on these broader LGBTQ interventions are seen as applicable to addressing the issue of gender-related victimization.

From this literature, we have identified four areas, which we address here. First, it is important to decrease prejudicial attitudes and stigma among both youth and adults within a school or community. For students, research has shown that this can be done by providing curricula in schools that address issues of diversity, and that doing so can improve attitudes towards LGBTQ people and reduce bullying (Rogers, McRee, & Arntz, 2009). For example, a research study by GLSEN (2012) showed that an inclusive curriculum yielded lower levels of victimization related to LGBTQ identity. Furthermore, this was associated with lower levels of missed class days and an increase in the likelihood that students would confide in their teachers about LGBTQ issues. The inclusive curriculum comprised positive examples of LGBT people, histories, and events in class content. Similarly, research by Rogers, McRee, and Arntz (2009) found that participants who took a human sexuality class that was inclusive of LGB material reported significantly lower levels of homophobia at the conclusion of the course.

Second, it is important to promote resilience in TGNC youth through exposure to information, positive messages, role models, and peer support related to (p. 127) their gender identity and expression. In part, this can be addressed by providing gender-diversity training to the broad audience described above. In addition, providing a format for TGNC youth to have peer support is highly recommended. While research has demonstrated the positive effect of gay-straight alliances on LGBT youth, these organizations are advised to use a name that is more clearly inclusive to TGNC youth, and ensure that their environments are able to support gender as well as sexual diversity.

Third, it is important to train teachers and other school staff to understand gender diversity and to feel comfortable intervening in gender-related bullying. Research has found that teachers are less likely to intervene in harassment related to gender presentation than in other forms of bias, including race, religion, and disability (California Safe Schools Coalition, 2004). GLSEN’s study showed that only 12.1% of LGBT students reported that teachers would intervene to stop negative gender-based remarks; in contrast, 55.8% felt that racist remarks would not be tolerated (Kosciw et al., 2010). Teachers’ reaction to such events also has an impact on student behavior and overall school climate. For example, students who reported likelihood of witnessing a teacher intervene in LGBT bullying reported increased likelihood of intervening themselves (Wernick, Kulick, & Inglehart, 2012). In addition, inaction of teachers may lead students who have experienced bullying to hesitate reporting such incidents. GLSEN’s report showed that the majority of LGBT students who were assaulted refused to report these events to parents or teachers (Kosciw et al., 2010). Training staff members, administrators, and teachers in the proper way to respond to gender-based victimization can enrich the learning environment for all students, including LGB and trans youth (Hong & Garbarino, 2012). School mental health workers must collaborate with administrators to promote a school climate that is safe and supportive for all students, particularly those targeted based on their gender minority status.

Fourth and finally, it is important for schools to arrange policy and school/community structure to discourage victimization of TGNC students. It has been shown that students feel safer and report less harassment in schools where specific groups are listed as protected by anti-bullying laws and policies (Hatzenbuehler, 2011; Kosciw et al., 2010). School personnel should be aware that gender-related harassment, including harassment based on perceived “failure to conform to stereotypical notions of masculinity and femininity,” must be addressed in accordance with federal guidelines under Title IX (Office for Civil Rights, U.S. Department of Education, 2010, pp. 7–8). While no research has been done on the structure of school environments, many have also pointed out the importance of implicit learning of preferred gender norms through binary division of sports teams, bathrooms, locker rooms, and even “line-up” routines in schools. By changing these structural factors to create affirming educational environments, schools can both encourage broad embrace of gender diversity and encourage self-acceptance in TGNC youth.

What Can Be Done Outside of Schools?

While bullying most often occurs in schools, the people and environments of youths’ lives outside of school are crucial influences on the extent to which victimization occurs and the effects of victimization on the mental health of TGNC (p. 128) youth. First, youth victimize TGNC peers because they learn through their culture that gender-nonconformity is a negative trait. In stark contrast, other current and historical cultures have valued gender-nonconformity, sometimes even believing that TGNC people had spiritual or healing roles to play in their society (Feinberg, 1996). In mainstream Western cultures, negative messages regarding gender-nonconformity are learned not only at school, but in the home, through the media, in religious contexts, and in the way communities are structured, healthcare is provided, and policies are crafted. Similarly, across these contexts there are often few positive messages, images, and role models speaking to the value of gender-nonconformity and TGNC people. Attitude change at a societal level will therefore require action at multiple levels and by all parties to reduce the negative and increase the positive messages youth receive about gender-nonconformity. While broad attitude change can seem like a daunting task, the progress of the civil rights and gay rights movements demonstrates how real change can occur when enough voices are heard. Ultimately such attitude change will be necessary to end victimization of TGNC youth.

However, there are many things we can do to positively affect outcomes for TGNC youth before societal changes come to fruition. Put simply, actors at all levels, including family, clergy, policy-makers, and providers, can help TGNC youth develop resilience. As discussed above, key aspects of resilience for TGNC youth include developing a sense of pride and connecting with others who share their identity and experience, as well as having acceptance and identity affirmation for LGBTQ youth (Ryan, Russell, Huebner, Diaz, & Sanchez, 2010). Youth should therefore be provided access to positive information, peers, and role models that reflect their own identities. In the past, such resources were not easily accessible to people in certain communities. However, with technology increasing access to resources and to other people on a global scale, ample resources and people now exist online to which youth can be steered. In addition, parents, providers, clergy, and others who interact with youth can be significant sources of affirmation and acceptance by doing simple things like asking for and endorsing a youth’s request for which pronouns and name to use, clothing to wear, and activities in which to engage.

Considering the high percentage of TGNC youth who report a history of suicide attempts, it is important for all to be attuned to warning signs and be aware of appropriate steps to take should a youth appear at risk for suicidal behavior. Youth who are TGNC and in distress need access to service providers and settings that are accepting and affirming of their identities, prepared to discuss the effects of gender-related victimization and minority stress on their mental health, and able to provide developmentally appropriate resources to support identity development, pride, and connection with others like themselves. The American Counseling Association (Association for Lesbian, Gay, Bisexual & Transgender Issues in Counseling [ALGBTIC], 2009) has developed Competencies for Counseling with Transgender Clients, in which they advocate an approach that is strength-based, multiculturally informed, and derived from feminist theories and social justice. Hendricks and Testa (2012) and Goldblum and colleagues (2012) provide further recommendations and resources for mental health clinicians working with TGNC people and TGNC youth. Work with families may be particularly important, as many TGNC youth experience negative treatment at home that further exacerbates their distress (Ryan et al., 2010). Programs such as the Family Acceptance Project in (p. 129) San Francisco (Family Acceptance Project, 2013) help families better understand, accept, and protect their children.

Finally, all interventions to address the high rates of bullying and suicidality among TGNC youth should be evidence-based. To date, it seems that more effort has been expended on documenting the problem than on developing interventions, with potentially harmful consequences. For example, the “It Gets Better” campaign, initiated by American author Dan Savage, has been both praised and criticized for its possible stimulus effect that can yield “copycat” suicide behavior. The American Foundation for Suicide Prevention, in partnership with the Gay and Lesbian Medical Association, met in November 2007 to promote improved understanding of how to reduce suicide risk and behavior in the LGBT population (Haas et al., 2011) and provided recommendations for media campaigns increase access to services and calls to expand culturally appropriate mental health and substance abuse programs for LGBT populations (Haas et al., 2011).

Summary of Recommendations

Suggestions for Healthcare Providers (Particularly Mental Health)

  • Promote TGNC youths’ resilience by facilitating access to TGNC peers and role models.

  • Educate yourself about how to provide culturally competent services for TGNC youth by accessing resources, such as the World Professional Association of Transgender Health’s Standards of Care Version 7 (Coleman et al., 2011) and the American Counseling Association’s Competencies for Counseling with Transgender Clients (ALGBTIC, 2009).

  • Assess TGNC youths’ exposure, including prior discrimination or victimization, expectations of future victimization or rejection, internalized transphobia, and expressions of resilience, and take necessary steps to minimize future occurrence of these stressors.

  • Be aware of what resources exist in the youths’ communities for TGNC youth who are experiencing minority stress and/or suicidality.

  • Communicate acceptance of TGNC youths’ identities and expressions, and respect for each youth’s unique strengths.

  • Make structural changes in your facility, by, for example, ensuring that intake forms and restrooms allow for gender diversity.

  • Recognize the limits of your training and your beliefs and attitudes about gender-nonconformity and refer out when appropriate.

Suggestions for Parents and Teachers

  • Provide educational curricula that teach all students to value people with diverse gender identities and expressions.

  • Facilitate TGNC youths’ access to TGNC peers and role models.

  • Educate yourselves and other adults in your community about gender diversity.

  • Train and empower all school staff to feel comfortable intervening in gender-related bullying.

  • (p. 130) Develop and enforce school policies, with awareness of Title IX, to protect TGNC youth and respond to gender-based victimization.

  • Make structural changes in school environments to represent gender diversity as a normal, respected identity by having gender-neutral bathrooms, locker-rooms, sports, and group work options, as well as curricula and texts that represent gender diversity.

  • Be sensitive to the unique stressors for TGNC youth and the related increased risk for suicidality, and encourage accessing culturally competent mental health resources when appropriate.

  • Communicate acceptance of TGNC youths’ identities and expressions, and respect for each youth’s unique strengths.

Suggestions for Policy Makers

  • Create and support policies that will promote school environments that are comfortable safe spaces for TGNC youth.

  • Develop and support policies that will increase access to culturally competent mental health resources for TGNC youth who are experiencing distress.

  • Ensure that non-discrimination policies include protections for TGNC people at the broadest levels of society, such that TGNC youth can have less negative expectations about their futures, and TGNC adults can become more accessible as role models to TGNC youth.

  • Encourage ongoing funding for programs of intervention and research that focus on TGNC youth.

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Notes:

1. A very few studies have found elevated rates of completed suicide among adult transsexuals (see Dhejne et al., 201;1 van Kesteren, Asscheman, Megens, & Gooren, 1997).