Transgender and Suicidality. How do you see it?

An investigation into the cause of increased suicidality in transgender youth. Is it the lack of access to transgendered healthcare or is it the co-existing social stressors and mental health issues?

Experiencing Gender Dysphoria (GD) increases the risk of suicidality. This statement is common and seems to be well accepted. However, what about transgender healthcare (TGH)? How does this help or hinder suicidality? Let’s investigate this question. The affirmation model with transgenderism leads to less psychiatric treatment and psycho-social supports being offered because it does not see transgenderism as a psychiatric disorder to be ‘fixed’ but a state of being to be embraced. In the place of psychiatric therapy, these people predominantly receive TGH. So, does this affirmation approach (with its lack of emphasis on therapy) actually maintain and prolong GD and therefore cause an increase in or prolonging of suicidality?

One of the most commonly quoted studies on the subject of transgender and suicidal behaviour is the PloS ONE study by Turban et al in 2022. It states that its primary data source is from the 2015 U.S. Transgender Survey (USTS). This survey is a cross-sectional, retrospective self-report of approximately 27,700 respondents. One of the key claims from the Turban et al study is that ‘Withholding or delaying transgender healthcare raises suicide risk’. Let’s have a look at this. Firstly, what is a ‘cross-sectional, retrospective self-report’? It is where researchers collect information in a one-off survey, asking people to remember and report their own past experiences or behaviours. The advantages of this kind of study are that it is quick and useful for spotting patterns or associations. An example might be that ‘people with lower income smoke more tobacco’. The disadvantages of this type of research are…

1. That you cannot use them to prove cause and effect, as you don’t know what comes first. For the above example, you don’t know if tobacco use leads to low income or vice versa.

2. Also, there is often Memory Bias. That is when people often misremember or forget events and details.

3. And there can be Self-report Bias. This is where people’s own bias (often influenced by social opinion/belief) leads to the under- or over-reporting of key or sensitive themes.

So, if one disadvantage of this form of research is the inability to prove cause and effect behaviours (acknowledged by the USTS authors), why has this Turban et al study made cause and effect claims regarding TGH and suicidality? Perhaps it is because the data gathered in the USTS is so comprehensive and detailed that they believed they were able to do so? Let’s have a look at this. What questions regarding suicide were used in the USTS to gather the data that the Turban et al authors used to make this cause-and-effect conclusion? The Yes/No questions were self-reported and were…

1. Have you ever attempted suicide (in your lifetime)?

2. And, have you in the past 12 months attempted suicide?

On the surface, the data from these two questions on suicide (from the USTS) do not seem to provide enough detail to correctly make any cause-and-effect conclusions. However, the Turban et al study also incorporated other USTS data on cross-sectional themes such as co-morbid mental health issues like GD, anxiety, and depression, and social factors such as socio-economic status, victimization, non-affirmation, and concealment, among others. Using this cross-sectional approach, they believe they were able to collect enough data to make their cause-and-effect conclusions. Again, is this sound? Can this cross-sectional data effectively do this, to factually state that ‘Withholding or delaying transgender healthcare raises suicide risk’?

Is there data from other research that can help clarify this question? It has been clearly documented that transgender youth are particularly at risk of exhibiting numerous co-morbid mental illnesses or experiencing significant social stressors (1, 2, 3, 4). Transgender studies report elevated rates (300-600%) of autism (13, 14), depression (5, 6, 12), unemployment (9, 11), psychiatric hospitalization (6, 8), incarceration (6), and death by suicide after receiving medical transition (6, 7, 10). These studies suggest a significantly different cause-and-effect narrative. That transgender suicidality increases because of the co-morbid psychiatric and psycho-social stressors associated with being transgendered, or increases because of receiving TGH, not the delaying or withholding of the same.

So how do these social stressors and co-morbid mental illnesses associated with transgenderism relate to suicidality, and which comes first, the egg or the chicken? One UK research report states that up to 25% of autistic people have attempted suicide or suicidal behaviours. With severe youth depression, one study states they are 230% more likely to attempt suicide than those without depression, and with an anxiety disorder, youth are 485% more likely to attempt suicide. Youth who have experienced Adverse Childhood Events (ACEs) are 200-500% more likely to attempt suicide. The more ACEs they experience, the higher the risk. Regarding ADHD, youth are 260% more likely to attempt suicide, with anorexia, it is 70% more likely, and with drug addiction, suicide is more than 240% more likely. Lastly, a UK study of 11-16-year-olds with a mental health diagnosis states that about 25.5% have self-harmed or attempted suicide.

So, youth with mental illnesses and significant social stressors are at higher risk of suicide. This is undisputed. So, the question is, are the co-morbid mental illnesses and social stressors in transgendered youth the root of the increased suicidality, or is it the GD itself (which is at the core of transgender identity) and restricted TGH access? To gain more clarity, ideally, we would look to a study which has a control group of transgendered youth without co-existing mental illness or significant social stressors and another group that does and examine the strength and frequency of suicidal thoughts and behaviours. However, I am unaware of such a study.

The closest I have been able to find to a control group study like that is the groundbreaking VU University Medical Centre puberty blocker research, which later went on to be known as the Dutch Protocol. This is the ‘founding father’ of transgender research and led to the mainstream use of TGH. There were 55 subjects in the study, which is not a large number statistically. Among the requirements of this 2012 study was they required the subjects…

1. Underwent a psychological assessment to establish their capacity.

2. That they had stable mental health without major untreated comorbid psychiatric disorders that might interfere with diagnosis or treatment.

3. And that they had family (parental) support with informed consent.

This founding GD research stated that for the vast majority of these subjects, 73-90%did not continue to experience GD in later teens to early adulthood. That is, they no longer experienced GD nor identified as transgender. They returned to identify with their sex of birth, with many of these going on to identify as homosexual. So, the suicide statistics for this group would likely mirror those of age-similar cisgender peers with no co-morbid mental illnesses. That appears to be the case. These young persons did receive TGH (puberty blockers) for a period of time, but as there were no co-morbid mental illnesses or significant social stressors, suicidality rates in a follow-up study stated they were not statistically significant. Again, this data does not seem to reinforce the Turban et al conclusion.

What I also found was the UK government-initiated report on suicide and GD. It investigated youth at the NHS Tavistock Clinic and was published in 2024. It is known as the Appleby report. Access to puberty blockers was first withdrawn from use in the Tavistock Clinic after court proceedings in 2020. They are now permanently withdrawn, apart from their use in small numbers in formal clinical studies. At that time, critics predicted that the restriction of these TGH interventions would lead to an ‘avalanche of suicides’ amongst these youth. The Good Law Project (GLP) is a not-for-profit UK campaign organization. They state that they use legal action, investigations, and public campaigning to hold the ‘powers that be’ accountable, and that they focus on fighting for fairness, transparency, and good governance. In 2024, they wrote an article titled ‘The shocking rise of deaths among young trans people’. In this article, they stated that…“Since the NHS imposed restrictions on treatment for young trans people, deaths have surged (GLP).”

What did the Appleby report find in regards to this predicted (and reported) shocking rise of suicides? It showed that there was not a significant increase in the suicide rate with GD youth after the withdrawal of puberty blockers, which directly contradicts the Turban et al conclusion and GLP claim. The report was taken across a six-year period, three years before the banning of hormones and three afterward. It looked at about 15,000 cases of young people who had been ‘accepted into care’ at the Tavistock Centre. It showed there were 12 suicides among current/former patients (6 under age 18 and 6 over) during this period. There were 5 suicides before the ban and 7 suicides after the ban. With so few completed suicides in total, the Appleby report stated that attributing changes in risk to a single factor (such as the availability of PBs) was not supported by the available data.

So, does access to TGH help reduce GD and suicidality or not? If it doesn’t, why are we utilising it? The Cass Review 2024 (which is the Gold Standard review of transgender research) states that there is no good-quality evidence that TGH helps reduce GD or Suicidality. Specifically, in regards to suicidality, it states that the rates of suicide are comparable to those of young people with co-morbid mental-health diagnoses or psychosocial challenges, not unique to or specific to GD. That is very conclusive. Some authors believe that TGH concretises (17) the GD, which does not allow the young person to explore (15, 16) their natural and as yet undiscovered sexuality. The UK Minister of Women and Equalities, Kemi Badenoch, calls this a new form of Conversion Therapy. One article stated this clearly when it said that… “in all the major articles, these children will revert to the natal sex through puberty. What we should do, then, is have confidence in the statistics and not mess the child up along the way.” And lastly, Hannah Barnes, in her whistleblower book ‘Time to Think’ (2023, p. 41), which revealed the activities going on in the Tavistock Clinic in the UK (2023), quotes Professor Russell Viner (UCL Institute of Child Health in London). The quote is…’ if you intervene early in a young person who would otherwise change (their mind), do you reinforce their Gender Identity Disorder? Do you remove the chance for change?

Other Input:

Renowned researcher and psychiatrist S.B. Levine states there are no studies that show that affirmation of transgender identity in minors permanently reduces suicide or suicidal ideation, or improves long-term outcomes, as compared to other therapeutic approaches (Levine, 2024, p. 11). The UK’s Cass Review (16 p.187) found that a GD diagnosis “is not predictive that the individual will go on to have a longstanding trans identity.” A 2020 report by the Swedish National Board of Health and Welfare concluded that “people with gender dysphoria who commit suicide have a very high rate of co-occurring serious psychiatric diagnoses, which in themselves sharply increase risks of suicide … it is not possible to ascertain to what extent GD alone contributes to suicide” (16 p. 73-74). And lastly, respected researcher Lisa Littman states, it is clear that the irreversible consequences of TGH (such as the use of puberty blockers, cross sex hormones, and gender surgery) do harm to any child or youth who was not trans to begin with but was gay, and now can never complete their sexual exploration and identification (17).

Conclusion:

So, where has our investigation of the Turban et al, 2022 conclusion that ‘Withholding or delaying transgender healthcare raises suicide risk’ led us? Firstly, it took the data to inform this conclusion from the 2015 U.S. Transgender Survey. This survey used a cross-sectional, retrospective self-report to gather its data. This methodology clearly indicates that it is not suited for cause and effect conclusions, and yet Turban et al have done so. The USTS asked two yes-or-no questions about suicide and also collected data on a number of other themes, such as mental health diagnoses and significant social stressors. We found ourselves wondering, OK, is the lack of access to TGH causing the increased suicidality and by default the increased mental health and social issues, or were the existing co-morbid mental health and social issues the cause of increased suicidality, as treatment for these were overlooked in exchange for TGH interventions? This is called ‘Diagnostic Overshadowing’ (17, 18).

The Dutch Protocol research ensured that all their subjects had no existing mental health or significant social issues upon entry to their clinical trial. Also, there were no concerns with suicidality with this cohort, bearing in mind that the significant majority of these clients in their later teens/early adulthood went on to re-identify as their sex of birth. The Appleby report, which was run before and after the cessation of puberty blockers at the Tavistock Clinic in the UK, examined the data of approximately 15,000 clients and showed there was no significant difference in suicide pre and post TGH. Lastly, the Gold Standard in transgender research, the Cass Review, as well as other researchers I have included, agree with the above opinion that delayed access to TGH does not increase rates of suicide. Dr Hilary Cass, who has made an exhaustive evaluation of current transgender research, went on to state that the significant majority of gender research was of disappointingly poor quality and was ideologically rather than scientifically based. Perhaps this describes the quality of the Turban et al study and the reason behind their cause-and-effect conclusion?

So which narrative does the data best suit? It seems that being transgender and experiencing GD per se do not make you more likely to commit suicide. Therefore, delaying or withholding TGH does not increase the chance of suicide. The co-morbid mental illnesses and significant social stressors that are common in this population do show an associated increased risk of suicidality. The affirmation model leads to less psychiatric therapy and psycho-social support to help treat these issues. Therefore, it seems safer to say that delaying or withholding TGH so that psychiatric and psycho-social therapy can be offered leads to decreased suicidality. And as many transgender young people return to identify with their sex of birth in later teens/early adulthood, their GD may self-resolve.