Suicide Risk Factors in Transgender and Gender Diverse Adults: The Role of Low Social Support and Community Connectedness

Abstract

Transgender and gender diverse (TGD) adults – those with a gender identity discrepant from their assigned sex at birth – are at elevated risk for suicide relative to cisgender (i.e., non-TGD) adults. Coinciding with increased visibility in the United States (US) over the past decade, TGD people are often subjected to hostile legislation, negative media messages about the TGD community, and elevated levels of discrimination, violence, and victimization. These experiences contribute to adverse mental health outcomes in TGD adults. In the US, an estimated 51% of TGD adults experience suicidal ideation (SI) and roughly 7% have a suicide attempt (SA) within a given year. Given that suicide in TGD adults is a public health crisis, and research has historically focused on risk factors associated with lifetime SI or SAs, studies are needed to identify risk factors associated with contemporary SI and future SAs in this population. Findings may aid the development of suicide interventions, inform mental health practitioners of contemporary suicide risk factors, and advise policymakers on structural-level ways to improve mental health outcomes for TGD adults.

This dissertation examines suicide risk factors in TGD adults and the potential role of perceived social support and community connectedness in mitigating suicide risk. Data are drawn from The LEGACY Project (LEGACY), a longitudinal clinic-based cohort study of TGD adults engaged in medical care, and the US Transgender Population Health Survey (TransPOP), a national probability study of TGD adults living in the US. In Study I, I assess factors associated with TGD adults’ risk of attempting suicide over 12 months of follow-up. According to the Interpersonal Theory of Suicidal Behavior (ITSB), engagement in non-lethal self-harm and having a prior SA may be associated with elevated risk for recent SI and a future SA. Using repeated measures data from The LEGACY Project and logistic generalized estimating equation (GEE) models, I demonstrate that TGD adults with moderate perceived social support at baseline, relative to those with high support, have statistically significantly higher odds of having a past 6-month SA at 6- or 12-months of follow-up (moderate support: adjusted odds ratio [aOR] = 4.25, 95% confidence interval [95% CI]: 1.65, 10.90). Additional factors associated with increased risk for a SA include having a transfeminine or nonbinary gender identity (relative to a transmasculine gender identity), engaging in concurrent non-lethal self-harm, and having a prior SA at baseline. The study concludes with a discussion about low social support, its relationship to differential attrition, and its role in explaining why our controlled direct association between social support at baseline and past 6-month SA is greater than our estimated total association for social support at baseline, engagement in future non-lethal self-harm, and past 6-month SA at 6- or 12-months follow-up.

In Study II, I examine whether experiencing a barrier to GA medical or behavioral healthcare in the past 6 months is associated with higher risk for concurrent SI in TGD adults. Using cross-sectional data from The LEGACY Project and log-Poisson regression models with sandwich estimator corrected standard errors, I observe no statistically significant relationship between experiencing a barrier to GA medical or behavioral healthcare in the past 6 months and TGD adults’ risk for SI during the same period. However, TGD adults with low to moderate social support, relative to high social support, have 20% higher risk for past 6-month SI (adjusted risk ratio [aRR] = 1.20, 95% CI: 1.02, 1.41). I also find having clinically significant psychological distress (i.e., screening positive on the Kessler-6), engaging in concurrent non-lethal self-harm, and reporting a prior SA are statistically significantly associated with higher risk for past 6-month SI in TGD adults. In Study III, I explore how interpersonal minority stressors (e.g., discrimination) are related to intrapsychic stress processes (e.g., internalized transphobia) and past-year SI in TGD adults. My analysis incorporates perceived social support and TGD community connectedness as confounders of (1) the relationship between interpersonal minority stressors and intrapsychic stress processes, and (2) the direct associations between interpersonal minority stressors and intrapsychic stress processes and past-year SI. These analyses utilize cross-sectional data from TransPOP and log-Poisson regression models with sandwich estimator corrected standard errors. A one standard deviation (SD) higher TGD community connectedness score is associated with statistically significantly lower levels (i.e., scores) of internalized transphobia (β = -0.23 SDs, 95% CI: -0.38, -0.07), and a one SD higher social support score is associated with statistically significantly lower levels of negative expectations for the future (β = -0.15 SDs, 95% CI: -0.26, -0.04). Age is protective against past-year SI in TGD adults, with a one-year increase in age being associated with 3% lower risk for past-year SI (aRR = 0.97, 95% CI: 0.95, 0.98). Factors associated with statistically significantly higher risk for past-year SI include having a nonbinary gender identity (relative to a transmasculine gender identity), elevated levels of gender-based victimization, and higher levels of negative expectations for the future. Combined, these studies suggest low social support is a risk factor for both future SAs and recent SI in TGD adults. Findings provide empirical evidence in support of the validity of the ITSB, with engagement in non-lethal self-harm and prior SAs being associated with elevated risk for contemporary SI and future SAs. This dissertation concludes with recommendations to (1) assist public health professionals in the development of interventions and programs to lower suicide risk in TGD adults; (2) aid mental health professionals in identifying suicide risk factors in their TGD adult patients; and (3) inform policymakers in their development of structural-level policies to support the well-being of TGD adults and lower their risk for suicide.