Suicide Facts and Myths

Every parent faced with a child claiming they are transgender will have heard the terrifying statistics about high suicide rates when transgender children are not supported in their preferred gender identity. It is frequently mentioned in news reports covering transgender issues and is often a strong emotional motivator for parents to support their child’s wish to transition. It is suggested that ‘affirmation’ and social and medical transition is the only answer to help children with gender dysphoria.

However, is this really true? Is there strong evidence to support this widely held view? We strongly believe that the answer is no.

Although there is no doubt that children and young people suffering gender dysphoria are an extremely vulnerable group deserving of our support and care, the oft-quoted suicide statistics are from surveys which are not robust and there is no evidence that transition is a ‘cure.’

Any risk of suicide is terrifying for parents, every suicide is an awful tragedy and for this reason we feel that exaggerating the risk and constantly using the threat of suicide is unhelpful and irresponsible. We have attempted to sort out the actual facts of this emotive subject.

Studies in the UK

There have been two studies conducted in the UK. We have analysed both in detail as well as contacting the academic groups who carried out the studies. We believe there are fundamental weaknesses in both studies which seriously undermine the claim that suicide is a major risk. We present our findings below.

STUDY 1

The RaRE study ¹ was a lottery-funded project set-up by the LGBT charity PACE. The lead academic was Dr Nuno Nodin from the Royal Holloway University of London (RHUL). A number of different aspects relevant to the LGBT community was investigated. One part of this included asking transgender people about their history of suicidal thoughts and attempts.

The study was conducted by questionnaire using a non-probability sampling method. This means that the questionnaire was promoted within the LGBT community and people chose whether or not to fill it in. In total 2078 questionnaires were analysed, however only 120 of these were transgender people, and only 27 of these were under the age of 26 years old. It is only the result from the 27 young trans people that was reported in relation to suicide.  Of these 27 young trans people 13 of them reported having attempted suicide at some point in the past. This is where the 48% of all trans youth attempt suicide stat comes from.

We have a number of problems with this study:

1. We don’t believe that the suicide history of just 27 self-selected trans people is sufficiently large for parents to make life-changing decisions for their children.
2. Participants were not randomly selected. This will mean that trans people who have experienced the most difficulties in life may be more likely to fill in the form. This risks artificially increasing the % of participants with a suicide history.
3. We don’t know when these suicide attempts occurred. Some or all may have occurred after social and/or medical transition and so may not reflect the true suicide risk if trans children are not supported to transition.
4. We also are not told if these 13 young trans people consider themselves gay or straight. Other data from the study shows that people who identify as lesbian, gay or bisexual are almost twice as likely to have attempted suicide that those who identify as straight (34% compared to 18%). This data is more robust than the trans data because it includes 289 LGB and 196 straight people. As LGB is clearly a risk factor for attempting suicide then surely we need to know if the trans people were gay or straight. If the majority of the trans people with a suicide history were gay whereas the majority of trans people with no suicide history were straight then this may have skewed the data making it look like a trans-related increase in suicide when actually it more accurately reflects the fact they were gay.

There is also disturbing evidence that the transgender charity Mermaids has misrepresented the study to make it appear stronger than it really is. This occurred during a presentation at a conference in front of an audience of lawyers, press, NHS representatives and government officials.² 

We contacted the lead academic who conducted the research and asked him these questions. He agreed with the limitations of the study that we pointed out. We then asked whether he was aware that his data had been misrepresented by others and presented without making these limitation clear. He agreed it was unfortunate when “research is used by non-scientists in the context of their own agendas” and that he would “continue to clarify the nature and breadth of the RaRE study findings.” ³

STUDY 2

In 2016 Stonewall commissioned the Centre for Family Research at the University of Cambridge to conduct a survey ⁴ with young people who are lesbian, gay, bi or trans (LGBT), or who think they might be, on their experiences in secondary schools and colleges across Britain. Between November 2016 and February 2017, 3,713 LGBT young people aged 11-19 completed an online questionnaire. Many aspects of LGBT life were asked about in this study. We have summarised the results relating to self-harm and suicide in the table below (Figure 1)

Once again the study was conducted by questionnaire using a non-probability sampling method. This means that the questionnaire was promoted to LGBT students in Secondary Schools and children chose whether or not to fill it in. In total 3717 questionnaires were analysed and of these 594 were from young people who self-identified as transgender. This is significantly higher than the 27 trans respondents in the earlier PACE study. The reported data shows that transgender young people experience high levels of self-harm (84%), suicidal thoughts (92%) and suicide attempts (45%). However, very high albeit slightly lower levels are seen for the non-trans young people.

Figure 1:

Despite the high number of respondents we have a number of major problems with this study. We asked the lead researcher for a methodology report but none was available. In the absence of such a report we followed up with a serious of detailed technical questions.⁵  However, despite repeated requests no answers were forthcoming. There has also been no publication based on this study in any peer reviewed journal so it is impossible to verify the validity of the results. For these reasons we have serious doubts over the robustness of this study and do not believe the data is sufficiently reliable.

The issues with the study include:

1. The questionnaire used non-probability based sampling methodology and so has all the same limitations as described above for the PACE study.
2. All the data is presented based on self-declared gender identity and not natal sex. This is important since suicide attempts are known to be more common for natal girls compared to natal boys in the general population. Recent GIDS referral data shows that trans-identification is more common in natal girls than in natal boys. These underlying trends will bias the final outcomes. (We have done further work to uncover natal sex of the trans children in this study.) ⁶
3. It is unknown what % of the trans respondents also identified as LGB. Was this based on being attracted to people opposite to their natal sex or opposite to their transgender identity?
4. There is also no definition of transgender and it is unclear whether non-binary is included under trans. 13% of respondents reported as non-binary and 16% reported as trans. It is unclear what percentage of trans students were also non-binary.
5. Obvious confounding factors that affect self harm/suicide such as mental health issues were not controlled for in the study.

CONCLUSION: There are fundamental methodology issues with both UK studies that report that almost half of transgender young people attempt suicide. This data is poor quality and should not be relied upon by parents when considering how best to support their children. The misuse of suicide figures is ethically questionable.

Our findings were confirmed by the UK Independent Factchecking charity Fullfact, after trans activist Paris Lees made this claim on the BBC 2 Question Time programme in March 2018:

“45% of young trans people in this country, modern Britain, have attempted suicide. Not thought about, attempted.”

Fullfact found:

“We can’t say how representative this is of the young trans community in Britain as a whole – the overall sample was not adjusted to try and be representative.” ⁷

U.S. study

A more rigorous study was published in the journal Pediatrics in 2018. Transgender Adolescent Suicide Behaviour (Toomey et al) ⁸ uses data on 121,000 adolescents aged from 11 to 19, who were surveyed at schools across the United States. In this study all the risk factors for attempted suicide, including sex and gender identity, sexual orientation, age, race, and parental education, are statistically analysed. Michael Biggs analysed the study results and his finding was that, statistically, the group most likely to report a suicide attempt is gender-non-conforming females, irrespective of how they identify or their sexual orientation. ⁹

This tallies with our finding that the use of the word ‘trans’ in the Stonewall school report may be hiding the fact that the highest rates actually apply to young females, now hidden by their identity as ‘boys’.¹⁰

What are the facts about suicide and self-harm?

Michael Biggs analysed the Tavistock GIDS and national suicide figures and found that suicide amongst young children in England and Wales is, thankfully, vanishingly rare and there is no evidence that there is a high rate among trans-identified children. In teenagers there are other conditions that carry a higher  suicide risk, including anorexia, depression and autism.¹¹  The Samaritans reported this year that suicides among teenage girls and young women between the ages of 10 and 24 have almost doubled in seven years, increasing by 94 per cent since 2012.¹² All of these factors may be significant when considering the adolescents who are being referred to the Tavistock GIDS.

The Tavistock GIDS states on the Evidence page of their website that amongst children referred to the clinic “suicide is extremely rare.” ¹³

At a conference in Bristol in October 2017, Dr Polly Carmichael, Director and Consultant Clinical Psychologist at the Tavistock, stated that the PACE survey is “deeply flawed” and that rates of self-harm, distress and suicidal ideation are similar to CAMHS figures overall.¹⁴ Dr Carmichael expressed concerns about the use of suicide statistics in the discourse around gender dysphoric young people which is so negative, and suggests a lack of agency and resilience.

Does medical transition help to reduce suicidal ideation?

The critical question is does transition help to reduce suicidal ideation? This is a key question in the treatment of adolescents but the evidence we have is mixed. The claim that allowing children to take puberty blockers will improve psychological well-being is sometimes made on the basis of low quality research and flawed evidence. A recent highly-publicised study for example was found to be unreliable and misleading in an analysis by Michael Biggs.¹⁵

The problem with studies on the effects of puberty blockers is that there is usually no control group, so we don’t know if a different kind of treatment would have the same result. There is one study (Costa et al 2015) which does compare two groups and found no significant difference between psychological support alone and psychological support + puberty suppression in terms of improved psychosocial functioning.¹⁶

The study most often quoted is the Dutch follow-up study from 2011.¹⁷ Although this study found that general functioning improved significantly during puberty suppression, there was no change in levels of anxiety and anger and females showed more problem behaviour both before starting blockers and at follow-up. Levels of gender dysphoria and body satisfaction did not change. It has to be taken into account that this cohort of children was carefully screened for psychological functioning before being accepted into the study.

In a report first published by Transgender Trend, Michael Biggs found worrying negative outcomes for children after one year on puberty blockers in an unpublished report to the Tavistock Board of Directors.

Only one change was positive: ‘according to their parents, the young people experience less internalizing behavioural problems’ (as measured by the Child Behavior Checklist). There were three negative changes. ‘Natal girls showed a significant increase in behavioural and emotional problems’, according to their parents (also from the Child Behavior Checklist, contradicting the only positive result). One dimension of the Health Related Quality of Life scale, completed by parents, ‘showed a significant decrease in Physical well-being of their child’. What is most disturbing is that after a year on blockers, ‘a significant increase was found in the first item “I deliberately try to hurt or kill self”’ (in the Youth Self Report questionnaire).¹⁸

The evidence therefore on short-term follow-up results is contradictory. From detransitioner testimonies we know that there is a ‘honeymoon period’ of euphoria and that doubts and regrets don’t creep in for an average period of around eight years. Evidence from detransitioners suggests that medical transition does not ‘cure’ mental health problems.¹⁹

This is confirmed by the one robust, long-term follow-up study we have. This Swedish study showed that after transition transgender people have a 19x higher rate of suicide than matched controls:

The overall mortality for sex-reassigned persons was higher during follow-up (aHR 2.8; 95% CI 1.8–4.3) than for controls of the same birth sex, particularly death from suicide (aHR 19.1; 95% CI 5.8–62.9). Sex-reassigned persons also had an increased risk for suicide attempts (aHR 4.9; 95% CI 2.9–8.5) and psychiatric inpatient care (aHR 2.8; 95%CI 2.0–3.9).²⁰

This US study from the National Center for Transgender Equality (2010) showed increased rates of attempted suicide after both medical and surgical transition.

Those who have medically transitioned (45%) and surgically transitioned (43%) have higher rates of attempted suicide than those who have not (34% and 39% respectively).²¹

What are the possible causes of suicidality?

Finally, we have to question what causes feelings of suicidality. Is it due to the difficulties of being transgender or does it stem from underlying mental health conditions? The problem with surveys such as the Stonewall School report is that they do not record data on pre-existing mental health issues. But (unlike the cohort in the Dutch study) adolescents referred to the Tavistock GIDS now have high rates of psychological problems and neurobiological differences such as autism.

A study of referrals to GIDS during the year 2012  found that “young people with gender dysphoria often present with a wide range of associated difficulties”.

“The most commonly reported associated difficulties were bullying, low mood/depression and self-harming.” ²²

A paper in the British Medical Journal on the assessment of children at the Tavistock GIDS reported:

“Around 35% of referred young people present with moderate to severe autistic traits.” ²³

Lisa Littman’s research study of parental reports of adolescents who had developed a trans identity after the start of puberty, reported that 63 per cent of the young people in the study had had ‘one or more diagnoses of a psychiatric disorder or neurodevelopmental disability’ before announcing they were transgender. It also found that almost half had self-harmed and that 50 per cent had suffered a traumatic event in their lives such as their parents divorcing, being bullied or suffering sexual abuse. 82.8 per cent of the adolescents were females.²⁴

Girls are overrepresented in referrals to gender clinics worldwide; at the Tavistock girls compromise around 75 per cent of referrals. This study from Finland reflected similar findings elsewhere:

“Natal girls were markedly overrepresented among applicants. Severe psychopathology preceding onset of gender dysphoria was common. Autism spectrum problems were very common.” ²⁵

Another recent study (Bechard et al 2016) showed the same:

“…a large percentage of adolescents referred for gender dysphoria have a substantial co-occurring history of psychosocial and psychological vulnerability.” ²⁶

Sven Román MD, a Swedish specialist in child and adolescent psychiatry, writes:

“Research shows that at least 75 percent of patients with gender dysphoria have other psychiatric problems. In the group of children and young adults, autism, eating disorders, self-harm behavior and abuse are common. For all these conditions there is evidence-based treatment. Given such, gender dysphoria often disappears, as it is usually secondary to these conditions.

Since gender dysphoria often is secondary to psychiatric conditions for which there is evidence-based treatment and gender-corrective therapy for adolescents lacks scientific support, all gender-corrective therapy for patients younger than 25 years should be discontinued.” ²⁷

The Swedish government has now instigated a 3 part review into treatments of children and adolescents with gender dysphoria. The Swedish National Board of Health and Welfare are now revising their treatment guidelines and have released a preliminary report. The summary conclusions of the report state:

“People with gender dysphoria, especially young people, have a high incidence of co-occurring psychiatric diagnoses, self-harm behaviors, and suicide attempts compared to the general population. Co-occurring psychiatric diagnoses among people with gender dysphoria are therefore a factor that needs to be considered more closely during investigation. Suicide mortality rates are higher among people with gender dysphoria compared to the general population. At the same time, 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. Therefore, it is not possible to ascertain to what extent gender dysphoria alone contributes to suicide, since these psychiatric diagnoses often precede suicide.” ²⁸

This raises the question of whether trans youth are especially vulnerable to suicidal ideation, or troubled and vulnerable young people are more susceptible to the belief that they are transgender (and believe that this is the reason for their distress and that transition will solve all their problems).

The common narrative is that trans youth have a high rate of attempted suicide and that the reasons for this are transphobia in society and lack of support. There is no evidence to support this claim. A detransition survey found that discrimination was the lowest scoring reason for feelings of regret about transition:

“By far, the two most common reasons for detransition were shifting political/ideological beliefs, at almost 63%, and finding alternative coping mechanisms for dysphoria, at 59%. The three most commonly cited reasons for detransition among trans activists–financial concerns, lack of social support, and institutional discrimination were among the lowest, at 18%, 17%, and 7%–in fact, institutional discrimination was the lowest scoring category.” ²⁹

Conclusion

In conclusion, although the statistics for suicide attempts have been exaggerated, this is a psychologically highly vulnerable population. A young person with mental health problems needs psychotherapeutic support and a young person who is feeling suicidal needs urgent psychiatric care. Much more research is needed into different care pathways for young people with gender dysphoria.

In this clinical area it is especially important to understand the possible underlying causative factors in suicidal ideation and provide appropriate therapeutic treatment, as the alternative (puberty blockers) carries a risk of exacerbating depressive symptoms. Depression is listed as a common or very common adverse effect for the drug Triptorelin (the form of blocker used by the Tavistock).³⁰

Every suicide is a terrible tragedy and we must be extremely careful in any message we send to young people on this subject. The Samaritans guidance ³¹ states that we should avoid speculation about any one ‘trigger’ for suicide and that we need to exercise caution in repeating suicide statistics. Transgender Trend would like to see this advice followed more carefully in the case of young people struggling with gender identity issues.

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References                                                                                                       

[1] The RaRE Research Report https://www.transgendertrend.com/wp-content/uploads/2017/10/RARE_Research_Report_PACE_2015.pdf

[2] A Scientist Reviews Transgender Suicide Stats, Transgender Trend (2016) https://www.transgendertrend.com/a-scientist-reviews-transgender-suicide-stats/

[3] Private correspondence https://www.transgendertrend.com/wp-content/uploads/2020/09/Pace-study-emails.pdf

[4] Stonewall School Report (2017) https://www.transgendertrend.com/wp-content/uploads/2017/10/the_school_report_2017.pdf

[5] Private correspondence https://www.transgendertrend.com/wp-content/uploads/2020/09/Stonewall-study-email.pdf

[6] Stonewall School Report: What Does the 45% Attempted Suicide Rate Really Mean? Transgender Trend (2017) https://www.transgendertrend.com/stonewall-school-report-what-does-suicide-rate-mean/

[7] Young trans people in Britain, FullFact (2018) https://fullfact.org/health/young-trans-people/

[8] Transgender Adolescent Behaviour, Toomey et al, American Academy of Pediatrics (2018) https://pediatrics.aappublications.org/content/142/4/e20174218?fbclid=IwAR15Mu-PDgAgdRqegPSViOkNulpV8IEy_XsHi9K77RalV8t9IbxPdhSBtW4

[9] Attempted suicide by American LGBT adolescents, 4thwavenow (2018) http://4thwavenow.com/2018/10/23/attempted-suicide-by-american-lgbt-adolescents/

[10] Stonewall School Report: What Does the 45% Suicide Rate Really Mean? Transgender Trend (2017) https://www.transgendertrend.com/stonewall-school-report-what-does-suicide-rate-mean/

[11] Suicide by trans-identified children in England and Wales, Biggs, M, Transgender Trend (2018) https://www.transgendertrend.com/suicide-by-trans-identified-children-in-england-and-wales/

[12] Suicides among teenage girls and young women have almost doubled in seven years, figures show, Bulman, M., Independent (2020) https://www.independent.co.uk/news/uk/home-news/suicides-teenage-girls-young-women-rise-figures-a9698296.html

[13] NHS GIDS Evidence Base http://gids.nhs.uk/evidence-base

[14] Dr Polly Carmichael at ACAMH Conference ‘Gender in 2017: Meeting the needs of gender diverse children and young people with mental health difficulties’. Bristol (2017) https://soundcloud.com/user-664361280/dr-polly-carmichael-developments-and-dilemmas

[15] Puberty Blockers and Suicidality in Adolescents Suffering from Gender Dysphoria, Letters to the Editor, Archives of Sexual Behaviour, Biggs, M (2020) https://www.transgendertrend.com/wp-content/uploads/2020/11/Biggs-10.1007@s10508-020-01743-6.pdf

[16] Psychological Support, Puberty Suppression and Psychosocial Functioning in Adolescents with Gender Dysphoria, Journal of Sexual Medicine, Costa et al (2015) https://www.jsm.jsexmed.org/article/S1743-6095(15)34443-X/pdf

[17] Puberty Suppression in Adolescents with Gender Identity Disorder: A Prospective Follow-up Study, deVries et al (2011) https://www.transgendertrend.com/wp-content/uploads/2020/11/de_Vries_Puberty_Suppression_in_Adolescents_with_GD.pdf

[18] Tavistock’s Experimentation with Puberty Blockers, Scrutinising the Evidence, Transgender Trend, Biggs, M (2019) https://www.transgendertrend.com/tavistock-experiment-puberty-blockers/

[19] Detransition, Transgender Trend https://www.transgendertrend.com/detransition/

[20] Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden, PLoS One, Dhejne et al (2011) https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0016885

[21] National Center for Transgender Equality, Preventing Transgender Suicide (2010) https://web.archive.org/web/20150213054306/http:/transequality.org/PDFs/NCTE_Suicide_Prevention.pdf

[22] Young people with features of gender dysphoria: Demographics and associated difficulties, Sage, Holt et al (2014) https://www.researchgate.net/publication/268879198_Young_people_with_features_of_gender_dysphoria_Demographics_and_associated_difficulties

[23] Assessment and support of children and adolescents with gender dysphoria, British Medical Journal, Butler et al (2018) https://adc.bmj.com/content/103/7/631.full?ijkey=HsMwyZDRtsKu83z&keytype=ref

[24] Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria, PLoS One, Littman, L. (2018) https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0202330

[25] Two years of gender identity service for minors: overrepresentation of natal girls with severe problems in adolescent development, BMC, Kaltiala-Heino, R. (2015) https://capmh.biomedcentral.com/articles/10.1186/s13034-015-0042-y#Tab1

[26] Psychosocial and Psychological Vulnerability in Adolescents with Gender Dysphoria: A “Proof of Principle” Study, Journal of Sex and Marital Therapy, Bechard, M. et al (2016)  https://www.tandfonline.com/doi/full/10.1080/0092623X.2016.1232325?src=recsys

[27] Psychiatrist: gender dysphoria spreads like an epidemic online, article republished by KIRJO (2019) https://www.ihmistenkirjo.net/blog/psychiatrist-gender-dysphoria-spreads-like-an-epidemic-online?s=03

[28] Swedish National Board of Health and Welfare report (translated by the Society for Evidence Based Gender Medicine for internal research purposes) https://www.transgendertrend.com/wp-content/uploads/2020/11/English-NBHW-report-002.pdf

[29] Female detransition and reidentification: Survey results and interpretation, guideonragingstars (2016) https://guideonragingstars.tumblr.com/post/149877706175/female-detransition-and-reidentification-survey

[30] Triptorelin side effects, NICE website https://bnfc.nice.org.uk/drug/triptorelin.html#sideEffects

[31] Media guidelines for reporting suicide, Samaritans https://www.samaritans.org/media-centre/media-guidelines-reporting-suicide/suicide-reporting-10-things-remember