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A Plausible Explanation of Increased Suicidal Behaviors Among Transgender Youth Based on the Interpersonal Theory of Suicide (IPTS): Case Series and Literature Review

Phillip, Antonia MD, MBA; Pellechi, Ashabari MD; DeSilva, Roshi DO; Semler, Keith DO; Makani, Ramkrishna MD, MPH

Author Information
Journal of Psychiatric Practice: January 2022 - Volume 28 - Issue 1 - p 3-13
doi: 10.1097/PRA.0000000000000604
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Abstract

According to the World Health Organization (WHO), half of all mental health conditions present before adulthood.1 The prevalence of mental illness is higher among lesbian, gay, bisexual, transgender, queer, questioning, and other sexual/gender minority (LGBTQ+) youth than among their cisgender counterparts.2 Specifically, numerous national and international studies have shown that LGBTQ+ adolescents experience elevated rates of emotional distress and mood and anxiety disorders.3 In addition, these youth have a greater propensity to later develop substance use and substance use disorders.4 There are mental health disparities, which are not present among youth who are not LGBTQ+, that likely account for this difference. Some disparities can be attributed to stigma, harassment, victimization, and resultant minority stress experiences.5 Consequently, this at-risk adolescent population experiences more frequent and severe suicidal ideation (SI), with associated nonsuicidal self-injury (NSSI) and suicidal behavior, compared with the non-LGBTQ+ population.2 According to an analysis by the Centers for Disease Control and Prevention (CDC) using the National Violent Death Reporting System (NVDRS), between 2013 and 2015, 24% of the 12- to 14-year-olds who died by suicide were LGBTQ+, compared with 3% to 4% of non-LGBTQ+ individuals in the same age group.6 Data from the NVDRS further demonstrated that family and peer rejection and bullying played the largest roles in the suicide disparity between LGBTQ+ and non-LGBTQ+ individuals and that the presence of these factors was positively correlated with both NSSI and younger age.6 A demonstrable correlation has also been found between suicidal behavior and LGBTQ+-specific rates of gender and sexual identity struggles at younger ages.7 Therefore, it is imperative to understand the impact that gender/sexuality-based dysphoria has during this vulnerable developmental stage in LGBTQ+ youth, where family and peer opinion heavily affect these individuals’ self-worth, resilience, and adaptive coping skills.

LGBTQ+ youth are at elevated risk of trauma, victimization, bullying, family/peer rejection, SI, and development of mental health conditions compared with non-LGBTQ+ youth.2 And although LGBTQ+ can serve as an umbrella term, minority youth can be separated into sexual and gender minorities, and these subcommunities carry varying vulnerabilities. Recent studies have aimed to identify factors associated with transgender and gender nonconforming (TGNC) youth.2 In multivariate logistic regression models predicting SI, suicide plans, and multiple suicide attempts, TGNC youth had significantly elevated suicide risk, even after controlling for sexual minority status.8 Rates of SI have been reported to be 2- to 4-fold higher in transgender youth compared with cisgender youth.9 Moreover, TGNC adolescents have been shown to be more likely to engage in risky behavior, such as alcohol, tobacco, and illicit drug use, and they are also more likely to think about, plan, and attempt suicide than cisgender adolescents.10 A recent study of 588 transfeminine and 745 transmasculine children found that 49% and 62%, respectively, developed a depressive disorder.11 Given these harrowing statistics concerning TGNC youth, it is clear that gender dysphoria is not uncommon, with a national survey of over 8000 New Zealand high school students finding that 1.2% reported being transgender and 2.5% reported that they were not sure about their gender.12

Several theories have been postulated to explain suicidality among LGBTQ+ individuals. The issue of family or peer rejection and bullying, among other factors, lends itself to a specific theory on suicide that has been studied for at least 15 years. This theory, the interpersonal theory of suicide (IPTS), which was first developed by Joiner and Van Orden13 and other researchers, best explains the pathology of suicidality among transgender populations.14 The IPTS speculates that the lethal, as well as the nonlethal behaviors associated with suicide, stem from severe interpersonal emotional conflicts.14 First, adolescence can trigger identity and role confusion, especially when the LGBTQ+ cultural atmosphere is not hospitable. This situation can lead to negative mental health outcomes because of the intense mental turmoil experienced. Adolescents have a natural desire to fit into their peer groups and communities while at the same time figuring out how to function in their sometimes controversial self-identities, which can lead to what is referred to as a thwarted sense of belongingness.14 Second, the resulting perception of being a burden to society and family can lead to youth conflict and distorted emotions devoid of rationality. For instance, LGBTQ+ youths may believe that their death by suicide, a selfless act, will be a welcomed occurrence as it will cause less burden to their family and friends.14 Together, thwarted belongingness and believed burdensomeness, over time, can lead to unresolved depression and thoughts of suicide, and consequently, parasuicidal behavior and suicide attempts.13 At the time of this review, there was a dearth of literature examining the pathologic basis for suicidality in transgender children and adolescents. As a result, this study attempts to demonstrate how Joiner’s IPTS is consistent with the experience of these at-risk youth.

METHODS

PubMed and PsycInfo were the databases used for this literature review. The literature was searched for publications on LGBTQ+, and transgender youths published up to and including October 2020, using the key words suicidal ideation, suicidality, transgender, transgender youth, gender dysphoria, and interpersonal theory of suicide. Inclusion and exclusion criteria were employed to identify relevant articles. The inclusion criteria were articles published through October 2020, in English, pertaining to the mental health of the LGBTQ+ population, related to suicidality, and involving individuals 18 years of age and younger. Literature involving individuals through 18 years of age was included because these individuals may still be in high school and also because the literature in this area is very limited. Relevant studies were selected based on their title, abstract, and/or the article in its entirety.

With regard to the case series presented in this article, case information from individual youth under 18 years of age who were transgender and seen at our outpatient clinic, with a chief complaint of depression, SI, and/or gender dysphoria, were included in this study. The participating youth and their parents or guardians provided verbal consent to participate in the study and have their cases published. Data were collected from 5 patients encountered over a 1-year period, which included taking a psychiatric history as well as obtaining responses to several questions. The questions included age of realization of gender identity, age of gender transitioning or “coming out” to family, family response leading to feelings of family rejection, SI, character, and duration of SI, suicide attempts, hospitalizations, and finally, presence of IPTS factors with which the patient identified. Both the case series and literature review had a particular focus on theories of suicidality as they pertain to the transgender population and IPTS.

RESULTS OF THE LITERATURE REVIEW

We initially identified 78 potentially relevant articles, which were ultimately narrowed down to 30 articles. A further review of this identified literature was performed ad hoc pertaining to the topic area of the study. The results of the literature review are summarized in Table 1.

TABLE 1 - Summary of Results of the Literature Review
References Title Study Methods Outcomes
Becerra-Culqui et al, 201811 Mental health of transgender and gender nonconforming youth compared with their peers Retrospective-prospective cohort study Transgender youth may present with mental health conditions requiring immediate evaluation and implementation of clinical, social, and educational gender identity support measures
Clark et al, 201412 The health and well-being of transgender high school students: results from the New Zealand Adolescent Health Survey Logistical regression analysis Transgender students are diverse and are represented across demographic variables, including their sexual attractions. Transgender youth face considerable disparities in health and well-being
Chu et al, 201714 The interpersonal theory of suicide: a systematic review and meta-analysis of a decade of cross-national research Systematic review and meta-analysis Supported the IPTS—thwarted belongingness and perceived burdensomeness were significant correlates of severity of suicidal ideation, and thwarted belongingness, perceived burdensomeness, and capability for suicide were significantly associated with suicide attempt history
de Vries et al, 201415 Young adult psychological outcome after puberty suppression and gender reassignment Longitudinal cohort study After gender reassignment, in young adulthood, gender dysphoria was alleviated and psychological functioning had steadily improved
Dowshen et al, 201616 Policy perspective: ensuring comprehensive care and support for gender nonconforming children and adolescents Individual policy perspective The information and recommendations contained in this perspective are intended to help practitioners, administrators, and policymakers understand the needs of gender nonconforming youth and the practices and policies that can contribute to their improved health outcomes
Edwards-Leeper and Spack, 201217 Psychological evaluation and medical treatment of transgender youth in an interdisciplinary “Gender Management Service” in a major pediatric center Practice protocols and guidelines This article presented a description of the clinic’s protocol and general patient demographics, along with treatment philosophy and goals
Grossman et al, 20165 Transgender youth and suicidal behaviors: applying the interpersonal psychological theory of suicide Longitudinal cohort study Higher suicidal behavior among transgender and gender nonconforming youth. Perceived burdensomeness and thwarted belongingness were related to suicidal behavior
Herman et al, 201418 Suicide attempts among transgender and gender non-conforming adults Cross-sectional national survey The study suggests that several negative experiences related to anti-transgender bias may contribute to the prevalence of suicide attempts among transgender people, such as experiences of harassment, family rejection, housing instability, and discrimination in health care
Hidalgo et al, 201319 The gender affirmative model: what we know and what we aim to learn Editorial Opinion piece regarding defining the gender affirmative model, dispelling myths, and ways practitioners and theoreticians can continue to use and develop the model
Horton et al, 201620 Preliminary examination of the interpersonal psychological theory of suicide in an adolescent clinical sample Observational cross-sectional cohort study IPTS constructs including perceived burdensomeness, thwarted belongingness, and acquired capability for suicide were independently associated with suicidal thoughts and behavior and may be useful in adolescents
Jackman et al, 202121 Suicidality among gender minority youth: analysis of 2017 Youth Risk Behavior Survey data Retrospective logistic regression analysis Compared with cisgender youth, transgender and gender-questioning youth had higher odds of past-year suicide attempts and past-year suicide attempts requiring medical treatment
James et al, 201622 The Report of the 2015 US Transgender Survey National survey report Data from the survey confirmed that transgender people reported facing discrimination and violence throughout society
Jordan, 20004 Substance abuse among gay, lesbian, bisexual, transgender, and questioning adolescents Literature review Substance abuse is a growing problem among youth and the problem is even greater among gay, lesbian, bisexual, transgender, and questioning youth
Joiner and Van Orden, 200813 The interpersonal-psychological theory of suicidal behavior indicates specific and crucial psychotherapeutic targets Theoretical summary Suggested that therapeutic interventions should focus on assessing the presence of the components of the IPTS and work to amend distortions, response styles, and coping behaviors to maintain suicidal urges
Kessler et al, 20071 Lifetime prevalence and age-of-onset distributions of mental disorders in the World Health Organization’s World Mental Health Survey Initiative Epidemiological survey data Among other findings relevant to this literature review, it was found that half of all mental health conditions present before adulthood
Kosciw et al, 201623 National School Climate Survey: the experiences of lesbian, gay, bisexual, transgender, and queer youth in our nation’s schools National survey report Reports on the school experiences of LGBTQ youth in schools, including the extent of the challenges that they face at school and the school-based resources that support LGBTQ students’ well-being
Committee on Adolescence, 201324 Office-based care for lesbian, gay, bisexual, transgender, and questioning youth Technical clinical practice report The adolescent’s psychosocial history will allow for discovery of any high-risk behaviors, and targeted behavioral interventions may be developed with the adolescent
Olson et al, 201625 Mental health of transgender children who are supported in their identities Community-based national survey Socially transitioned transgender children who are supported in their gender identity have normative levels of depression and minimal elevations in anxiety, suggesting that psychopathology is not inevitable within this group
Rafferty, 201826 Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents Statement from the American Academy of Pediatrics Practice recommendations that provide suggestions for pediatric providers that are focused on promoting the health and positive development of youth that identify as TGD while eliminating discrimination and stigma
Ream, 20196 What’s unique about lesbian, gay, bisexual, and transgender (LGBT) youth and young adult suicides? Findings from the National Violent Death Reporting System (NVDRS) Secondary analysis of NVDRS data The LGBT versus non-LGBT suicide disparity is greatest at younger ages, and each LGBT subgroup has its own specific risk profile for suicide
Ream, 20207 An investigation of the LGBTQ youth suicide disparity using National Violent Death Reporting System narrative data Secondary analysis of NVDRS data The LGBTQ+/non-LGBTQ+ suicide disparity may be greater among adolescents than among other age groups because LGBTQ+-specific contributing circumstances are more prevalent among adolescents
Russell and Fish, 20162 Mental health in lesbian, gay, bisexual, and transgender (LGBT) youth Literature review Highlights promising directions for prevention, intervention, and treatment that may foster LGBT youth mental health
Ryan et al, 201027 Family acceptance in adolescence and the health of LGBT young adults Community-based survey study Family acceptance of LGBT adolescents is associated with positive young adult mental and physical health
Spivey and Prinstein, 20198 A preliminary examination of the association between adolescent gender nonconformity and suicidal thoughts and behaviors Secondary analysis of data from the Youth Risk Behavior Surveillance Survey (N=7730) Gender nonconformity was significantly associated with higher odds of reporting suicidal ideation, suicide plans, and multiple suicide attempts in the past year above and beyond other known risk factors
Suicide Prevention Resource Center, 200828 Suicide risk and prevention for lesbian, gay, bisexual, and transgender youth Practice recommendations The greater risk of suicidal behavior among LGBT youth may be seen as largely a function of our social environment, including discrimination and stigma
Testa et al, 20179 Suicidal ideation in transgender people: gender minority stress and interpersonal theory factors Regression analysis This study demonstrated pathways through which the gender minority stress and resilience model and IPTS constructs relate to one another and confer risk for suicidal ideation among TGNC individuals
Thoma et al, 201929 Suicidality disparities between transgender and cisgender adolescents Cross-sectional online survey Transgender adolescents had higher odds of all suicidality outcomes, and transgender males and transgender females had high risk for suicidal ideation and attempt
Vance et al, 201430 Psychological and medical care of gender nonconforming youth Literature review The review emphasized a multidisciplinary approach with collaboration of medical, mental health, and advocacy providers in the care of gender nonconforming children
Whitaker et al, 201631 School-based protective factors related to suicide for lesbian, gay, and bisexual adolescents Logistic regression analysis School protective factors were related to reduced suicidal ideation in LGB adolescents, when risk factors and demographic variables were controlled for
Wilson and Cariola, 20203 LGBTQI+ youth and mental health: a systematic review of qualitative research Systematic review Findings from the studies included in the review identified 5 core themes and suggested that community, school, and family resources to support resilience will optimize LGBTQI+ mental health
IPTS indicates interpersonal theory of suicide; LGB, lesbian, gay, bisexual; LGBTQI+, lesbian, gay, bisexual, transgender, queer, questioning, and other sexual/gender minority; TGD, transgender and gender diverse; TGNC, transgender and gender nonconforming.

CASE SERIES

Key characteristics of the patients described below are summarized in Table 2.

TABLE 2 - Summary of the Case Series
History Case 1 Case 2 Case 3 Case 4 Case 5
Chief complaint “I don’t want to live.” “I got tired.” “Depression and anxiety.” “I hate my life.” “Depression.”
Age at presentation 11 y old; sixth grade 14 y old; ninth grade 17 y old; 11th grade 15 y old; 10th grade 16 y old; 11th grade
Age of realization (y) 4-5 3 12 4 5
Age of “coming out” (y) 9 11 14 13 13
Feeling of family rejection No No No Yes Yes
Psychiatric comorbidities None known MDD, anxiety, GD MDD, anxiety, GD MDD, ODD, GD MDD, GAD, GD
Self-injurious behavior None known Yes Yes Yes Yes
Suicidal ideation; timing Yes; ongoing Yes; intermittent Yes; intermittent Yes; intermittent Yes; intermittent
No. suicide attempts 0 1 2 2 3
No. previous psychiatric hospitalizations 0 1 2 1 3
Identifiable IPTS factors PB TB PB; TB PB; TB PB; TB
GAD indicates generalized anxiety disorder; GD, gender dysphoria; IPTS, interpersonal theory of suicide; MDD, major depressive disorder; ODD, oppositional defiant disorder; PB, perceived burdensomeness; TB, thwarted belongingness.

Case 1

An 11-year-old Hispanic transgender male [female to male (FtM)], in sixth grade, with typical development and no formal psychiatric history, initially presented to a community emergency department with complaints of persistent SI. The patient had preferred male pronouns and clothing for over 6 months with full family support. He also reported that friends and faculty at school were supportive of his gender identification. Per collateral information obtained from his family, the patient was a well-supported, loved individual. The patient’s family members were committed to creating the needed environmental and cosmetic changes. Neither parent consented for the patient to take mood-altering medications. The patient was enrolled in a partial hospitalization program where the patient received therapy to learn coping mechanisms and to build frustration tolerance. At the time of the initial encounter, the patient had no history of psychiatric hospitalization and no history of self-injurious behavior. The patient expressed the desire to have reassignment surgery. Unfortunately, the patient also perceived himself to be a burden to his family and had ongoing depressive symptoms, as well as gender dysphoria and continued interpersonal ineffectiveness. The patient also endorsed intermittent SI. His gender journey included feeling uncomfortable in his own body from ∼4 or 5 years of age and then “coming out” to his family and friends at age 9.

Case 2

A 14-year-old African American transgender male (FtM), in ninth grade with typical development and with a psychiatric history of recurrent major depressive disorder (MDD), gender dysphoria, and unspecified anxiety, presented after a recent suicide attempt and reports of depressed mood. The patient’s gender journey included feeling uncomfortable in his own body from ∼3 years of age and then “coming out” to his family and friends at age 11. He reported having been bullied and rejected both at school and by his extended family. His mother, however, was supportive and accepting when he initially identified as male ∼3 years earlier, and per the patient, she had been his only support. He preferred the male pronoun, and now that he was at a new school, related completely as transgender, without the knowledge of any of his school friends. He reported frustration because of his inability to pursue hormone therapy and sexual reassignment surgery. His medication history included a failed trial of fluoxetine and an incomplete trial of sertraline. His psychiatric history included partial hospitalization for ∼3 months and 1 prior psychiatric hospitalization. He endorsed a thwarted sense of belongingness and ongoing SI, with recurrent parasuicidal behavior, which included the self-injurious superficial cutting of his forearm.

Case 3

A 17-year-old white transgender male (FtM), in 11th grade, with a psychiatric history of MDD, gender dysphoria, and unspecified anxiety disorder, with 2 prior inpatient psychiatric hospitalizations and no significant medical history, presented with worsening of depression and self-injurious behavior. His psychiatric history included 2 suicide attempts and ongoing self-injurious behavior over the previous 5 years. The patient’s medication trials included sertraline, bupropion, hydroxyzine as needed, and, currently, escitalopram. The patient reported a thwarted sense of belonging and perceived burdensomeness. The patient’s gender journey included feeling uncomfortable in his own body from ∼10 years of age, with confirmed self-realization of his transgender identity at age 12, and then “coming out” to his family and friends at age 14. When the patient “came out,” not all family members were reportedly accepting of the patient’s transgender identity, and he reported that the road to acceptance often felt more like “being tolerated.” Friends had also reportedly rejected the patient, which increased his depression, despite good LGBTQ+ support in school. The patient began experimenting with smoking marijuana and tobacco and experienced a worsening of his mood and emotional instability, leading to self-injurious behavior and suicide attempts as described above. The patient was referred to the gender clinic for further services.

Case 4

A 15-year-old white transgender male (FtM), in 10th grade, with a psychiatric history of MDD, gender dysphoria, and oppositional defiant disorder, with 1 previous inpatient psychiatric hospitalization and completion of a partial care program, and no significant medical history, presented after a recent suicide attempt that occurred following discharge from an inpatient psychiatric unit. The patient had a history of 1 previous suicide attempt and self-injurious behavior during the past 3 years. The patient’s medication trials included fluoxetine and aripiprazole, and he was most recently taking sertraline and aripiprazole. The patient reported having a religious family and endorsed a lack of family support with feelings of thwarted belongingness and perceived burdensomeness. The patient’s gender journey involved feeling uncomfortable in his own body since he was 4 years of age and “coming out” to family and friends at age 13. Gender clinic resources were discussed with the family and the patient, but at the time of evaluation, they refused this treatment, preferring outpatient follow-up instead.

Case 5

A 16-year-old transgender male (FtM), in 11th grade, with a psychiatric history of MDD, generalized anxiety disorder and gender dysphoria, 3 previous inpatient psychiatric hospitalizations, and no significant medical history, presented with worsening of mood symptoms and a recent suicide attempt. The patient had a history of 2 previous suicide attempts before the most recent attempt and self-cutting behavior during the past 4 years. At presentation, the patient was taking fluoxetine and hydroxyzine as needed. The patient’s gender journey started at ∼5 years of age when he first reported feeling uncomfortable with his birth sex; the patient “came out” to family and friends at age 13. The patient reported that his friends were supportive, but his family rejected his gender identification. The patient endorsed experiencing feelings of thwarted belongingness and perceived burdensomeness.

Results of the Case Series

Demographic Findings

All of the 5 patients studied in this case series identified as transgender males, with female sex assigned at birth (FtM). Three were white (cases #3 to #5), 1 patient was Hispanic (case #1), and 1 patient was African American (case #2). The average age at which the patients initially presented to our outpatient clinic was 14.6 years (range: 11 to 17 y old). The average age of the patients at the time of realization of their gender identity was 5.7 years (range: 3 to 12 y old), and the average age of “coming out” was 12 years (range: 9 to 14 y old). Therefore, these patients presented to our clinic ∼9 years after the initial realization of their transgender identity and 2.6 years after “coming out” to others.

Psychiatric Symptoms, Severity, and Suicidality

All 5 patients in this case series endorsed the presence of low, depressed mood within their chief complaint. Four of the 5 patients (cases #2 to #5) were given a diagnosis of MDD, and 3 of those 4 patients were diagnosed with comorbid anxiety disorders (cases #2, #3, and #5). In addition, all 5 patients endorsed SI, with 4 of them reporting this as intermittent (cases #2 to #5) rather than ongoing (case #1) in nature. These same 4 patients (cases #2 to #5) also reported nonsuicidal self-injurious behavior. Two patients (cases #4 and #5) endorsed the feeling of rejection from their families. Four patients (cases #2 to #5) reported previous suicide attempts, with an average of 2 attempts (range: 1 to 3). Furthermore, of the 4 patients who had made previous suicide attempts, 3 patients (cases #3 to #5) endorsed the presence of both perceived burdensomeness and thwarted belongingness, rather than just 1 IPTS factor, as reported in cases 1 and 2. In the setting of psychiatric severity and active suicidality, 4 of the 5 patients had a history of at least 1 previous psychiatric hospitalization (cases #2 to #5), and the average number of hospitalizations of these 4 patients was 1.75 (range: 1 to 3).

DISCUSSION

The case series presented here involved transgender (FtM) adolescents who endorsed depression with intermittent SI. Four of the patients in this series endorsed the vulnerability of perceived burdensomeness according to Joiner’s IPTS, which was consistent with the findings of our literature review. Four patients also reported thwarted belongingness, which coincided with either family and/or community lack of support for their gender identity. Of the 5 patients, 4 were on pharmacotherapy for management of depression. None of the patients was receiving transgender hormone therapy. Three of the 5 patients desired surgery for gender reassignment, but none was yet at the eligible age of 18 years. Understanding the etiology and mental illness that leads to SI and suicide attempts is important to intervene at a critical point in a youth’s life. The issue of mitigating dysphoria in pediatric LGBTQ+ populations is a difficult one. In fact, Becerra-Culqui et al11 found that mental health problems in transgender individuals may begin about 6 months before the individual identifies as transgender. Individuals identifying as transmasculine were observed to experience more depressive symptoms and disorders, while those who identify as transfeminine, were found to display more disruptive behavior disorders.11 In an article published in 2008, Joiner and van Orden13 described the IPTS, which can help explain why suicidal desires develop (Fig. 1). One factor is a distorted sense of being a burden, which can occur despite the presence of supportive family and communities. Another factor that can interact with the sense of being a burden and further compound the problem is thwarted belongingness.14 Ideologies and cultural norms may subconsciously become factors that can predispose to a feeling of thwarted belongingness.

F1
FIGURE 1:
Schematic diagram of the interpersonal theory of suicidal behavior. Created based on concepts in Joiner and Van Orden.13

As with the general population, assessing suicidality in transgender youth requires a careful approach to understanding factors that place the patient at risk as well as those that provide protection. To provide comprehensive care to the transgender population, it is important to understand that many risk factors for suicide are either unique to or more prevalent among transgender individuals than in the general population. Such risk factors include gender nonconformity, victimization, lack of social support, dropping out of school, family discourse, homelessness, substance abuse, and suicide attempts by acquaintances.28 Thus, while cisgendered adolescents may share some similar experiences, these issues are more prevalent among transgender youths.28 Many of these proposed risk factors are interpersonal in nature. As such, Van Orden et al32 suggested that indicators of thwarted belongingness include social isolation, family conflict, and lack of social support. Further, in that report, Van Orden and colleagues connected the second major facet of the IPTS, perceived burdensomeness, to the distress from homelessness, burden to family, low self-esteem, and shame, among other issues. The unique risk factors for suicide associated with the transgender population fall directly in line with interpersonal conflict. In fact, a 2010 study by Ryan et al27 found that transgender youth in nonaccepting families were more than 3 times as likely to consider and attempt suicide as those with highly accepting families. Another more recent study by Olson et al25 confirmed that transgender children in accepting families were as psychologically healthy as their cisgendered peers.

The 2015 US Transgender Survey found that 1 in 4 adults who identified as transgender avoided visits to the doctor because of fear of mistreatment.22 We cannot assume that the situation with regard to a sense of belonging is any better in the pediatric population. The first step in ensuring the delivery of effective care for transgender youth is to maintain an accepting and safe clinical setting, which includes a focus on confidentiality, promoting openness and trust, and training all staff on diversity and sensitivity.33 In addition, developing a model for the treatment of mental health disturbances in transgender youth is critically important. Due to the complex nature of the treatment, which requires a wide scope of expertise, a collaborative effort between multiple providers is necessary to reduce the sense of rejection by the community. Gender dysphoria may in part represent the outward and inward consequences of ineffective availability and delivery of care resulting in thwarted belongingness.

The leading and most widely accepted approach to successfully caring for transgender adolescents is gender affirmation. The gender-affirmative care model is described as the process of reflection and acceptance of gender expression and, for some, medical intervention.19 Of course, supportive family and friends are associated with better mental and physical health outcomes.19 This model also views gender identity as a culmination of biology, society, and culture, and absolutely not as a mental disorder. Thus, if a mental disorder exists, it is often related to stigma and negative experiences rather than an intrinsic problem.19 The recommended team for the delivery of gender-affirmative care would consist of a pediatric provider, a mental health provider, a pediatric endocrinologist, and social/legal support,17 with the ultimate goal of reducing the perceived sense of burdensomeness to society in this population.

Limitations

The findings of this study need to be considered in the context of several limitations. First and foremost, there, unfortunately, remains a dearth of research on which to build at this time. In addition, our research study was nonbinary, insufficient in sample size, limited to a literature review and case series, and thus it was not systematic. In addition, all patients in the case series were FtM. We were also not able to compare the case sample with a cisgender group.

CONCLUSIONS

Pediatric transgender populations are at risk of gender identity-related distress, dysphoria, and suicidality, even in the absence of mental illness and family dysfunction. This indicates a need for immediate social, mental, medical, and educational measures to reduce gender identity-related burden. Several theories concerning suicide provide hypotheses concerning risk factors and mitigating strategies. Among the available theories, the IPTS proposed by Joiner and colleagues provides a highly plausible explanation, which our case series further supports, for suicide-related behavior among LGBTQ+ pediatric populations. The triadic model of thwarted belongingness, perceived burdensomeness, and acquired capability of suicide was exemplified in our case series and literature review. Nevertheless, more studies are needed in this pediatric population to increase clinical understanding and develop strategies for providing more effective care.

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        Keywords:

        transgender youth; suicidal behavior; interpersonal theory of suicide; LGBTQ+; gender dysphoria

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