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Suicide Protective Factors Among Trans Adults


Abstract and Figures

A recent study indicated a suicide attempt rate of 41 % among trans (e.g., trans, transgender, transexual/transsexual, genderqueer, two-spirit) individuals. Although this rate is alarming, there is a dearth of literature regarding suicide prevention for trans individuals. A vital step in developing suicide prevention models is the identification of protective factors. It was hypothesized that social support from friends, social support from family, optimism, reasons for living, and suicide resilience, which are known to protect cis (non-trans) individuals, also protect trans individuals. A sample of self-identified trans Canadian adults (N = 133) was recruited from LGBT and trans LISTSERVs. Data were collected online using a secure survey platform. A three block hierarchical multiple regression model was used to predict suicidal behavior from protective factors. Social support from friends, social support from family, and optimism significantly and negatively predicted 33 % of variance in participants' suicidal behavior after controlling for age. Reasons for living and suicide resilience accounted for an additional 19 % of the variance in participants' suicidal behavior after controlling for age, social support from friends, social support from family, and optimism. Of the factors mentioned above, perceived social support from family, one of three suicide resilience factors (emotional stability), and one of six reasons for living (child-related concerns) significantly and negatively predicted participants' suicidal behavior. Overall, these findings can be used to inform the practices of mental health workers, medical doctors, and suicide prevention workers working with trans clients.
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Suicide Protective Factors Among Trans Adults
´rie Moody Nathan Grant Smith
Received: 10 October 2011 / Revised: 22 December 2012/ Accepted: 22 January 2013
The Author(s) 2013. This article is published with open access at
Abstract A recent study indicated a suicide attempt rate of
41 % among trans (e.g., trans, transgender, transexual/trans-
sexual, genderqueer, two-spirit) individuals. Although this
rate is alarming, there is a dearth of literature regarding sui-
cide prevention for trans individuals. A vital step in devel-
oping suicide prevention models is the identification of pro-
tective factors. It was hypothesized that social support from
friends, social support from family, optimism, reasons for
living, and suicide resilience, which are known to protect cis
(non-trans) individuals, also protect trans individuals. A sample
of self-identified trans Canadian adults (N=133) was recruited
from LGBT and trans LISTSERVs. Data were collected online
using a secure survey platform. A three block hierarchical mul-
tiple regression model was used to predict suicidal behaviorfrom
protective factors. Social support from friends, social support
from family, and optimism significantly and negatively pre-
dicted 33 % of variance in participants’ suicidal behavior after
controlling for age. Reasons for living and suicide resilience
accounted for an additional 19 % of the variance in participants’
suicidal behavior after controlling for age, social support from
friends, social support from family, and optimism. Of the factors
mentioned above, perceived social support from family, one of
three suicide resilience factors (emotional stability), and one of
six reasons for living (child-related concerns) significantly and
negatively predicted partic ipants’ suicidal behavior. Overall,
these findings can be used to inform the practices of mental health
workers, medical doctors, and suicide prevention workers work-
ing with trans clients.
Keywords Trans Transgender Transsexual Suicide
Protective factors
Suicide is a serious, preventable, global health problem (World
Health Organization, 2011). The WHO estimates that almost
1 million people die by suicide globally per year. Furthermore,
the WHO estimates that suicide attempts occur approximately
20 times more frequently than completed suicides. Current life-
time suicide attempt rates in adults are estimated to be between
1.9 and 8.7 % in the U.S. and between 0.4 and 5.1 % worldwide
(Nock et al., 2008).
Suicide Attempts in Lesbian, Gay, and Bisexual (LGB)
It has been well-established that being a sexual or gender
minority puts one at greater risk for suicidal thoughts and
behaviors (Haas et al., 2011;Kingetal.,2008; McDaniel, Pur-
cell, & D’Augelli, 2001). Significant relationships have been
documented between same-sex behavior/sexual orientation and
suicide attempts, both in LGB youth (see Marshal et al., 2011)
and LGB adults (see King et al., 2008). One literature review
identified the suicide attempt rates in LGB individuals to be
between 20 and 53 % (McDaniel et al., 2001).
It is important to note that the majority of the studies that have
investigated suicidal ideation and attempts in LGB individuals
have made references to this phenomenon being due, at least in
part, to societal anti-LGB opinions, internalized homophobia,
stigma, rejection, and discrimination, with some studies testing
this hypothesis directly. Relatedly, Meyer (1995,2003) noted
that LGB mental health problems (including suicidal ideation
C. Moody (&)N. G. Smith
Department of Educational and Counselling Psychology, McGill
University, 3700 McTavish St., Montreal, QC H3A 1Y2, Canada
Arch Sex Behav
DOI 10.1007/s10508-013-0099-8
and attempts) are related to minority stress, the chronic stress of
living in homophobic social environments. Moreover, the recent
National Strategy for Suicide Prevention (2012) released by the
U.S. Surgeon General and the National Action Alliance for
Suicide Prevention explicitly outlines the link between minority
stress and suicidal behaviors for LGB and T (trans
) individuals.
Suicide Attempt Prevalence Rates in Trans Populations
A number of large- and small-scale needs assessments have
been conducted in the U.S. that provide information regarding
suicide attempts in trans individuals. Results from two needs
assessments conducted in Philadelphia showed that 30.1 % of
the 182 participants had attempted suicide at least once (Kenagy,
2005). A needs assessment conducted in Chicago found that
27 % of the 108 participants had attempted suicide (Kenagy &
Bostwick, 2005). Lastly, a needs assessment conducted with
trans people of color in Washington, DC showed that 16 % of
participants had attempted suicide at least once (Xavier, Bobbin,
Singer, & Budd, 2005).
Results from studies using convenience samples show similar
suicide attempt rates. In a sample of 55 trans youth, 26 % of par-
ticipants had attempted suicide at least once (Grossman &
D’Augelli, 2007). Among trans adults, studies have found sui-
cide attempt rates of 23.3 % (Mathy, 2002), 28–31.2 % (Nutt-
brock et al., 2010), and 32 % (Clements-Nolle, Marx, & Katz,
2006). In Canada, among a sample of 433 trans individuals living
in Ontario, the lifetime suicide attempt rate was 43 % (Scanlon,
Travers, Coleman, Bauer, & Boyce, 2010). In a sample of indi-
viduals from Minnesota, 47 % of trans participants reported hav-
ing considered or attempted suicide in the last three years, which
was a significantly higher rate when compared to the other sexual
minority participants (Bockting, Huang, Ding, Robinson, & Ros-
ser, 2005). The National Transgender Discrimination Survey, a
recent nation-wide U.S.-based survey of 6,456 self-identified
transgender/gender non-conforming individuals, found that 41 %
of participants reported attempting suicide at least once (Grant
et al., 2011). For a summary of the literature regarding suicide
attempt rates in trans populations, please see Ramsay (n.d.).
Suicide Risk Factors Among Trans Individuals
Many of the studies mentioned above have examined suicide
risk factors among trans adults. For instance, Mathy (2002)
found a non-significant difference in suicide attempt rates
between trans individuals and lesbians,whichledMathytodraw
a parallel between the sexism and heterosexism experienced by
both these groups. Mathy concluded that these forms of oppres-
sion may be elements that place both trans individuals and les-
bians at risk for suicidal ideation and behavior. Mathy also found
significant differences between trans participants who had
attempted suicide and those who had not, with attempters report-
ing higher rates of prior and current therapy, prior and current
psychiatric medication, and past problems with alcohol and drug
Clement-Nolle et al. (2006) found that younger age, depres-
sion, past alcohol or drug treatment, forced sex or rape, gender
discrimination (being discriminated against due to one’s gender
identity/presentation), and physical gender victimization (being
beaten or physically abused due to one’s gender identity/pre-
sentation) were each independent predictors of attempted sui-
cide. Nuttbrock et al. (2010) examined the relationships betw een
physical gender-related abuse, psychological gender-rela-
ted abuse, and suicidal ideation and behavior across five life
stages of trans participants. Significant associations were found
between both types of abuse and suicidal ideation and behavior
during early and late adolescence for the 19–39 year-old partic-
ipants, as well as during all life stages for the 39–59 year-old
participants, with the exception of psychological gender-related
abuse in the early-young adult life stage.
Scanlon et al. (2010) found that, of the participants who
reported experiencing suicidal ideation in the past year, 47 %
had experienced physical or sexual assault at some point in
their lives due to being trans. Of the participants who reported
attempting suicide in the past year, 29 % had experienced phys-
ical or sexual assault at some point due to being trans.
Protective Factors
To date, there exist no published studies examining suicide pro-
tective factors among trans individuals. In addition to identifying
risk factors, it is important to identify protective factors for at-risk
individuals (Eisenberg & Resnick, 2006; Wang, Lightsey, Pie-
truszka, Uruk, & Wells, 2007). Suicide protective factors are
generally those factors that lower the risk of suicide (White,
1998) or that help a person defend against suicidal behaviors
(Rutter, Freedenthal, & Osman, 2008). It is important to note that
protective factors are not simply the absence of risk factors (Cha
&Nock,2008) nor are they simply the opposite of risk factors
(Gutierrez & Osman, 2008). Empirically identifying suicide
protective factors, when combined with risk factors, can there-
fore lead to the development and improvement of suicide pre-
vention models and interventions (Gutierrez & Osman, 2008).
The purpose of the present study was to examine suicide
protective factors in trans adults by identifying factors that are
negatively associated with suicidal behavior in this popula-
tion. Although risk factors were not combined with protective
factors, it is our hope that this study is a first step in identifying
possible protective factors that can then be combined with
risk factors in future research and suicide prevention models.
In context of the current article, trans is used as an umbrella term that
refers to a wide variety of self-identities, including, but not limited to,
trans, transgender, transexual/transsexual, genderqueer, Two-Spirit, and
people with trans histories.
Arch Sex Behav
A vast number of protective factors for cis individuals (cis-
gender and cissexual individuals, which refer to non-trans indi-
viduals) have been identified in existing literature. A complete
review of all of the protective factors that have been identified is
beyond the scope of this article; however, certain well-tested or
promising protective factors will be reviewed, including their
theoretical or empirical associations to LGB suicidal ideation and
Reasons for Living
Reasons for living, as operationalized by Linehan, Goodstein,
Nielsen, and Chiles (1983), are‘‘life-oriented beliefs and expec-
tations that might mitigate against committing suicide’’ (p. 277).
Linehan et al. postulated that certain beliefs, namely reasons for
not committing suicide, were an important factor that differen-
tiated suicidal people from non-suicidal people. Linehan et al.
have been credited with being the first to operationalize and mea-
sure suicide protective factors through their development of the
Reasons for Living Inventory (Rutter, 2008).
The examination of reasons for living among LGB popula-
tions has been carried out in a small number of studies (e.g.,
Hirsch & Ellis, 1998; McBee-Strayer & Rogers, 2002). These
studies have found that, compared to heterosexual participants,
sexual minority participants reported significantly fewer rea-
sons for living related to most or all categories. Hirsch and Ellis
contextualized their findings in the stigma and minority status
experienced by gay and lesbian individuals. They postulated
that stigma and minority status may lead to gay men and lesbians
having a more difficult time coping with their environments
when compared to heterosexuals, which may lead to fewer rea-
sons for living. On the other hand, it has recently been postulated
that perhaps the lower endorsements of reasons for living among
sexual minorities is related to the measurement of reasons for
living. McBee-Strayer and Rogers conducted an exploratory
factor analysis on the Reason for Living (RFL) Scale in order to
test its construct validity when used with sexual minorities. Their
results did not support the scale’s reported structure. A recent
qualitative exploration (Garrett, Waehler, & Rogers, 2012)
of 19 LGBT individuals’ perceptions of the RFL indicated that
some of the scale’s items may not capture sexual minorities’
reasons for living or may be ambiguous for LGBT individuals.
Despite these challenges, alternative scales for measuring reasons
for living in LGBT samples are lacking. In addition, it is unknown
how reasons for living are related to suicidal behavior in trans
individuals. As such, though there are measurement limitations,
the current study sought to examine reasons for living and their
association with suicidal behavior in a sample of trans individuals.
Suicide Resilience
Suicide resilience is a relatively new protective construct that has
emerged in the suicide literature. It is defined as‘‘the perceived
ability, resources, or competence to regulate suicide-related
thoughts, feelings, and attitudes’’ (Osman et al., 2004, p. 1351).
Suicide resilience has yet to be investigated in LGB popula-
tions. It has, however, been integrated into a conceptual model
regarding LGB youth suicide. Rutter (2008) developed the cumu-
lative factor model, in which both risk and protective factors
were taken into account when examining suicidal ideation
and attempts in LGB youth. Rutter proposed that the exami-
nation of the intersection of certain protective factors (social
support, suicide resilience, and optimism) and known risk fac-
tors for LGB youth suicide (mental healthproblems, substance
suicide assessments and interventions for LGB youth. The cumu-
lative factor model was not tested in the current study; how-
ever, it is mentioned here due to the fact that it clearly illus-
trates the importance of identifying protective factors, as well
as pointing to a number of protective factors that may be
beneficial to investigate.
Social Support
Social support is considered to be an important suicide protective
factor (Goldsmith, Pellmar, Kleinman, & Bunney, 2002;Gut-
ierrez & Osman, 2008;Nocketal.,2008). Many studies have
examined the relationship between social support and suicidal
ideation and/or attempts, with results indicating that social sup-
port is a negative predictor of suicidal ideation and attempts. For
instance, social support negatively predicted suicidal ideation in
a sample of African American female college students (Marion
& Range, 2003) and it negatively predicted suicidal ideation
above and beyond hopelessness and depression in a sample of
Norwegian undergraduate students (Chioqueta & Stiles, 2007).
Social support has been shown to be a suicide protective factor
for both LGB youth (Eisenberg & Resnick, 2006; Fenaughty &
´,2003) and older adults (D’Augelli, Grossman, Hersh-
berger, & O’ Connell, 2001).
Dispositional optimism is a stable trait that‘‘reflects the extent to
which people hold generalized favorable expectancies for their
future’’ (Carver, Scheier, & Segerstrom, 2010,p.879).Asmall
number of studies have examined the relationship between dis-
positional optimism and suicidal ideation and/or attempts.
Results have been mixed; some studies have shown support for
optimism as a protective factor (Hirsch, Conner, & Duberstein,
2007; Rasmussen & Wingate, 2011) while others have not
(Hirsch & Conner, 2006). Optimism has yet to be investigated in
LGB populations, but was integrated into Rutter’s (2008)con-
ceptual cumulative factor model as a protective factor for LGB
Arch Sex Behav
Purpose and Hypothesis
There is an absence of empirical data regarding suicide protec-
tive factors in trans populations. Given the high suicide attempt
rates that have been documented in trans communities, the inves-
tigation of protective factors appears to be overdue.
It was hypothesized that optimism, perceived social support
from friends, and perceived social support from family will neg-
atively predict suicidal behavior in trans adults. Furthermore, it is
hypothesized that reasons for living and suicide resilience will
also negatively predict suicidal behavior in trans adults, above
and beyond optimism, perceived social support from friends, and
perceived social support from family.
The data used in the present analyses were collected between
September 2010 and February 2011. It was not possible to deter-
mine how many participants began the survey and subsequently
withdrew their consent due to the fact that participants had the
option of clearing their responses before exiting the survey plat-
form. A total of 134 participants completed and submitted the
questionnaires. One participant experienced computer difficul-
ties (this was explained by the participant in the comments sec-
tion of the questionnaire) and was subsequently only able to com-
plete the demographic questions and one other scale. This par-
ticipant’s responses were not included in the final sample, result-
ing in a total sample of 133 participants.
Participants were self-identified trans adults living in Canada
who ranged in age from 18 to 75 years (M=36.75, SD =13.01).
A wide variety of identities were reported by participants, with
the majority of participants identifying as transgender (51.1 %,
n=68), trans (50.4 %, n=67), transexual/transsexual (45.1 %,
n=60), man or boy (37.6 %, n=50), and woman or girl (37.6 %,
n=50) (see Table 1). The categories were not presented in a
mutually-exclusive manner. In a question separate from identity,
an almost equal number of participants reported being on the
FTM spectrum (42.1 %, n=56) and on the MTF spectrum
(44.4 %, n=59), while 2.3 % reported having an intersex con-
dition (n=3) and 11.3 % offered answers under other (n=15).
Although the recruitment material stated that trans adults were
invited to participate in the study, it is important to note that many
participants underlined the fact that they were people of trans
experience, with trans experience, or who have transitioned, with-
out necessarily identifying as trans.
The majority of participants reported living in Que
´bec (33.8
%, n=45), 32.3 % reported living in Ontario (n=43), 23.3 % in
British Columbia (n=31), and 9.0 % (n=12) elsewhere in
Canada (Alberta, Saskatchewan, Manitoba, and New Bruns-
wick). Most participants completed the study in English (82.7 %,
n=110), with the rest participating in French. Participants
reported a variety of sexual orientations (for details, see Table 1).
Participants were asked to identify their ethnocultural back-
ground with no predetermined answers offered; as such, respon-
ses were read through and grouped according to common race,
ethnicity, culture, or geographic location. The majority of par-
ticipants identified their ethnocultural background as White/
Caucasian (see Table 1). Participants reported living in different
areas: 75.2 % of participants reported living in an urban area
(n=100), 17.3 % reported living in a suburban area (n=23),
and 6 % reported living in a rural area. Numerous participants rep-
orted being agnostic or atheist (45.9 %, n=61) while other par-
ticipants reported a variety of religious identities (see Table 1).
The majority of participants did not consider themselves to be
practicing members of their current religious group (46.6 %,
n=62) while 22.6 % did (n=30), and the remaining 30.8 % (n=
41) either did not answer the question or answered under other
(e.g., ‘‘Sometimes,’’ ‘‘It’s complicated’). Over 90 % of partici-
pants reported being Canadian citizens (91.7 %, n=122). A total
of 37 % of participants (n=49) reported living with either a vis-
ible or invisible disability or disabilities and/or a chronic illness.
The majority of participants reported having completed some
college (21.8 %, n=29), having completed college (17.3 %,
n=23), or having obtained an undergraduate degree (20.3 %,
n=27) (see Table 1). Most participants reported working full-
time (33.8 %, n=45) (see Table 1), and the majority of par-
ticipants reported earning less than $10,000 per year in per-
sonal yearly income (27.1 %, n=36), with 19 of these par-
ticipants also being students (see Table 1). Lastly, almost
one third of participants reported being single/never married
(32.3 %, n=43) (see Table 1).
Measures that were not available in a standardized French ver-
sion were translated into French and subsequently validated by
back-translation. A company specializing in English–French and
French–English translation did both of these translations.
Demographic Information
A demographic form asked participants to self-identify various
demographic characteristics such as age, gender identity, sexual
orientation, ethnocultural background, and relationship status.
As trans is an umbrella term that is used to describe many dif-
ferent kinds of people, participants were asked to indicate how
they currently identify using a list of 26 possible identities, with
the additional choice of other. Choices were not mutually exclu-
Arch Sex Behav
Optimism was assessed with Scheier, Carver, and Bridges’
(1994) Life Orientation Test Revised (LOT-R). The LOT-R is a
10-item self-report scale that measures generalized optimism.
The measured optimism was not related to any event(s) in par-
ticular; participants were simply asked to report the frequency of
optimism they felt in general. Participants rated items such as ‘‘In
Table 1 Demographic information
Current identity
Man or boy 50 37.6
Woman or girl 50 37.6
Trans 67 50.4
Transgender 68 51.1
Transexual/transsexual 60 45.1
FTM 36 27.1
MTF 39 29.3
Someone on the FTM spectrum 20 15.0
Someone on the MTF spectrum 23 17.3
Genderqueer 33 24.8
Two-spirit 10 7.5
Transman 33 24.8
Transwoman 41 30.8
Man of trans experience 11 8.3
Woman of trans experience 10 7.5
Androgyne 11 8.3
Woman; boy; gender blender; bi-gender; polygender/
pangender; cross-dresser; transvestite; intersexual; drag
40 30.4
Other: e.g., Ft other; gender bent; third gender; gender fucker;
trans woman
14 10.6
Current sexual orientation
Lesbian 32 24.1
Gay 14 10.5
Bisexual 35 26.3
Queer 54 40.6
Dyke 13 9.8
Fag/faggot 15 11.3
Heterosexual/straight 31 23.3
Pansexual 20 15.0
Two-spirit; same-gender loving; asexual
21 15.8
Not sure or questioning 16 12.0
Other: e.g., heteroflexible 12 9.0
Ethnocultural background
White/Caucasian 45 34.9
European 21 16.3
Canadian or French-Canadian or Que
´cois(e) 19 14.7
European-Canadian 15 11.6
Jewish 6 4.7
Asian 6 4.7
Bi/multi-ethnicity 6 4.7
Aboriginal descent; Latino/Latina; Middle-Eastern; other
11 8.6
Religious identity
Buddhist 9 6.8
Catholic 16 12.0
Jewish 9 6.8
Protestant 9 6.8
Aboriginal spirituality; Hindu; Muslim; Wiccan
12 9.1
Table 1 continued
Agnostic or atheist 61 45.9
Other 44 33.1
Highest level of education to date
Less than high school; high school or equivalent; trade
school; other
30 22.6
Some college 29 21.8
College 23 17.3
Undergraduate degree 27 20.3
Master’s degree 18 13.5
Doctoral degree 6 4.5
Current employment situation
Work full-time 45 33.8
Work part-time 19 14.3
Self-employed 23 17.3
Unemployed 23 17.3
Unable to work 14 10.5
Student 37 27.8
Retired; homemaker/stay at home parent
8 6.1
Other 15 11.3
Personal yearly income
Below $10,000 36 27.1
Between $10,001 and $20,000 29 21.8
Between $20,001 and $30,000 14 10.5
Between $30,001 and $40,000 10 7.5
Between $40,001 and $50,000 10 7.5
Between $50,001 and $60,000 7 5.3
Between $60,001 and $70,000 10 7.5
Over $70,000 14 10.5
Relationship status
Single (never married) 43 32.3
In one or more relationship(s)/dating, living apart 31 23.3
In one or more relationship(s)/dating, living together 11 8.3
Married 19 14.3
Common law union 12 9.0
Separated; divorced
15 11.3
Other 2 1.5
Categories in current identity, current sexual orientation, ethnocultural
background, and current employment situation were not mutually
exclusive; thus, sums may be greater than 100 %
Categories combined due to low cell size
Arch Sex Behav
uncertain times, I usually expect the best’’ and‘‘If something can
go wrong for me, it will’’ (reverse coded) on a 5-point Likert-type
scale (1 =I disagree a lot to 4 =I agree a lot). Four items were
fillers and therefore not coded. Three items were reverse coded
and participants’ responses were summed, with higher scores
indicating higher levels of optimism. Cronbach’s alpha for the
original scale was .78 and, in the current study, it was .85. Valid-
ity was evidenced by both exploratory and confirmatory factors
analyses in which all six items loaded onto one factor (with
results from the confirmatory analysis supporting both a one and
two factor model). Furthermore, scores on the LOT-R were
correlated in the expected directions with scores on conceptu-
ally-related scales (Scheier et al., 1994).
Social Support
Perceived social support was assessed with Procidano and Hel-
ler’s (1983) Perceived Social Support Scale from Friends and
Family (PSS-Fr and PSS-Fa). The PSS-Fr and PSS-Fa are two
separate self-report questionnaires, consisting of 20 items each
that assess the extent to which participants perceive their family
and friends meet their needs for support, feedback, and infor-
mation. Participants answered Yes,No,orDon’t know to items
such as‘‘I rely on my friends for emotional support’’(in the PSS-
Fr) and‘There is a member of my family I could go to if I were
just feeling down, without feeling funny about it later’’ (in the
PSS-Fa). Items were scored appropriately (Yes =1, and No =0,
Don’t know =0) and six items in the PSS-Fr and five items in the
PSS-Fa were appropriately reverse coded (Yes =0, and No =1,
Don’t know =0). The ratings were summed for each scale, with
higher scores indicating greater levels of perceived social sup-
port. Cronbach’s alpha was .88 for the PSS-Fr scale and .90 for
the PSS-Fa scale. In the current study, Cronbach’s alpha was .89
for the PSS-Fr scale and .94 for the PSS-Fa scale. Validity was
evidenced in both the PSS-Fr and PSS-Fa by scores on these mea-
sures being significantly correlated in the expected directions
with scores on measures of distress, psychopathology, and social
network availability (Procidano & Heller, 1983).
Suicide Resilience
Suicide resilience was assessed with Osman et al.’s (2004)Sui-
cide Resilience Inventory 25 (SRI-25). The SRI-25 is a 25-item
self-report measure used to assess factors that help defend against
suicidal thoughts and behaviors. It is comprised of three sub-
scales, two of which (External Protective and Emotional Sta-
bility) include the assessment of suicide-specific resilience. The
External Protective subscale assesses people’s positive percep-
tions or beliefs that they are able to seek help from those close to
them should they experience suicidal thoughts; the Emotional
Stability subscale assesses people’s positive perceptions or
beliefs that they are able to resist acting on suicidal thoug hts when
experiencing them. The third subscale, the Internal Protective
subscale, assesses people’s satisfaction with life and positive feel-
ings about themselves overall. Participants rated items such as‘I
like myself’’ (Internal Protective Factors subscale), ‘‘I can deal
with the emotional pain of rejection without thinking of killing
myself’’(Emotional Stability Factors subscale), and‘‘Icould
openly discuss thoughts of killing myself with people who are
close to me, when it is necessary’ (External Protective Factors
subscale). The ratings were averaged by subscale, with higher
total scores indicating greater resilience against committing
suicide. Cronbach’s alphas were above .90 for the total scale and
each subscale in both the original and current studies.
Validity was evidenced by confirmatory factors analyses in
which all items significantly loaded onto one of three factors, with
the exception of one item that loaded onto its primary factor and
one other factor (Osman et al., 2004). Furthermore, the SRI-25
successfully differentiated participants with past suicidal idea-
tion or behavior from participants with no reported history of sui-
cidal ideation and behavior as measured by the Suicidal Behav-
iors Questionnaire Revised (Osman et al., 2001), a validated mea-
sure of suicidal ideation and attempts (Osman et al., 2004). Sui-
cide resilience also was shown to negatively correlate with sui-
cidal ideation in a diverse sample of college students (Rutter et al.,
Reasons for Living
Reasons for living were assessed with Linehan et al.’s (1983)
Reasons for Living Inventory (RFL). The RFL is a 48-item self-
report scale that measures participants’ endorsement of certain
reasons for living. It is used to measure different reasons for
living in both participants who have experienced suicidal idea-
tion and those who have not. The RFL is based on the premise
that adaptive beliefs and expectations can serve as factors that
protect individuals against suicidal ideation and behavior. The
RFL is comprised of six subscales that each measure different
types of reasons for living: survival and coping beliefs (beliefs
about the value of life and one’s coping capabilities), responsi-
bility to family (beliefs about one’s responsibility to one’s family
as a reason for staying alive), child-related concerns (reasons for
staying alive related to one’s child or children), fear of suicide
(beliefs about suicide relating to one’s apprehension and fear of
committing the act), fear of social disapproval (fear of what other
people’s perception would be if one were to commit suicide), and
moral objections (religious and moral beliefs related to suicide).
Participants rated items such as ‘I believe I can find other
solutions to my problems’’ (Survival Coping Subscale) and‘‘The
effects on my children could be harmful’’ (Child-Related Con-
cerns Subscale) on a 6-point Likert-type scale (1=Not at all
important as a reason for not killing myself to 6 =Extremely
important as a reason for not killing myself). The ratings were
averaged by subscale, with higher scores indicating greater
endorsement of that category of reasons for living. Cronbach’s
alpha in the original scale was not reported by Linehan et al.
Arch Sex Behav
(1983); however, Osman et al. (1993) showed it to be .89 for the
total scale, and ranging from .79 to .92 for the subscales. In the
current study, Cronbach’s alpha was .93 for the total scale; .95 for
the Survival Coping Beliefs subscale, .91 for the Responsibility
to Family subscale; .88 for the Child-Related Concerns subscale;
.84 for the Fear of Suicide subscale; .81 for the Fear of Social
Disapproval subscale; and .75 for the Moral Objection subscale.
Validity was evidenced by four exploratory factors analyses; six
factors emerged in all four analyses and items with ambiguous
factor loadings were subsequently dropped. Furthermore, rea-
sons for living have been assessed in a wide array of samples and
have been found to differentiate between past suicide attempters
and non-attempters in the general population (Linehan et al.,
1983), as well as in samples of individuals hospitalized for men-
tal health reasons (Linehan et al., 1983; Lizardi et al., 2007;
Malone et al., 2000).
Suicidal Behavior
Suicidal ideation and behavior was assessed with Osman et al.’s
(2001) Suicidal Behaviors Questionnaire Revised (SBQ-R),
which is an adaptation of Linehan’s (1981) longer SBQ. The
SBQ-R is a four-item self-report scale that measures distinct
aspects of suicidal behavior. It measures lifetime suicidal idea-
tion and/or behavior (‘‘Have youever thought about or attempted
to kill yourself?’’), the frequency of suicidal ideation in the past
year (‘‘How often have you thought about killing yourself in the
past year?’’), the communication of suicidal thoughts to others
(‘‘Have you ever told someone that you were going to commit
suicide, or that you might do it?’’), and the likelihood of attempt-
ing suicide in the future (‘How likely is it that you will attempt
suicide in the future?’). Participants rated these items along their
corresponding response scales and the ratings were summed for a
total scale score. Higher scores indicate higher levels of risk for
suicidal behavior. Summing participants’ responses for a total
scale score is one of two ways (the other is to use a single item) the
SBQ-R has been validated (Osman et al., 2001) and is consistent
with existing literature (e.g., Bryan, Cukrowicz, West, & Mor-
row, 2010; Charbrol, Chauchard, & Girabet, 2008; Johnson,
Gooding, Wood, & Tarrier, 2010; Osman et al., 2002;Taylor,
Wood, Gooding, & Tarrier, 2010). Cronbach’s alpha was .76 in
both the original and current studies. Validity was evidenced by
total SBQ-R scores accurately differentiating between suicidal
and non-suicidal subgroups in separate samples of clinical and
nonclinical adolescents and adults (Osman et al., 2001). In the
clinical samples, the SBQ-R accurately differentiated between
individuals who were hospitalized due to a serious threat of
suicide or a suicide attempt and reported recent ideation/attempt
(suicidal) and those who were hospitalized due to another mental
health problem and reported no recent ideation/attempt (non-
suicidal). In the non-clinical samples, the SBQ-R accurately dif-
ferentiated between individuals who reported recent ideation/
attempt (suicidal) and those who reported no recent ideation/
attempt (non-suicidal).
Recruitment e-mails were sent to participants via LGBT and
trans LISTSERVs and organizations. Data collection was con-
ducted online using a secure survey platform and participation
was anonymous. To assure complete anonymity, the survey plat-
form was configured to not save IP addresses or date/time stamp
of completed entries. Participants had the option of participating
in English or in French. Participants were invited to register their
informed consent and complete a series of questionnaires. Par-
ticipants had the choice to withdraw their consent at any point
while completing the series of questionnaires. They could do so
in one of two ways: they could stop the survey at any point by
clicking on the‘‘Exit and clear survey’ icon or, once at the end of
the survey, they could click on‘‘Exitand clear survey’’rather than
‘Submit.’’Both of these actions ensured that their answers were
not included in the study. A paper-and-pencil version of the ques-
tionnaires was available upon request, with a postage-paid return
envelope included. To encourage participation in the study, par-
ticipants could opt to be included in a lottery for three prizes of
$100 each. If participants opted into the draw, they were asked to
enter their e-mail address for notification in a separate online sur-
vey in order to protect the anonymity of their previous responses.
The study received approval by the Research Ethics Board of
McGill University.
An anonymous, online data collection methodology was used
for two reasons. Online recruitment and participation in research
has been described in the literature as a suitable and appropriate
method of reaching participants belonging to hidden popula-
tions, including trans populations (Miner, Bockting, Swinburne
Romine, & Raman, 2012; Rhodes, Bowie, & Hergenrather,
2003). Furthermore, as the current research project collected data
nationally, in-person data collection was impossible. As partic-
ipation was anonymous and IP addresses were not collected, the
possibility exists that participants completed the questionnaires
twice, producing duplicate submissions. The chance of this occur-
ring was low, however, as participation took 45–60 min and partici-
pants could enter a lottery rather than receive direct compensation.
Data were nonetheless verified manually and no two participants
entered the same demographic information. Furthermore, all par-
ticipants met the eligibility criteria; all participants were required to
enter their age and all participants indicated their identity under the
broader term of trans.
Data Analysis
Mean item substitution was used when a minimum of 80 % of the
items on a given subscale was answered, with two exceptions.
Mean item substitution was not used for missing data on the SBQ-R
Arch Sex Behav
due to the scale being comprised of four items that measured
four distinct aspects of suicidal behavior. Furthermore, mean
item substitution was not used for missing data on the RFL-
48, as per the specific scoring guidelines for that scale. Ma-
halanobis distance was used to detect multivariate outliers;
the data set contained no such outliers. All analyses were
carried out using SPSS 17. Values of variation inflation factors
(VIF) and tolerance were examined in order to detect multicol-
linearity. The generally accepted rule of a VIF value above 10 and/
or a tolerance value below .2 indicating multicollinearity was
applied; no multicollinearity was detected.
Data distributions were evaluated prior to conducting the
analysis; certain data were either positively or negatively skewed.
As recommended by Tabachnick and Fidell (2007), data that
were moderately skewed were transformed using a square root
transformation; data that were substantially skewed were trans-
formed using a logarithm transformation; and data that were
severely skewed were transformed using an inverse transfor-
mation. Data that were negatively skewed were reflected in addi-
tion to being transformed; reflection refers to the process of con-
vertingnegativelyskeweddatato positively skewed data for the
purpose of transformation. Specifically, data from the SRI-25
External Protective subscale were transformed using an inverse
transformation; data from the RFL Fear of Suicide subscale were
transformed using a logarithm transformation; and data from the
Perceived Social Support from Friends Scale were reflected in
addition to being transformed using a square root transformation.
Suicidal Behavior Scores
All but one participant (n=132) answered all four questions on
the SBQ-R. The mean total score was 9.8 (SD =3.7) out of a
possible range of 3–18. Although not used in the context of this
research, the SBQ-R has two validated cutoff scores indicating
risk for suicidal behavior: scores C7, validated with undergrad-
uate students and scores C8, validated with adult inpatients.
Score distributions of the SBQ-R are shown in Table 2.Pre-
liminary analyses (i.e., t-tests and ANOVA) examined whether
participants’ suicidal behavior scores differed significantly
according to demographic variables. Results indicated that sui-
cidal behavior scores did not differ significantly as a function of
demographic variables.
Correlations Between Suicidal Behavior and Predictor
The means, SD, and correlations between variables are shown in
Table 3. Optimism and perceived social support from family
were significantly negatively correlated with suicidal behavior.
Perceived social support from friends was significantly pos-
itively correlated with suicidal behavior; however, the data from
this variable were transformed and reflected prior to the analysis.
The direction of the correlation should, therefore, be reversed
when looking at the results. All three suicide resilience factors
(internal protective factors, emotional stability, and extern al pro-
tective factors) were also significantly negatively correlated with
suicidal behavior, as were certain reasons for living (survival cop-
ing beliefs, responsibility to family, and child-related concerns).
Regression Model
As mentioned above, mean item substitution was used when a
minimum of 80 % of the items on a given subscale was answered.
Six cases had less than 80 % of items answered per subscale and
were therefore deleted listwise, resulting in a final sample of 127
participants included in the regression model. Hierarchical
multiple regression analysis wasusedtopredictsuicidalbehav-
ior from protective factors. Specifically, a three-blockmodel was
tested to determine whether protective factors would negatively
predict variance in participants’ suicidal behavior (i.e., total
SBQ-R score, comprised of lifetime suicidal ideation and/or
behavior, suicidal ideation in the past year, threats of suicide
attempt, and likelihood of suicidal behavior in the future). As
previously mentioned, being younger than 25 years old has been
found to be an independent predictor of suicide attempts in trans
individuals (Clements-Nolle et al., 2006). Age was entered in the
first block in order to control for the effects of this variable. Due to
no significant difference being found in suicidal behavior scores
across participants who identified as someone on the FTM spec-
trum, on the MTF spectrum, or as having an intersex condition/
other, this variable was not included in the regression model.
Blocks 2 and 3 were decided upon using Cohen’s (1986)
guidelines regarding hierarchical mul tiple regression. Cohen
stipulates that ‘‘the order of precedence is such that one is pre-
pared to assume that no factor coming later in the series can caus-
ally effect one coming earlier’’ (p.39). In theory, optimism, social
support from friends, and social support from family could caus-
ally effect reasons for living and suicide resilience.Therefore, the
former three variables were entered simultaneously in the second
block and the latter variables were entered simultaneously in the
third block.
Once the variance in suicidal behavior due to age was con-
trolled for, optimism, social support from friends, and social sup-
port from family significantly negatively predicted variance in
participants’ suicidal behavior, DR
=.33, change in F(3, 122) =
19.72, p\.001. Once the variance in suicidal behavior due to
age, optimism, social support from friends, and social support
from family was controlled for, suicide resilience and reasons for
living contributedsignificant variance to participants’ suicidal
behavior, DR
=.19, change in F(9, 113) =5.17, p\.001.
Information regarding these analyses and results is available from the
corresponding author upon request.
Arch Sex Behav
Results of the full hierarchical regression model are shown in
Table 4. Of the variables included in the second block, perceived
social support from family significantly and negatively predicted
participants’ suicidal behavior, t=-2.72, p\.01. Of the vari-
ables included in the third block, one suicide resilience factor
(emotional stability, t=-3.80, p\.001) and one RFL (child-
related concerns, t=-2.11, p\.05)significantly and negatively
predicted participants’ suicidal behavior.
As social support from friends was not found to be a signifi-
cant predictor of suicidal behavior, a secondary analysis was con-
ducted in which scores for social support from friends and social
support from family were compared. Participants reported sig-
nificantly less social support from family than from friends,
t(132) =7.36, p\.001.
The present study was the first to examine suicide protective
factors among trans adults. Given the high rates of suicide
attempts in trans communities, identifying factors that protect
trans individuals against suicidal ideation and behavior appears
timely. Results indicated that perceived social support from fam-
ily, emotional stability (an aspect of suicide resilience), and child-
related concerns (a reason for living) were associated with lower
suicidal behavior scores in trans individuals. Taken together,
these results provided support for the hypothesis that there were
significant relationships between some factors typically found to
protect cis individuals from suicidal behaviorand trans individu-
als’ suicidal behavior.
The suicide resilience factor of emotional stability was found
to be an important protective factor against suicidal behavior. It
should be noted that the mean scores for all three suicide resil-
ience subscales were lower than would be expected in a conve-
nience sample. The subscale means for participants in the current
study were 4.3 (SD =1.2), 4.7 (SD =1.2), and 4.7 (SD =1.2) for
the Internal Protective subscale, the Emotional Stability sub-
scale, and the External Protective subscale, respectively. These
means were lower than the means found in both Osman et al.
(2004) and Rutter et al. (2008). The finding that the current sam-
ple had lower than average rates of suicide resilience may have
meaningful implications for practitioners working with clients
who are trans or who have a trans history. The delivery of inter-
ventions that are aimed at increasing suicide resilience may
prove to be beneficial with certain clients, particularly those expe-
riencing suicidal ideation.
In addition to emotional stability being an important protec-
tive factor against suicidal behavior, child-related concerns
emerged as an important protective factor. This finding was con-
sistent with studies that include both a general population sample
and a sample of hospitalized individuals. Indeed, Linehan et al.
(1983) found that child-related concerns differentiated between
individuals who had no reported history of suicidal behavior or
brief ideation and those who had a reported history of serious
ideation or behavior in a general population sample. They also
found that child-related concerns differentiated between indi-
viduals who were currently non-suicidal and those who were
currently suicidal in a sample of hospitalized individuals. Lastly,
child-related concerns also differentiated between those who
were experiencing current ideation and those who had attempted
suicide in the same group of hospitalized individuals.
Perceived social support from family significantly and nega-
tively predicted participants’ suicidal behavior scores. This find-
ing was consistent with the extant research regarding social sup-
port and suicide ideation and/or attempts. Marion and Range
(2003) found that perceived social support significantly and neg-
atively predicted suicide ideation in a sample of African Amer-
ican college students. In a more recent study, Chioqueta and Stiles
(2007) found that social support significantly and negatively
Table 2 Suicidal ideation and behavior
Lifetime suicide ideation/attempt
Never 11 8.3
It was just a brief passing thought 28 21.1
I have had a plan at least once to kill myself 59 44.4
I have attempted to kill myself 35 26.3
Frequency of suicide ideation in past year
Never 34 25.6
Rarely (1 time) 23 17.3
Sometimes (2 times) 23 17.3
Often (3–4 times) 21 15.8
Very often (5 or more times) 32 24.1
Communication of suicidal thoughts to others
No 61 45.9
Yes, at one time, but did not really want to die 26 19.5
Yes, at one time, and really wanted to die 15 11.3
Yes, more than once, but did not want to do it 10 7.5
Yes, more than once, and really wanted to do it 20 15.0
Likelihood of suicidal behavior in the future
Never 20 15.0
No chance at all 19 14.3
Rather unlikely 48 36.1
Unlikely 22 16.5
Likely 15 11.3
Rather likely 6 4.5
Very likely 3 2.3
If a participant answered the fourth question with‘‘likely,’’‘rather likely’
or ‘‘very likely,’’ the following message appeared: ‘‘Although the mea-
sures you filled out are not diagnostic tools, based on this information,
you are highly encouraged to call the National Suicide Prevention Life-
line at 1-800-273-8255 and to consult a mental health professional.
Always consult with a trained suicide prevention volunteer and/or
mental health professional if you are experiencing serious thoughts of
ending your life. Furthermore, if you are currently experiencing serious
thoughts of ending your life, you should immediately go to the emer-
gency department of your local hospital to seek help’’
Arch Sex Behav
predicted suicidal ideation, above and beyond hopelessness and
depression, in a sample of 314 university students. Social support,
as measured by specific questions regarding distinct areas of
support, was also associated with both lower rates of suicidal
ideation and attempts in a sample of 2,255 youth who had had at
least one same-sex sexual experience (Eisenberg & Resnick,
2006). Of particular interest, social support from family, as mea-
sured by a group of questions assessing family connectedness,
was shown to be an important protective factor among these
youth. Both male and female youth who reported high levels
of family connectedness had almost half the odds of suicidal
ideation and attempts than youth who reported lower levels
of family connectedness, with the exception of males who had
.60 the odds of suicidal attempts. Likewise, Bouris et al. (2010)
conducted a systematic review of the literature regarding parental
influences on the health of LGB youth and found that parental
closeness and support was a suicide protective factor among these
Table 3 Correlations between suicidal behavior, age, optimism, perceived social support, suicide resilience, and reasons for living
Variable 1 1a 1b 1c 1d 2 3 4 5 6
1. SBQ-R total score
1.a. Lifetime suicide ideation/attempt .71***
1.b. Ideation in past year .85*** .42**
1.c. Communication of suicidal
thoughts to others
.66*** .42*** .44***
1.d. Likelihood of suicidal behavior
in the future
.85*** .53*** .60*** .40***
2. Age -.01 .08 -.09 -.08 .06
3. Optimism -.53*** -.41*** -.46*** -.28** -.45*** .08
4. Perceived support from friends
.17* .14 .17* .02 .16* .11 -.30*** –
5. Perceived support from family -.42*** -.28** -.41*** -.23** -.35*** .06 .43*** -.23** –
6. Internal protective -.55*** -.34*** -.47*** -.36*** -.50*** .09 .74*** -.41*** .39***
7. Emotional stability -.64*** -.38*** -.50*** -.35*** -.67*** .04 .59*** -.34*** .38*** .69***
8. External protective
-.45*** -.29*** -.34*** -.27** -.46*** -.04 .54*** -.44*** .36*** .53***
9. Survival coping beliefs -.49*** -.31*** -.37*** -.21** -.55*** .00 .43*** -.24** .25** .54***
10. Responsibility to family -.17* -.09 -.20* .06 -.21* .19* .19* -.10 .49*** .14
11. Child-related concerns -.24** -.26** -.15* -.11 -.24** .30*** .14 .04 .08 .13
12. Fear of suicide
.07 .08 .00 .10 .07 -.15* -.17* .08 .02 -.14
13. Fear of social disapproval -.04 -.01 -.01 .09 -.14 -.15* -.10 .09 .08 -.05
14. Moral objections -.10 -.02 -.07 -.03 -.15 .00 .02 .02 .11 .07
Mean 9.76 2.89 2.94 1.76 2.17 36.75 12.83 12.38
7.83 4.29
SD 3.74 .91 1.55 .80 1.46 13.01 6.14 5.45
6.58 1.15
Variable 7 8 9 10 11 12 13 14
7. Emotional stability
8. External protective
.64*** –
9. Survival coping beliefs .54*** .39***
10. Responsibility to family .17* .21** .25**
11. Child-related concerns .12 .09 .32*** .38***
12. Fear of suicide
-.15* -.11 .04 .09 -.01 –
13. Fear of social disapproval -.10 -.04 .16* .40*** .17* .30***
14. Moral objections .06 -.07 .29*** .20* .16* .25** .34***
Mean 4.66 4.70
4.01 3.56 2.64 2.61
2.37 1.56
SD 1.16 1.23
1.16 1.51 1.87 1.22
1.37 .99
*p\.05, ** p\.01, *** p\.001
Transformed distribution with a reflection. Interpretation of the direction of the results should therefore be reversed
Transformed distribution
Means and standard deviations from non-transformed distribution for comparison purposes
Arch Sex Behav
Participants reported significantly less social support from
family than from friends. This finding was in line with current liter-
ature that underlines the occurrence of rejection of trans individ-
uals from their families of origin due to transphobia and trans-
prejudice (Association of Lesbian, Gay, Bisexual, and Transgen-
der Issues in Counseling, 2009). Despite the fact that trans par-
ticipants in the current sample perceived that they receivedmuch
less social support from their families than from their friends, it
was the social support from their families that was significantly
associated with lower rates of suicidal behavior. Given that there
were high scores and a restricted range seen in the Perceived
Social Support from Friends Scale responses, the non-significant
associations between perceived social support from friends and
suicidal behavior may be due to a ceiling effect. However, given
that perceived social support from families appears to be a sui-
cide protective factor, the development of interventions aimed at
the families of trans individuals’ may prove to have beneficial
outcomes for the trans individuals themselves.
That having been said, it must be stressed that the data in ques-
tion were cross-sectional and thus causal relationships between
variables cannot be assumed. Alternate explanations regarding
the association between perceived social support from family
and suicidal behavior are entirely feasible. For example, the asso-
ciation between the two variables may operate in the opposite
direction; individuals with lower suicidal behavior scores may
have the perception that they receive higher levels of social sup-
port from family. There is also the possibility one or more other
variables moderate the relationship between perceived social sup-
port and suicidal behavior.
As mentioned above, data were cross-sectional and obtained
through questionnaires; causal relationships between variables
therefore cannot be assumed. Furthermore, as there was no com-
parison group in the current study, interpretation of the lower
scores on some of the measures (e.g., SRI-25) is tentative at best.
Moreover, results may not be generalizable due to the small sam-
ple size based on convenience, non-random sampling, as well as
the somewhat homogeneous ethnocultural backgrounds of the
participants. In addition, although a paper version of the survey
was available to those who requested it, all recruitment was con-
ducted online. Therefore, individuals who did not have access to a
computer, the internet, or who were not on the LGB and trans
LISTSERVs on which the recruitment emails were distributed
most probably did not see the recruitment advertising and were
not able to participate. Lastly, it was the first time that the mea-
sures were administered to trans individuals. Though many of the
correlations found among cis individuals were also found in the
current study, the validity of the measures with trans populations
should continue to be explored. In addition, only suicide resil-
ience, reasons for living, and selected general suicide protective
factors were assessed. Therefore, one should be cautious against
considering only these protective factors; factors associated with
Table 4 Hierarchical multiple regression analysis predicting suicidal behavior from optimism, perceived social support, suicide resilience, and
reasons for living
Predictor BSEBBtR
Adjusted R
change Fchange df
Step 1 .00 -.01 .00 .01 1, 125
Age .02 .02 .06 .85
Step 2 .33 .31 .33 19.72*** 3, 122
Optimism -.07 .06 -.12 -1.16
Perceived support from friends
-.39 .29 -.11 -1.38
Perceived support from family -.13 .05 -.23 -2.72**
Step 3 .52 .47 .19 5.17*** 9, 113
Internal protective -.26 .38 -.08 -.67
Emotional stability -1.29 .34 -.40 -3.80***
External protective
-.29 1.35 -.02 -.22
Survival coping beliefs -.37 .29 -.12 -1.30
Responsibility to family .34 .23 .14 1.52
Child-related concerns -.32 .15 -.16 -2.11*
Fear of suicide
.09 1.23 .01 .07
Fear of social disapproval -.21 .22 -.08 -.96
Moral objections .07 .28 .02 .26
n=127. Regression coefficients reported from final step
*p\.05, ** p\.01, *** p\.001
Transformed distribution with a reflection. Interpretation of the direction of the results should therefore be reversed
Transformed distribution
Arch Sex Behav
lower suicidal behavior scores in the current study are but some
factors out of a plethora of potential protective factors already
identified for cis individuals. Lastly, the current study was con-
ceptually limited due to the fact that risk factors were not asses-
sed, which made the mediating or buffering effect of the protec-
tive factors impossible to analyze.
Despite these limitations, we suggest that the current study
was a first step in the identification of suicide protective factors
among trans individuals. Although it was not possible to examine
the mediating or buffering role of the protective factors against
risk factors, the analysis of protective factors through negative
and significant predictions of variance in suicidal behavior scores
was in line with common practices for identifying suicide pro-
tective factors (e.g., Marion & Range, 2003). It is our hope that
much more research will be conducted on this topic and that the
results will be used to inform the practices of mental health work-
ers, medical doctors, and suicide prevention workers working
with trans clients.
Directions for Future Research
Future research should use conceptual models that take risk fac-
tors, in addition to protective factors, into account. Such can be
done in a number of ways, such as testing integrative models
(Rutter, 2008) or by investigating the moderating effects of pro-
tective factors on the relationship between risk factors and sui-
cidal behavior. Furthermore, in order to avoid the limitations
associated with cross-sectional designs, future research would
benefit from longitudinal designs. However, it should be noted
that although this recommendation is simple to make in theory, it
may be rather inappropriate to carry out in practice due to the
ethical and legal concerns that must be considered when con-
ducting research regarding suicidal ideation and/or attempts.
Future research may also benefit from examining the rela-
tionships between protective factors and suicidal ideation and/
or attempts in different groups of trans individuals in order to
understand potential important within-group differences. For
example, although no significant differences were found in
suicidal behavior scores across participants who reported being
on the FTM spectrum, the MTF spectrum, or being a person with
an intersex condition/other in the current sample, this may not be
the case in other samples and thus the investigation of differ-
ences among protective factors across groups of trans individ-
uals may be warranted. Different factors may also be protective
for trans people of color than for White trans individuals, and for
LGB trans individuals than for heterosexual trans individuals,
and for young adult trans individuals than for older adult trans
individuals. Lastly, future research would also benefit from the
exploration of protective factors that were not included in the
present study and/or factors that may be protective specifically
for trans individuals. As the investigation of protective factors is
in its infancy, the above future directions will allow for the
development of specific and appropriate suicide prevention
models and interventions for suicidal trans individuals.
Acknowledgments The authors would like to thank Dr. Monique
´quin for her expert consultation; Sam Talbot for verification of the
English to French translation; Ryan Kochen, Morgen Pilon and members
of the CORE research team for assistance with the design of the study and
manuscript preparation; and the participants who very generously par-
ticipated in the study. This research was conducted with the support of
the Fonds de la Recherche en Sante
´du Que
´bec via the Re
´seau Que
de Recherche sur le Suicide.
Open Access This article is distributed under the terms of the Creative
Commons Attribution License which permits any use, distribution, and
reproduction in any medium, provided the original author(s) and the
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... The latest in a series of Private Lives research (Hill et al., 2020) reports a significant increase in depression and anxiety, stress, suicidal thoughts and suicide attempts compared to the general population. Skerrett, Kölves, and De Leo (2016; find that the main factor leading to suicide in LGBT individuals is a lack of family support (see also Bauer et al., 2015;Trujillo et al., 2017;Moody and Smith, 2013). Other additional factors include abuse of psychoactive substances, minority stress and related repression and discrimination (Mereish, O'Cleirigh and Bradford, 2014;Hatzenbuehler et al., 2015). ...
... Pri LGBT+ osebah, ki so del LGBT+ skupnosti, je verjetnost depresije nižja (McLaren, Gibbs in Watts, 2013). Pri tistih, ki imajo podporo družine, je tveganje za samomor nižje, celo pri osebah, ki so izpostavljene povečanemu trpinčenju in zavračanju s strani širše družbe (Bauer in dr., 2015;Trujillo in dr., 2017;Moody in Smith, 2013), še posebej pa je podpora družine in drugih bližnjih pomembna v postopku medicinske spremembe spola pri transspolnih osebah (Moody in dr., 2015). Prisotnost duševnih motenj povečuje tveganje za samomorilno vedenje: po raziskavi Mustanskega, Garofala, in Emersona (2010) približno tretjina LGBT mladih izpolnjuje kriterije za vsaj eno duševno motnjo, največkrat za depresijo in tesnobnostne motnje (glej tudi Skerrett, Kölves in De Leo, 2015;, vedenjske motnje in potravmatsko stresno motnjo. ...
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Research in Slovenia and abroad shows an increased threat to the mental health of LGBT+ people. Protecting their mental health is a challenge for various psychosocial care professionals, including psychotherapists. In order to achieve a better quality of professional assistance to LGBT+ individuals, a lot needs to be changed at the institutional and wider societal level. An important positive step in this direction is the withdrawal of all categories related to transgender identities from ICD-11 and the introduction of a new category of sexual incon- gruence. In Slovenia, the Resolution on the National Mental Health Programme 2018-2028 is expected to indirectly improve the lives of LGBT+ people with mental health challenges (as a more vulnerable and often socially excluded social group), by for instance increasing access to medical and psychosocial care services. Also important is the legal regulation of private mental health care. Support of the LGBT+ population by non-governmental organizations is insufficient due to increasing needs. Legebitra and TransAkcija are the main organizations that offer psychosocial counselling to the LGBT+ population, the latter being the only one that focuses exclusively on working with transgender people. At the level of a LGBT+ individual seeking help or support there are chal- lenges associated with psychiatric treatment in the medical process of gender confirmation (medical transition). There is also a lack of relevant knowledge among professionals who offer various forms of psychosocial care. At the societal level, a major problem in the daily lives of LGBT+ people is (still) discri- mination, which also has a negative effect on their mental health. One of the potentially more stressful events in the life of an LGBT+ person is the disclosure of sexual identity or sexual orientation to loved ones, especially parents.
... (Perrin et al., 2020), which demonstrated that identity pride (i.e., self-acceptance of one's identity) and self-esteem are positively associated with mental health. Acceptance of one's identity has indeed shown to be protective against suicidality risk among SGM populations, including among older adults (Fredriksen-Goldsen et al., 2017) and trans people (Moody & Smith, 2013). Further, some SGM women have indicated that finding meaning in their SGM identity by engaging in collective action, including SGM rights activism, supports their positive mental health and resiliency (Drabble et al., 2018). ...
Lesbian, bisexual, trans, queer, and other sexual and gender minority (SGM) women are at high risk of suicide. Stigma, discrimination, and exclusion are known risk factors. Contrasting longstanding trends of risk-focused research, this study examines the experiences of SGM women who have attempted suicide focusing on their embodied strengths and resiliencies to continue living post-attempt. Qualitative data from Photovoice methods and in-depth interviews with 11 Canadian-based women who survived a suicide attempt were collected in 2017. Analysis involved an inductive, reflexive thematic approach informed by the minority strengths model. The analysis generated three interconnected themes: 1) reconciling identities and traumas, 2) anchoring to life, and 3) staying afloat: blending professional- and self-help. First, participants described the importance of reconciling past traumas and coming to terms with – and embracing – their SGM identities to live well post-attempt. Second, participants emphasized the potential for community supports to facilitate connectedness, belonging, and a sense of purpose following a suicide attempt. Importantly, this “anchoring” to community also provided a key outlet through which SGM women could process and mitigate experiences of mental health hardship, thereby directly buffering against suicidality. Third, participants underscored that staying afloat post-attempt was a journey requiring persistent and proactive efforts, including use of effective self-management strategies and professional mental-health services. Taken together, these findings offer important insights into the strengths and resiliencies of SGM women who have attempted suicide to guide the efforts of mental health practitioners and the design and evaluation of tailored suicide prevention programs.
... ). Η ύπαρξη σχέσεων (οικογενειακών, φιλικών ή/και ερωτικών) στις οποίες τα άτομα αισθάνονται ότι μπορούν να εκφράσουν ελεύθερα όλες την ταυτότητα φύλου τους και μέσα από τις οποίες μπορούν να λάβουν υποστήριξη και αποδοχή, μπορεί να τα βοηθήσει να έχουν μια πιο θετική εικόνα για τον εαυτό τους, ακόμα και όταν έρχονται αντιμέτωπα με στρεσογόνους παράγοντες.Εκτός από την ισχύ του υποστηρικτικού δικτύου, η σύσταση του είναι πιθανό να επηρεάζει επίσης την επίδραση που αυτό έχει στην αυτοεκτίμηση. Για παράδειγμα, η υποστήριξη από την οικογένεια, ειδικότερα για τα πιο νέα σε ηλικία άτομα, μπορεί να διαδραματίσει καταλυτικό ρόλο στην μείωση της αυτοκτονικότητας(Bauer et al., 2015, Moody & Smith, 2013, ενώ η ύπαρξη υποστηρικτικών δικτύων που να απαρτίζονται από άλλα ΛΟΑΤΚΙ άτομα έχει φανεί επίσης να λειτουργεί προστατευτικά απέναντι στην επίδραση των διακρίσεων στην ευεξία των ατόμων(Leahy & Chopik, 2020). Η αλληλεπίδραση του υποστηρικτού δικτύου και των εμπειριών μη επιβεβαίωσης της ταυτότητας φύλου για την πρόβλεψη της αυτοεκτίμησης ήταν η μόνη που έδειξε στατιστική σημαντικότητα. ...
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Το μοντέλο του μειονοτικού στρες (Meyer, 1995) υποστηρίζει πως οι λεσβίες, οι γκέι άντρες και τα αμφιφυλόφιλα άτομα αντιμετωπίζουν ένα επιπρόσθετο είδος στρες, το οποίο σχετίζεται με το ότι φέρουν μια μειονοτική ταυτότητα, και είναι διαφορετικό από τα στρεσογόνα γεγονότα ζωής που είναι κοινά για όλα τα άτομα. Το μοντέλο αυτό αργότερα προσαρμόστηκε και για τα τρανς άτομα (Hendricks & Testa, 2012). Οι υπάρχουσες έρευνες επιβεβαιώνουν το μοντέλο του μειονοτικού στρες, αναδεικνύοντας σημαντικές συσχετίσεις μεταξύ εμπειριών βίας, διάκρισης και απόρριψης με αυξημένες προκλήσεις ψυχικής υγείας, όπως αυτοκτονικότητα και αυτοτραυματισμούς, αγχώδεις διαταραχές, κατάθλιψη και χρήση ουσιών (Goldblum et al., 2012, Nuttbrock et al. 2014, Bockting et al., 2013). Ωστόσο, αν και τα τρανς άτομα έρχονται αντιμέτωπα με περισσότερα στρεσογόνα γεγονότα, λόγω της μη κανονιστικής τους ταυτότητας, φαίνεται πως αρκετά από αυτά δεν αντιμετωπίζουν αυξημένες προκλήσεις ψυχικής υγείας και έχουν παρόμοια επίπεδα ψυχοσυναισθηματικής ευεξίας και προσαρμογής με cis άτομα (Herrick et al., 2013, Meyer, 2015). Το γεγονός ότι η επίδραση του μειονοτικού στρες δεν είναι καθολική, αποτελεί ένδειξη για την ύπαρξη παραγόντων οι οποίοι μπορούν να δράσουν προστατευτικά, ανακόπτωντας τη διαβρωτική επίδραση των διακρίσεων και βοηθώντας τα άτομα να αναπτύξουν την ψυχική τους ανθεκτικότητα. Η υπάρχουσα βιβλιογραφία έχει αναδείξει την προσταυτευτική για την ψυχική ευεξία δράση συγκεκριμένων παραγόντων όπως η αίσθηση σύνδεσης με τη ΛΟΑΤΚΙ κοινότητα, η ύπαρξη υποστηρικτικού δικτύου, αλλά και η αίσθηση υπερηφάνειας αναφορικά με την ταυτότητά τους (Bauer et al., 2015, Testa et al., 2015, Singh, 2013). Παρότι τα τελευταία χρόνια υπάρχουν ολοένα και περισσότερες μελέτες για την ψυχική υγεία των τρανς ατόμων μέσα από το πρίσμα της επίδρασης των διακρίσεων και όχι μιας παθολογιοποιητικής προσέγγισης που ερμηνεύει την ύπαρξη προκλήσεων ως αποτέλεσμα της ίδια της μειονοτικής ταυτότητα φύλου, δεν υπάρχουν μέχρι σήμερα γνωστές αντίστοιχες έρευνες στο ελληνικό πλαίσιο. Στόχος της παρούσας έρευνας ήταν η μελέτη των στρεσσογόνων παραγόντων, των παραγόντων ψυχικής ανθεκτικότητας και της ψυχικής υγείας των τρανς ατόμων στην Ελλάδα, στη βάση του μοντέλου του μειονοτικού στρες. Η μελέτη εστιάστηκε στη διερεύνηση της επίδρασης των εμπειρών διάκρισης, θυματοποίησης, αναμονής απόρριψης και μη επιβεβαίωσης της ταυτότητας φύλου στην αυτοεκτίμηση και την ψυχική υγεία των τρανς ατόμων, καθώς και της επίδρασης της σύνδεσης με τη ΛΟΑΤΚΙ κοινότητα, του αισθήματος υπερηφάνειας και της ύπαρξης υποστηρικτικού δικτύου, παρουσία των προαναφερθέντων -δυνητικών- παραγόντων επικινδυνότητας. Το δείγμα της έρευνας αποτελείται από 129 άτομα που αυτοπροσδιορίζονται ως τρανς ή gender non-conforming και ζουν στην Ελλάδα, ηλικίας 16 έως 66 ετών. Τα αποτελέσματα αναδεικνύουν την αρνητική επίδραση της αναμονής απόρριψης, της μη επιβεβαίωσης της ταυτότητας φύλου, των γεγονότων διάκρισης και των γεγονότων θυματοποίησης στην αυτοεκτίμηση και την ψυχική υγεία των ατόμων, σε συμφωνία με την υπάρχουσα βιβλιογραφία. Ως προς την επίδραση των pροστατευτικών παραγόντων, η σύνδεση με την κοινότητα φάνηκε να έχει σημαντική θετική επίδραση στην αυτοεκτίμηση, ανακόπτωντας την μείωση της σε συνθήκες υψηλής θυματοποίησης και αναμονής απόρριψης. Τα ευρήματα αυτά φαίνεται να συμφωνούν με την υπάρχουσα βιβλιογραφία, ως προς την θετική επίδραση που έχει στην ανάπτυξη ψυχικής ανθεκτικότητας η σύνδεση με την κοινότητα. Επιπλέον, η αίσθηση υπερηφάνειας λειτουργεί προστατευτικά για την ψυχική υγεία απέναντι στα γεγονότα θυματοποίησης. Η παρούσα έρευνα αποτελεί ένα πρώτο εγχείρημα για τη μελέτη των παραγόντων επικινδυνότητας και των προστατευτικών παραγόντων για την ψυχική υγεία των τρανς ατόμων στην Ελλάδα. Άλλοι παράγοντες όπως το εσωτερικευμένο στίγμα και η επίδραση του φύλου θα μπορούσαν να αποτελέσουν αντικείμενο μελέτης μελλοντικών ερευνών, με στόχο την αύξηση της κατανόησης σχετικά με την επίδραση τόσο των στρεσσογόνων όσο και των προστατευτικών παραγόντων στην ψυχική υγεία των τρανς ατόμων.
... Studies on reasons for living in patients with atypical gender are scarce. Moody and Smith (2013) stated that there is a «significant relationship between some factors typically found to protect cis individuals from suicidal behavior and trans individuals' suicidal behavior», but 86.5% of the participants in that study identified themselves as FTM (female to male) and MTF (male to female). In previous studies, the 48-item version of RFL was used. ...
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The study aimed to investigate factors associated with non-binary gender identity in Russian female psychiatric inpatients with suicidal ideation. This case–control study included 38 female inpatients with non-binary gender identity and a control group—76 cisgender women matched for age (age range 19–35 years, M age, 21.5 years); both groups were psychiatric inpatients with suicidal thoughts. All patients underwent the Self-Injurious Thoughts and Behaviors Interview and completed the brief Reasons for Living Inventory. We also used the WHO Quality of Life Questionnaire (WHOQOL-100) and the Life Style Index (LSI). Non-binary gender identity in inpatients with suicidal ideation was associated with lower educational level, higher unemployment rate, being more socially reticent in preschool, and lifetime sexual experience with both male and female partners. In addition, they were younger at the time of the first suicidal ideation, suicide plan development, and attempt. Non-binary inpatients had lower scores in freedom, physical safety, and security facets of WHOQOL-100 and a higher level of intellectualization on LSI. People with non-binary gender identity face educational, employment, and communication issues. They also have distinct suicidal thoughts and behavioral profiles. These issues and differences mean unique approaches to suicide prevention for a population of inpatients with non-binary gender identity are needed.
As a result of experiencing oppression-based stressors and trauma, suicide rates for lesbian, gay, bisexual, and transgender (LGBTQ+) individuals are much higher than in the general population; and for trans and gender non-binary (TGNB) individuals specifically, rates of suicidality are even higher. To best understand how to engage in suicide prevention and intervention efforts for TGNB individuals, it is therefore crucial to understand factors that may mitigate suicidality for TGNB individuals. The purpose of this study was to examine the relationship between protective factors-body acceptance, optimism, social support, and pride-and suicidality for TGNB adults. A total of 139 TGNB participants completed an online survey about suicidal behaviors, transgender-specific risk factors, and transgender-specific protective factors. High rates of suicidality were observed in our sample. Initial results suggested that only optimism was inversely significantly related to suicidality. Given that optimism, which suggests a belief in a better future, has been found in previous studies to buffer the effects of deleterious stressors, optimism was also examined as a mediator between body acceptance (a key feature of gender dysphoria) and suicidality. Results suggested that optimism did mediate the relationship between body acceptance and suicidality. Optimism appears to be an important protective factor against suicidality for TGNB individuals and thus a potentially important target of intervention.
Transgender veterans have a long history with the military. They face a variety of health and social disparities, which affect areas such as housing and employment. Transgender clients are also more likely to experience suicidal ideation, attempt suicide, and experience other mental health disorders. Furthermore, this population utilizes health care at a lower rate than others. Transgender veterans are more likely to experience military sexual trauma while previously on active duty with rates as high as one in five transmen are sexually assaulted. This chapter further explores the unique experiences of both male to female (MTF) and female to male (FTM) transgender veterans. Treatment considerations, including responding to and providing holistic treatment as well as psychological assessment and guidelines for hormone therapy, are further explored and discussed.KeywordsTransgenderVeteran MTFVeteran FTMGender non-conformingTGNCHormone therapy
Data on unmet mental health needs is limited for transgender men. This analysis aims to determine the prevalence and correlates of lifetime suicidal ideation and suicide attempt among transgender men in San Francisco. Between 2014 and 2015, 122 transgender men aged ≥18 years from the San Francisco Bay Area were recruited using a hybrid venue- and peer referral-based sampling method (starfish sampling) to participate in a survey that included mental health indicators. Multivariable Poisson regression models determined associations of lifetime suicidal ideation and lifetime suicide attempt, separately, with demographic, substance use, and psychosocial factors. Mean age of participants was 29.6 years (range 18–56); 22% identified as transgender men of color (6 Asian, 8 Black/African American, 4 Hispanic/Latinx, and 9 other/mixed race); 52% reported ever receiving a depression diagnosis. Overall, 81% ( n = 98) reported suicidal ideation, of whom 48% ( n = 47) reported suicide attempt. Identification as a transgender man of color (adjusted prevalence ratio [PR] 1.23, p = .03) and prior depression diagnosis (PR 1.46, p < .01) were associated with lifetime suicidal ideation. Perceived social support was associated with a decreased risk of suicidal ideation (PR 0.82, p = .02). Prior depression diagnosis (PR 2.23, p < .01) and low to moderate (≤3 episodes vs. none) binge alcohol use in the last 6 months (PR 1.60, p = .03) were correlates of lifetime suicide attempt. Suicidal behaviors were highly prevalent among this community-derived sample of transgender men. Targeted mental health-focused interventions, specifically among ethnic minorities, may help to address these disparities in this underserved group.
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Abstract Background: Lesbian, gay and bisexual (LGB) people may be at higher risk of mental disorders than heterosexual people. Method: We conducted a systematic review and meta-analysis of the prevalence of mental disorder, substance misuse, suicide, suicidal ideation and deliberate self harm in LGB people. We searched Medline, Embase, PsycInfo, Cinahl, the Cochrane Library Database, the Web of Knowledge, the Applied Social Sciences Index and Abstracts, the International Bibliography of the Social Sciences, Sociological Abstracts, the Campbell Collaboration and grey literature databases for articles published January 1966 to April 2005. We also used Google and Google Scholar and contacted authors where necessary. We searched all terms related to homosexual, lesbian and bisexual people and all terms related to mental disorders, suicide, and deliberate self harm. We included papers on population based studies which contained concurrent heterosexual comparison groups and valid definition of sexual orientation and mental health outcomes Results: Of 13706 papers identified, 476 were initially selected and 28 (25 studies) met inclusion criteria. Only one study met all our four quality criteria and seven met three of these criteria. Data was extracted on 214,344 heterosexual and 11,971 non heterosexual people. Meta-analyses revealed a two fold excess in suicide attempts in lesbian, gay and bisexual people [pooled risk ratio for lifetime risk 2.47 (CI 1.87, 3.28)]. The risk for depression and anxiety disorders (over a period of 12 months or a lifetime) on meta-analyses were at least 1.5 times higher in lesbian, gay and bisexual people (RR range 1.54-2.58) and alcohol and other substance dependence over 12 months was also 1.5 times higher (RR range 1.51-4.00). Results were similar in both sexes but meta analyses revealed that lesbian and bisexual women were particularly at risk of substance dependence (alcohol 12 months: RR 4.00, CI 2.85, 5.61; drug dependence: RR 3.50, CI 1.87, 6.53; any substance use disorder RR 3.42, CI 1.97-5.92), while lifetime prevalence of suicide attempt was especially high in gay and bisexual men (RR 4.28, CI 2.32, 7.88). Conclusions: LGB people are at higher risk of mental disorder, suicidal ideation, substance misuse, and deliberate self harm than heterosexual people.
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In this article the author reviews research evidence on the prevalence of mental disorders in lesbians, gay men, and bisexuals (LGBs) and shows, using meta-analyses, that LGBs have a higher prevalence of mental disorders than heterosexuals. The author offers a conceptual framework for understanding this excess in prevalence of disorder in terms of minority stress— explaining that stigma, prejudice, and discrimination create a hostile and stressful social environment that causes mental health problems. The model describes stress processes, including the experience of prejudice events, expectations of rejection, hiding and concealing, internalized homophobia, and ameliorative coping processes. This conceptual framework is the basis for the review of research evidence, suggestions for future research directions, and exploration of public policy implications.
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Health research on transgender people has been hampered by the challenges inherent in studying a hard-to-reach, relatively small, and geographically dispersed population. The Internet has the potential to facilitate access to transgender samples large enough to permit examination of the diversity and syndemic health disparities found among this population. In this article, we describe the experiences of a team of investigators using the Internet to study HIV risk behaviors of transgender people in the United States. We developed an online instrument, recruited participants exclusively via websites frequented by members of the target population, and collected data using online quantitative survey and qualitative synchronous and asynchronous interview methods. Our experiences indicate that the Internet environment presents the investigator with some unique challenges and that commonly expressed criticisms about Internet research (e.g., lack of generalizable samples, invalid study participants, and multiple participation by the same subject) can be overcome with careful method design, usability testing, and pilot testing. The importance of both usability and pilot testing are described with respect to participant engagement and retention and the quality of data obtained online.
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This study examined 392 regrettable sex stories submitted by college students attending a large public university in the northeast. Stories were coded for common themes. In nearly half the sexual episodes (49%), the individuals were drinking. However, only 16% cited “I was drunk” as the primary reason for regretting the sexual experience. Other common reasons cited by students for regretting a sexual experience were: “It was a disappointing first time” (25%), “It was unprotected sex” (22%), “I was cheating on my partner” (17%), “It was a one-night stand” (17%), and “It ruined our friendship” (11%). Implications for educating college students are discussed.
Two Philadelphia-based HIV service organizations and a local university collaborated on a study of health and social service needs of transgender people. Transgender people were the primary resource for the development of the needs assessment survey. In this article, the survey development process, including two discussion groups and two focus groups, are described. Findings on barriers to care, violence, perception of public safety and comfort, suicide and health and social service needs are presented. Total sample size was 81, with 49 male-to-female and 32 female-to-male transgender individuals. Most (68%) were African American. About half of the respondents had thought about attempting suicide. High levels of violence were reported, especially among male-to-females. Health and social service needs included job training/work, dental care, health care, legal services, transportation, education and housing.