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Archives of Suicide Research
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/usui20
Past-Year Suicidal Ideation Among Transgender
Individuals in the United States
Andrew Yockey , Keith King & Rebecca Vidourek
To cite this article: Andrew Yockey , Keith King & Rebecca Vidourek (2020): Past-Year Suicidal
Ideation Among Transgender Individuals in the United States, Archives of Suicide Research, DOI:
10.1080/13811118.2020.1803165
To link to this article: https://doi.org/10.1080/13811118.2020.1803165
Published online: 11 Aug 2020.
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Past-Year Suicidal Ideation Among Transgender Individuals
in the United States
Andrew Yockey , Keith King, and Rebecca Vidourek
ABSTRACT
This study assessed potential correlates to past-year suicide ideation
among a national sample of transgender adults in the United States.
A secondary analysis of the 2015 Transgender Survey was con-
ducted. The 2015 Transgender Survey is the first and largest survey
assessing health behaviors among transgender individuals living in
the United States. Participants were recruited by several methods
(e.g., social media, random sampling, photobooth campaigns.
Weighted logistic regression analyses adjusting for covariates were
conducted to investigate potential associations to whether or not an
individual thought about suicide. A total of 27,795 individuals who
self-identified as transgender participated in the study. Of the sam-
ple, 34.0% identified as a man, 29.8% identified as a woman, 20.6%
identified as non-binary, and 15.5% identified as part time one gen-
der/part time another. Nearly half of participants (48.5%) reported
past year suicide ideation. Significant predictors included gender
identity, age, income, race, low family support, and self-reported
physical and sexual assault. This is one of the first studies that we
are aware of examining past-year suicidal ideation among a large,
nationally representative sample of transgender individuals.
Interventions (e.g., acceptance therapy, evaluation, focus groups) are
desperately needed to address this burgeoning problem among
transgender individuals.
KEYWORDS
Suicide; trans-
gender; violence
INTRODUCTION
Suicide is the 10th leading cause of death and is a national health epidemic. The
American Foundation for Suicide Prevention estimated that in 2017, 47,713 people died
due to suicide (American Foundation for Suicide Prevention, 2019). Moreover, nearly
1.5 million suicide attempts were made across the United States in 2017 (American
Foundation for Suicide Prevention, 2019). In 2015, more than half a million people vis-
ited the emergency department for suicidal behaviors (American Foundation for Suicide
Prevention, 2019). While suicidal behaviors (e.g., ideation) have been linked to
decreased mental health, poor quality of life, and impairments with individual psycho-
social well-being (American Psychiatric Association (APA), 2013; World Health
Organization, 2019), more research is warranted to identify correlates to suicidal idea-
tion, especially among lesbian, gay, bisexual, and transgender (LGBT) individuals, given
that a high percentage of LGBT individuals report suicide ideation (as high as 51%)
ß2020 International Academy for Suicide Research
ARCHIVES OF SUICIDE RESEARCH
https://doi.org/10.1080/13811118.2020.1803165
(Adams, Hitomi, & Moody, 2017; Perez-Brumer, Hatzenbuehler, Oldenburg, &
Bockting, 2015; Testa et al., 2012).
Evidence suggests that transgender individuals and gender minorities (e.g., individuals
who identify as something other than male or female) are at elevated risk for suicidal
ideation. A review by Adams et al. (2017) demonstrated suicidal ideation to be signifi-
cantly higher among transgender adults, compared to their LGB counterparts. Several
reasons have been posited for such elevated rates including psychopathology (e.g., anx-
iety) and antitransgender stigma (Adams et al., 2017).
With research indicating numerous health disparities experienced by LGBT individu-
als, a heightened need in examining suicidal ideation among transgender individuals
has arisen. Perez-Brumer et al. (2015) investigated suicidal behaviors among 1,229 trans-
gender individuals in the United States and found an association between high levels of
stigma and increased suicidal attempts. Furthermore, demographic covariates including
gender identity, race, and education increased the risk for suicidal attempts (Perez-
Brumer et al., 2015). A recent review by Wolford-Clevenger, Frantell, Smith, Flores, and
Stuart (2018) found that lack of connectedness and psychological/emotional pain were
unique risk factors associated with suicidal ideations among this population.
Violence against transgender individuals is another risk factor that may contribute to
increased suicidal thoughts. Testa et al. (2012) found a significant relationship between
violence and suicidal ideation among 271 transgender individuals in the Virginia
Transgender Health Initiative Survey–those who reported being victimized more had
increased chances of suicidal ideation. Furthermore, research from Clements-Nolle,
Marx, and Katz (2006) demonstrated an association between increased victimization
and suicidal attempts among 392 transgender individuals in San Francisco. Additionally,
previous research found that experiencing any type of harassment or discrimination was
associated with increased risk for suicidal behaviors among a statewide sample of 350
transgender individuals (Rood, Puckett, Pantalone, & Bradford, 2015).
Meyer’s Minority Stress Theory (MST) posits that LGBT individuals experience worse
health outcomes, due to the chronic stress from identifying in a socially disadvantaged
group. Furthermore, ostracization from the predominant population in a society has
been linked to substance use (Meyer, 2003). Proximal and distal factors such as internal-
ized homophobia, emotional distress, and acceptance have all been linked to adverse
health outcomes (e.g., suicidal ideation). For example, one study found that due to
increased discrimination from society, a high percentage (64.9%) of transgender individ-
uals reported suicidal ideation (Rood et al., 2015).
While much research has investigated the relationship between experiencing discrim-
ination/harassment and suicidal ideation among transgender individuals, additional
research investigating correlates to suicidal ideation among transgender individuals has
been warranted (Wirtz, Poteat, Malik, & Glass, 2020). Secondly, the number of hate
crimes against the transgender community has risen (Veldhuis, Drabble, Riggle,
Wootton, & Hughes, 2018). The Human Rights Campaign (HRC) (2019) reported that
at least 19 transgender individuals, many of whom have been harassed or discriminated
against, have been killed by shooting or other violent means. It is important to elucidate
factors that may be associated with these acts so that preventative measures can be cre-
ated to mitigate this epidemic of violence. Moreover, to our knowledge, there is a
2 A. YOCKEY ET AL.
paucity of literature examining health experiences of nationally representative samples
of transgender individuals. Therefore, the present study sought to identify correlates to
suicidal ideation among a nationally representative sample of transgender individuals.
We hypothesized that a large percentage of individuals would endorse past-year suicide
ideation and would differ based on demographic and violence/harassment correlates.
METHOD
We conducted a secondary data analysis of the 2015 Transgender Survey. The 2015
Transgender Survey is the largest survey and first one conducted in the United States to
assess the experiences on a variety of social phenomena among transgender individuals.
Questions assessing health, health care, substance use, employment, mental health, and
housing were utilized. Data were collected from participants across all 50 states, the District
of Columbia, Samoa, Puerto Rico, and other military bases overseas. Prior to implementa-
tion, a pilot survey was conducted through an online test survey website to assess feasibility
and technicality. Among 100 individuals who participated, all feedback and suggestions
were added into the final survey to be distributed. The final survey was found to have high
interrater reliability (>80%) among the research team (James, Herman, Keisling, Mottet, &
Anafi, 2015). A University Institutional Review Board concluded the present study non-
human subjects and was therefore exempt from internal review.
Procedures
The population of interest were individuals who identified as transgender (i.e., individu-
als on the transgender spectrum, which included queer, genderqueer, non-binary, trans-
gender, trans, and other identities). Data were collected in the summer of 2015 over a
34-day period. Recruitment methods took place via several different modalities includ-
ing fliers, a website, photo booth campaign, and other communication efforts (e.g.,
social media). All surveys were conducted online to ensure participant confidentiality
and privacy. Moreover, data were ensured private through secure firewalls and servers
by the research team. As an incentive for completing the survey, participants were put
into a prize drawing raffle for a cash incentive. Other methods for procedures regarding
the survey are detailed elsewhere (James et al., 2015).
Measures
The present study utilized two sections of the survey: demographics/covariates and
victimization.
Demographics/Covariates
Questions assessing current gender, age, income, and race were asked. Gender was assessed
by the question: “What gender do you currently live in on a day-to-day basis?”(1 ¼
“Man,”2¼“Woman,”3¼“Neither man nor woman/Genderqueer/Non-binary,”4¼
“Part time one gender/part time another gender”). Age was asked and categorized in four
categories (18–24 years old, 25–44 years old, 45–64 years old, and 65þ). Race was assessed in
ARCHIVES OF SUICIDE RESEARCH 3
several categories. Income was asked in a categorical nature (“No income”to “$100,000þ”).
Family support was assessed by the question, “Yousaidsomeorallofyourimmediatefam-
ily you grew up with (mother, father, sisters, brothers, etc.) know that you are trans. On
average, how supportive are they of you being trans?.”For family support, we used the mul-
tiple-imputed variable provided the survey team. Answers were ordinal in nature (0 ¼
“Supportive,”1¼“Neutral,”2¼“Unsupportive”).
Psychological Victimization/Harassment
To assess past-year victimization and harassment, all participants were asked the ques-
tion, “How were you physically attacked in the past year? (Mark all that apply),”was uti-
lized. Option responses for this question included: “With a gun,”“With a knife,”“With
another weapon (like a baseball bat, frying pan, scissors, or a stick),”“By something
thrown (such as a rock or a bottle),”“By someone grabbing, punching, or choking you,”
“Unwanted sexual contact (such as rape, attempted rape, being forced to penetrate),”
and/or “Other Methods.”Responses were binary in nature (1 ¼“Yes,”0¼“No”).
Outcome Variable
Our dependent variable was past-year suicidal ideation. To assess past-year suicidal
ideation, the question, “The next few questions are about thoughts of suicide. At any
time in the past 12 months did you seriously think about trying to kill yourself?”, was
used. Answers were binary in nature (1 ¼“Yes”,0¼“No”).
Analytical Plan
We conducted analyses in Stata SE 15 (StataCorp, 2017) using the “svy”commands to
account for the complex sampling design, poststratification, weighting procedures, and
non-response (Heeringa, West, & Berglund, 2017). Missing data were minimal (<5%)
and handled with multiple imputation procedures. Weights provided by the National
Transgender Survey team were applied to all analyses to compensate for variable selec-
tion probabilities, oversampling, and possible sampling frame deficiencies. Prior to
application, weights were assessed for outlying values, skewness, and missing data, and
were addressed if any problems arose. We calculated frequencies to determine demo-
graphics of individuals and those who reported past-year suicidal ideation. Bivariate
relationships were conducted to assess significant associations between predictor varia-
bles of interest and past-year suicidal ideation using Rao-Scott X
2
tests for homogeneity,
which correct for the complex study design (Rao & Scott, 1987) We used multivariable
logistic regression to determine conditional associations, controlling for covariates. All
analyses were two-tailed and the level of significance was set at p<0.05.
RESULTS
Differences in Suicide Ideation Based on Demographics
A total of 27,715 respondents participated in the study (See Table 1). Of the sample,
33.9% (n¼9,418) identified as men, 29.8% (n¼8,271) identified as women, 20.6%
4 A. YOCKEY ET AL.
TABLE 1. Sample characteristics and correlates to past year suicidal ideation.
Variable
Full Sample,
N¼27,715
No Thoughts About
Suicide, n¼14,411,
Weighted %
Thought About
Suicide, n¼13,304,
Weighted % p
What Gender do you Live on a
Day to Day Basis?
<0.0001
Male 9,418 56.9 43.1
Female 8,271 52.0 48.0
Neither Man nor Woman/
Genderqueer/Nonbinary
5,721 47.0 53.0
Part time one gender/Part time
another Gender
4,305 45.8 54.2
Age <0.0001
18–24 Years Old 11,840 38.8 61.2
25–44 Years Old 10,987 56.5 43.5
45–64 Years Old 4,085 70.6 29.4
65þ803 85.1 14.9
Race <0.001
White 23,000 52.8 47.2
Alaska Native/American Indian 319 45.8 54.2
Asian/NH/PI Alone 786 55.2 44.8
Biracial/Multiracial 1,551 46.1 53.9
Black/African-American 796 52.5 47.5
Latino/a/Hispanic 1,473 47.5 52.5
Middle Eastern/North African 132 42.0 58.0
Individual Income <0.0001
$100,000 or more 1,634 74.1 25.9
$50,000–$99,999 3,237 69.4 30.6
$25,000–$49,999 4,477 63.0 37.0
$10,000–$24,999 6,110 51.2 48.8
$1–$9,999 7,756 40.3 59.7
No income 4,501 40.6 59.4
Family Support <0.0001
Supportive 19,000 54.6 45.4
Neutral 4,459 49.2 50.8
Unsupportive 3,787 39.8 60.2
Past Year Attacked with a Gun? <0.0001
No 27,642 51.9 48.1
Yes 73 15.8 84.2
Past Year Attacked with a Knife? <0.0001
No 27,555 51.9 48.1
Yes 160 22.1 77.9
Past Year Attacked with
Another Weapon?
<0.0001
No 27,489 52.0 48.0
Yes 226 23.8 76.2
Past Year Attacked By
Something Thrown?
<0.0001
No 26,616 52.7 47.3
Yes 1,099 28.4 71.6
Past Year Attacked Grabbed,
Punched, or Choked?
<0.0001
No 24,995 54.1 45.9
Yes 2,720 29.5 70.5
Past Year Attacked Unwanted
Sexual Contact?
<0.0001
No 26,720 52.9 47.1
Yes 995 21.6 78.4
Past Year
Attacked–Other Methods
<0.001
No 27,381 51.9 48.1
Yes 334 39.1 60.9
N¼27,715, percent refers to weighted valid percent; missing values excluded. Data are weighted, so percentages may
not necessarily add up exactly to 100%,
ARCHIVES OF SUICIDE RESEARCH 5
identified as neither/genderqueer/non-binary (n¼5,721), and 15.5% (n¼4,305) identi-
fied as part time one gender, part time another. Past-year suicidal ideation differed sig-
nificantly based on gender (p<0.001), age (p<0.001), race (p<0.0001), income
(p<0.001), family support (p<0.0001), and all violence measures (p<0.0001).
Multivariable Regression and Associations to Past-Year Suicide Ideation
Significant variables were entered into a multivariable binary logistic regression, adjust-
ing for covariates (e.g., age, race, gender, income) (See Table 2). Compared to
18–25 year olds, those who reported their age between 25 and 44 (aOR: 0.63; 95% CI,
0.58–0.69), 45–64 (aOR: 0.38; 95% CI, 0.34–0.43), and/or 65þ(aOR: 0.17; 95% CI,
0.14–0.22) reported decreased risk of thinking about suicide in the past year. Compared
to White individuals, individuals who identified as Asian/PI had a decreased odds of
thinking about suicide in the past year (aOR: 0.74; 95% CI: 0.63–0.88). Individuals who
TABLE 2. Multivariate logistic regression for past year suicide ideation.
Item aOR (95% CI)
Gender Identity
Man 1.00 –
Woman 1.76 1.47–2.10
Non-Binary/GenderQueer 1.48 1.25–1.75
Part Time One Gender/Part Time Another Gender 1.34 1.11–1.45
Age
18–24 years old 1.00 –
24–44 years old 0.63 0.58–0.69
45–64 years old 0.38 0.34–0.43
65þ0.17 0.14–0.22
Race
White 1.00 –
Alaska Native/American Indian 1.24 (0.97, 1.60)
Asian/NH/PI Alone 0.74 (0.63, 0.88)
Biracial/Multiracial 1.09 (0.96, 1.23)
Black/African American 0.96 (0.82, 1.13)
Latino/a/Hispanic 1.05 (0.93, 1.19)
Middle Eastern/North African 1.24 (0.85, 1.81)
Income
$100,000þ1.00 –
$50,000–$99,999 1.16 (0.97, 1.38)
$25,000–$49,999 1.36 (1.16, 1.61)
$10,000–$24,999 1.82 (1.55, 2.14)
$1–$9,999 2.26 (1.91, 2.67)
No Income 2.22 (1.85, 2.65)
Family Support
Supportive 1.00 –
Neutral 1.18 1.08–1.30
Unsupportive 1.70 1.53–1.88
Past-Year Violence
Attacked with a Gun 2.77 1.30–5.89
Attacked with a Knife 1.22 0.64–2.31
Attacked with Another Weapon 1.19 0.76–1.87
Attacked by Something Thrown 1.44 1.16–1.80
Attacked–Grabbed, Punched, or Choked 1.79 1.56–2.05
Attacked–Unwanted Sexual Contact 1.78 1.39–2.29
Attacked–Other Methods 1.19 0.83–1.72
N¼27,715; missing values excluded. p<0.001; p<0.01, p<0.05. Boldface indicates statistical signifi-
cance (p<0.05)
6 A. YOCKEY ET AL.
reported low income, compared to those who had $100,000þ, had a significant
increased odds of thinking about suicide, with the highest risk for individuals who
reported no income (aOR: 2.22; 95% CI 1.85–2.65). Compared to men, women (aOR:
1.76; 95% CI: 1.47–2.10), non-binary/genderqueer individuals (aOR: 1.48, 95% CI
1.25–1.75), and individuals who lived part time one gender/part time another (aOR:
1.34, 95% 1.11–1.45) had an increased risk of reporting suicide ideation in the past
year. Individuals who reported neutral (aOR: 1.18; 95% CI: 1.08–1.30) or an unsupport-
ive family (aOR: 1.70; 95% CI: 1.53–1.88) was associated with higher odds of thinking
about suicide in the past year. Regarding victimization, transgender individuals who
reported being attacked with a gun (aOR: 2.77; 95% CI 1.30–5.89), something thrown
(aOR: 1.44; 95% CI 1.16–1.80), grabbed/punched/choked (aOR: 1.79; 95% CI 1.56–2.05),
and/or had unwanted sexual contact (aOR: 1.78; 95% CI 1.39–2.29) had significantly
higher odds of thinking about suicide in the past year.
CONCLUSIONS
The present study utilized a large, nationally representative sample of transgender indi-
viduals across the United States. Nearly five out of ten transgender individuals reported
thinking about suicide in the past year, which is higher than previous research (38%,
respectively) (Barboza, Dominguez, & Chance, 2016; Tucker, Testa, Reger, Simpson,
Shipherd, & Lehavot, 2019). Such an alarming percentage warrants increased need for
public health attention to this issue. Studies are needed to more thoroughly examine
reasons why suicidal ideation is high among transgender individuals.
The present study assessed novel risk factors associated with past-year suicide idea-
tion including different types of victimization, gender identity, and age. Many demo-
graphic factors such as current gender and gender identity were associated with a
higher odds of thinking about suicide, concurrent with previous literature (Clements-
Nolle et al., 2018). Different gender identities encompass certain psychological and per-
sonality characteristics and behaviors that may be discriminated against, due to societal
norms. Furthermore, increased age and identifying as Asian or Pacific Islander had the
opposite effect–a decreased risk for thinking about suicide. Certain cultural barriers
(e.g., acceptance) in the Asian culture may be protective against suicide (Leong, Leach,
Yeh, & Chou, 2007). A novel finding in this population, as age increased, the risk for
thinking about suicide decreased. Perhaps as one ages, different coping mechanisms are
utilized which serve as protective factors against suicidal ideation (Rood et al., 2015). It
could also be the case that increased age is accompanied with increased self-acceptance
with one’s gender identity. Individuals may become more comfortable and understand-
ing with who they are and place less emphasis on what others want them to be accord-
ing to societal norms.
Individuals who reported low annual incomes (<$25,000) were more likely to think
about suicide compared to those who reported a higher income. Blakely, Collings and
Atkinson (2003) reported an association between unemployment rates/low incomes and
suicidal behaviors among people living in New Zealand. Individuals with low levels of
financial capital may experience economic hardships which can lead to increased anx-
iety, worry and feelings of self-doubt; all of which are risk factors for suicidal ideation
ARCHIVES OF SUICIDE RESEARCH 7
(American Psychiatric Association (APA), 2013). Research has found that individuals
who are transgender tend to report low levels of income and high levels of discrimin-
ation at work; therefore, economic opportunities to advance in society may be difficult
to come by (Bradford, Reisner, Honnold, & Xavier, 2013). Income levels and suicidal
ideation among transgender individuals needs to be further researched.
Individuals who reported neutral or lack of family support reported increased odds of
thinking about suicide in the past year. Family support is multi-dimensional, encompass-
ing several aspects including warmth, love, and togetherness (Yockey, King, & Vidourek,
2019) Moreover, family support serves as a protective factor against engaging in a vast
array of inimical health consequences (e.g., suicidal thoughts and behaviors) as well as
depression (Aquilino, 2006) Family support also contributes to increased self-esteem/sub-
jective well-being (Aquilino, 2006). Family systems theory states that increased family sup-
port is important for the development of well-being and positive development
(Rothbaum, Rosen, Ujiie, & Uchida, 2002). Previous research has shown an association
between lack of family support and elevated tendencies of suicidal behavior among trans-
gender individuals (Klein & Golub, 2016). As a result of low support from family and
friends (Rothbaum et al., 2002), transgender individuals may turn to thinking about sui-
cide as a coping strategy for their difficulties with life. Intervention techniques such as
increased acceptance therapy, affirmative psychotherapy (e.g., positive stance toward
accepting oneself and having others accept transgender individuals), and family support
may prove useful for strengthening connectedness among transgender individuals and
families (Riley, Wong, & Sitharthan, 2011). Future research may examine specific aspects
of family support and suicidal ideation among transgender individuals.
Concurrent with previous literature (Barboza et al., 2016), enduring different types of
victimization was significantly associated with suicidal ideation. Being victimized or
attacked is associated with poor mental health, degradation of self-worth, and increased
risk for suicide (Garnets, Herek, & Levy, 1990). Baumeister (1990) posited individuals
attempt suicide as a way to “escape”the self or current stressful situations. Since trans-
gender individuals report high levels of victimization (Perez-Brumer et al., 2015; Wirtz
et al., 2020), thinking about suicide may be viewed by some as a possible “escape”from
victimization. Enhancement of coping mechanisms (e.g., thinking positively, changing
thoughts, increasing self-confidence, verbalizing feelings to others, utilizing effective
mental health coping skills) may prove useful when attempting to reduce rates of sui-
cidal ideation. Support groups with individuals who have been victimized can prove
useful, as they can show individuals they are not alone and there are others who can
specifically relate to and understand their situation and subsequent feelings (Garnets et
al., 1990; Riley et al., 2011).
While this study provides important insights into suicidal ideation among a large
national sample of transgender individuals, limitations should be noted. First, data were
self-reported, so under/over-reporting may occur. Data were cross-sectional in nature;
thus, causal relationships could not be determined.
This is one of the first studies examining correlates to suicidal ideation among a
large, national sample of transgender individuals in the United States. Individuals who
reported low income, low family support, different types of victimization, gender, and
unique gender identities were at increased risk for suicidal thoughts in the past year.
8 A. YOCKEY ET AL.
It is important for public health educators, mental health professionals, and policy ana-
lysts to collaborate in educating public understanding regarding suicidal ideation among
transgender individuals as well as to develop and implement data-based interventions
aimed to decrease rates of suicidal ideation among this population.
AUTHOR NOTES
Andrew Yockey, Health Promotion and Education Program, School of Human Services, College
of Criminal Justice, Education, and Human Services, University of Cincinnati, OH. Center for
Prevention Science, Cincinnati, OH.
Keith King, Health Promotion and Education Program, School of Human Services, College of
Criminal Justice, Education, and Human Services, University of Cincinnati, OH. Center for
Prevention Science, Cincinnati, OH.
Rebecca Vidourek, Health Promotion and Education Program, School of Human Services,
College of Criminal Justice, Education, and Human Services, University of Cincinnati, OH.
Center for Prevention Science, Cincinnati, OH.
Correspondence concerning this article should be addressed to Robert Andrew Yockey, MS,
Graduate Assistant; Health Promotion and Education Program, 2600 Clifton Avenue, Cincinnati,
OH 45221-0068, USA; E-mail: yockeyra@mail.uc.edu
ORCID
Andrew Yockey http://orcid.org/0000-0002-2140-2418
Rebecca Vidourek http://orcid.org/0000-0001-8151-0288
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