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Self Harming Behaviour
Clinical Child Psychology
and Psychiatry
2022, Vol. 27(3) 716–729
© The Author(s) 2022
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/13591045211073941
journals.sagepub.com/home/ccp
Suicidal and nonsuicidal self-harming
thoughts and behaviors in clinically
referred children and adolescents
with gender dysphoria
Amelie Hartig
1
, Catharina Voss
1,2
, Lena Herrmann
1
,
Saskia Fahrenkrug
1
, Carola Bindt
1
and Inga Becker-Hebly
1
1
Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, University Medical Center
Hamburg-Eppendorf, Hamburg, Germany
2
Behavioral Epidemiology, Institute of Clinical Psychology and Psychotherapy, Technical University Dresden, Dresden,
Germany
Abstract
Background: Young transgender or gender nonconforming (TGNC) children and adolescents or
those with a gender dysphoria (GD) diagnosis show an increased risk of suicidal and nonsuicidal self-
harming thoughts and behaviors (STBs). Data from German-speaking regions on this topic and
studies comparing self- and parent-reported STBs have been scarce. The study aims were therefore
to examine: (a) frequencies of self- and parent-reported STBs in a German clinical sample of
children and adolescents with GD and (b) differences between age and gender groups, as well as
between self- and parent-reports.
Methods: Two items from the Child Behavior Checklist (CBCL) and the Youth Self-Report (YSR)
were used to assess self- and parent-reported STBs in a sample of 343 adolescents and 49 children
who presented to the Hamburg Gender Identity Service (Hamburg GIS) between 2013 and 2019.
Seventy-eight percent of the analysis sample was assigned female at birth (AFAB), and 22% were
assigned male at birth (AMAB).
Results: Parents reported STBs on the CBCL for 16% and 6% of the cases in childhood and for 20% and
29% of the adolescent cases, respectively. STBs were self-reported by 38% and 45% of the adolescents
who could report on the YSR. STBs were higher among adolescents than among children and in self-
reports (YSR) compared to parent reports (CBCL). AFAB adolescents reported higher degrees of STBs
than AMAB adolescents.
Conclusions: Children and adolescents with GD are a high-risk population for STBs, especially
pubescent and AFAB individuals. Mental health professionals should screen early for STBs to
prevent possible suicidal ideation-to-action transitions.
Corresponding author:
Inga Becker-Hebly, Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, University
Medical Center Hamburg-Eppendorf, Martinistraße 52, W29, Hamburg 20246, Germany.
Email: i.becker@uke.de
Keywords
adolescence, suicidal behavior, self-harm, gender dysphoria, transgender
Introduction
Young transgender or gender nonconforming (TGNC) populations are faced with different chal-
lenges early in life. Youth with a gender dysphoria (GD) diagnosis (according to the DSM-5) often
wish to undergo a social and medical gender transition to alleviate the experienced distress resulting
from gender incongruence or a persistent identification with a gender other than the sex assigned at
birth (American Psychiatric Association, 2013;Becker et al., 2017;Coleman et al., 2012). Ac-
cording to two population-based studies, between 1.8% and 2.7% of high school students from the
US were identified as transgender (Johns et al., 2019;Rider et al., 2018), and in a survey from
middle schools, 1.3% of students (grades 6–8) self-identified as transgender (Shields et al., 2013).
For Germany, Becker et al. (2017) reported gender incongruence among 0.9% of adolescents aged
10–16 years old in a school-based population. Individuals assigned male at birth (AMAB) and
identifying as female are often addressed as transfemale and those assigned female at birth (AFAB)
and identifying as male as transmale (Newcomb et al., 2020). Gender experiences of TGNC in-
dividuals, however, can include a variety of gender identifications. Beyond the binary under-
standing of gender, TGNC individuals sometimes do not (entirely) identify as either female or male
(i.e., nonbinary and genderqueer).
Children and adolescents with GD or who identify as TGNC report increased mental health
problems (Becerra-Culqui et al., 2018;Connolly et al., 2016;de Graaf et al., 2018;Levitan et al.,
2019;Newcomb et al., 2020;Su et al., 2016), including suicidal and nonsuicidal self-harming
thoughts and behaviors (STBs) (Aitken et al., 2016;Arcelus et al., 2016;de Graaf et al., 2020;
Grossman & D’Augelli, 2007;Heino et al., 2021;Skagerberg et al., 2013;Taliaferro et al., 2019;
Thoma et al., 2019).
Suicide was defined as the second most common cause of death in youths in the general
population in 2016 by the World Health Organization (World Health Organization, 2019). STBs are
even more common in adolescents than actual suicides (Nock et al., 2013;Voss et al., 2019,2020)
and are associated with a broad range of negative (long-term health) outcomes (Brière et al., 2015;
Resch et al., 2008;Steinhausen & Metzke, 2004). Suicidal thoughts or behaviors include suicidal
ideation, plans and attempts with the intention to die (O’Connor & Nock, 2014). Nonsuicidal self-
injury (NSSI) means self-harming without any intention to kill oneself and can function as a form of
self-punishment or regulation of feelings and emotions (Claes & Vandereycken, 2007).
In the 1991 version of the Child Behavior Checklist (CBCL) or Youth Self-Report (YSR), two
items can be used to assess STBs in children and adolescents from different (parental and youth)
perspectives referring to the previous 6 months; however, these do not distinguish between suicidal
and nonsuicidal behaviors (Achenbach, 1991a,1991b). In a random general population sample
from Germany, suicidal ideation/thoughts were reported by 3.8%, and self-harming behavior and
suicide attempts by 2.9% of adolescents (aged 11–17 years old), with comparably lower parent-
reported rates: 2.2% and 1.4%, respectively (Resch et al., 2008).
Among transgender populations, suicide rates are nearly four times higher than in the general
population; for example, Wiepjes et al. (2020) reported 40 per 100.000 compared to 11 per 100.000
deaths in the Dutch general population. Existing studies have indicated an elevated risk for committing
suicide in both transgender children and adolescents, as well as a high prevalence of STBs independent
of the respective sample selection (general population, community-based or clinical samples;
Hartig et al. 717
Surace et al., 2021). For example, in a recent meta-analysis, Surace et al. (2021) summarized the overall
risk of suicidal behavior and NSSI for young TGNC clinical populations (age up to 25 years old) and found
a mean prevalence of 28.2% for NSSI, 28.0% for suicidal ideation and 14.8% for suicide attempts. Aitken
et al. (2016) conducted a study to examine the prevalence of suicidality and behavioral problems among
children aged 3–12 years old referred to a gender clinic and compared these measures with three control
groups: siblings, children referred to a clinic for other reasons, and nonreferred children. The group of
gender-referred children was 15 times more likely to talk or think about suicide and 32 times more likely to
engage in suicide attempts/self-harm than the nonreferred group. Among pubescent adolescent populations
with GD, the prevalence of STBs is higher than that in prepubescent children, and there seem to be gender
differences (Becker et al., 2014;Holt et al., 2016;Skagerberg et al., 2013). When examining transgender
adolescents aged 10–17 years old, AFAB people were 144 times more likely to self-harm than a reference
group of male youth. Similarly, suicidal ideation seemed to be 45 times more frequent in AFAB people than
in reference males, and AMAB people were 31 times more likely to think about suicide than reference
females (Becerra-Culqui et al., 2018). De Graaf et al., (2020) found that STBs were more frequently reported
by AFAB adolescents than by AMAB adolescents. Additionally, some studies have found evidence for
more suicidal and nonsuicidal actions in AFAB individuals and more suicidal ideation in AMAB indi-
viduals (Holt et al., 2016;Ream, 2019;Skagerberg et al., 2013;Toomey et al., 2018). In contrast, the results
of Fisher et al. (2017) and Newcomb et al. (2020) showed that young AFAB individuals were more likely to
think about suicide, while young AMAB individuals, in contrast, were more likely to carry out self-harming
actions.
Aims of the study
Multiple studies from around the world have shown that clinical populations of TGNC youth or
youth with GD present higher prevalence rates of different types of STBs. However, studies in this
population remain scarce (Cha et al., 2018), and there have only been a limited number of clinical
studies from the German-speaking part of Europe focusing on children and adolescents with GD
(e.g., Becker et al., 2014;Levitan et al., 2019). The present clinical descriptive study aims to explore
STBs in a German clinical population of children and adolescents aged 5–18 years old who received
a GD diagnosis at the Hamburg Gender Identity Service (GIS) from different perspectives.
The following research questions are addressed in the present study: a) How often do parents of
children and adolescents, as well as adolescents with a GD diagnosis, report different aspects of STB
(self-harming behavior/suicide attempts vs. suicidal ideation/thoughts)? b) Do children (5–10 years
old) and adolescents (11–18 years old) differ with regard to STBs (as reported by parents on the
CBCL)? c) Do AMAB and AFAB children and adolescents differ regarding their STBs (as reported
by either parent- or self-reports)? and d) Do parent- and self-reported degrees in suicidality scores
(on the CBCL and YSR) reported for the adolescent population differ from each other?
Methods
Study design and sampling
The present study was part of a clinical research project addressing TGNC youth and those with a GD
diagnosis in childhood (aged 5–10 years old) and adolescence (aged 11–18 years old), as well as their
caregivers/parents, in a specialized clinical unit for GD at the University Medical Center Hamburg-
Eppendorf (Hamburg GIS). The department provides specialized care to children and youths with
questions around their gender identity when they self-identify as transgender or experience GD and related
718 Clinical Child Psychology and Psychiatry 27(3)
distress. A multidisciplinary team consisting of specialized psychiatrists, psychologists and endocrinol-
ogists provides assessment, diagnostic, psychotherapeutic and medical treatment for TGNC youth and their
families. After several sessions with the child/adolescent and their caregivers, the corresponding clinicians
complete a therapeutics-based questionnaire, including a DSM-5 checklist on GD criteria.
Data collection occurred during the first visit to the Hamburg GIS before receiving any treatment.
All individuals who visited the Hamburg GIS between September 2013 and December 2019 (N=
859 families; 74% AFAB) were invited to voluntarily participate in a questionnaire-based research
project. Written informed consent was obtained from all of the participants (including caregivers
and adolescents themselves) according to guidelines from the local ethical institution.
The exclusion criteria for participation were insufficient understanding of the German language and a
current severe psychiatric disease (e.g., psychosis). Figure 1 shows the referral rates, study participants and
sex ratios at the Hamburg GIS. A total of N= 859 families were referred between September 2013 and
December 2019. Of these families, n= 278 families chose not to participate, and n= 103 dropped out due
to missing data. Furthermore, n= 51 families were excluded because they had sought help or treatment
prior to attending the Hamburg GIS, and n= 35 did not fulfill the diagnostic criteria for GD (neither
criterion A nor B of the DSM-5 definition). This process resulted in a total of n= 392 datasets eligible for
study analysis. The final analysis sample consisted of n=49children(aged5–10 years old) and n= 343
adolescents (aged 11–18 years old) with a diagnosis of GD or ongoing diagnostic procedure (TGNC) (see
Figure 1). For a detailed description of the sampling and sample, please also refer to Levitan et al. (2019).
Measures
During their first visit, participating families were invited to complete a set of questionnaires that
included, among others, a self-constructed questionnaire on sociodemographic characteristics and
the German versions of the Child Behavior Checklist (CBCL; Achenbach, 1991a;D¨
opfner et al.,
1998a) and the Youth Self-Report (YSR; Achenbach, 1991b;D¨
opfner et al., 1998b).
With regard to sociodemographic characteristics, the present study analyzed the age at as-
sessment and the sex assigned at birth. For more sociodemographic details on a previous sample
from the same study, please refer to Levitan et al. (2019).
The CBCL and the YSR are standardized measures for emotional and behavioral problems that
are completed by caregivers/parents (for children and adolescents aged 4–18 years old) and ad-
olescents (aged 11–18 years old), respectively. The German versions of the CBCL and YSR were
found to be reliable and valid (D¨
opfner et al., 1994,1995). For adolescents (aged 11 years old and
older), both the YSR and CBCL were used to obtain self- and parent-reported information, whereas
for children (5–10 years old), only the CBCL was used to obtain parent-reported information.
Suicidal and nonsuicidal self-harming thoughts and behaviors
STBs comprising either suicidal ideation or NSSI (self-harming behavior) and suicide attempts were
assessed using the following two items from the CBCL (Achenbach, 1991a)orYSR(Achenbach, 1991b).
Self-harming behavior and suicide attempt
Intentionally hurting or attempting suicide was assessed using Item 18 from the YSR/11–18 (“I
deliberately try to hurt or kill myself”). Item 18 from the CBCL/4–18 (“Deliberately harms self or
attempts suicide”) was used to evaluate parent-reported perceptions of self-harm or attempts of their
Hartig et al. 719
children to kill themselves. Like all of the items from the CBCL or YSR, Item 18 was rated on a
scale from 0 to 2 (0 = “not true,”1=“somewhat or sometimes true,”2=“very true or often true”).
Suicidal ideation/thoughts
Item 91 from the YSR/11–18 (“I think about killing myself”) was used to measure suicidal ideation/
thoughts directly via adolescents’self-reports. Information was also obtained from a parent or other
guardian asking whether their children ever talked about killing themselves using Item 91 from the
CBCL/4–18 (“Talks about killing self”). Like all of the items from the CBCL or YSR, Item 91 was rated
onascalefrom0to2(0=“not true,”1=“somewhat or sometimes true,”2=“very true or often true”).
Statistical analysis
Data were analyzed using SPSS software, version 22.0. Prevalence rates including 95% confidence
intervals (95% CIs) were determined for self- and parent-reports and for self-harming behavior/
suicide attempts and suicidal ideation, separately. An overall sum score out of Items 18 and 91 from
the CBCL/YSR was created, resulting in the Sum Suicidality Index (SSI) with a range of 0–4to
compare degrees of different aspects of suicidality/STBs among children and adolescents and to
Figure 1. Referral rates and study participation at the Hamburg gender identity service for children and
adolescents.
720 Clinical Child Psychology and Psychiatry 27(3)
evaluate gender differences and differences between the self-reported and parent-reported data. Group
comparison was conducted using the ttest. Tests were performed with a 2-sided alpha level of .05.
Results
Sociodemographic features
Table 1 summarizes the sociodemographic characteristics of the participants. The analysis sample of
adolescents (n= 343, 87%) consisted of 84% AFAB people and 16% AMAB people with a mean
age of 15.5 years, and there were no significant age differences between AFAB and AMAB
adolescents. The sample further included 49 children (13%), of whom 39% were AFAB and 61%
were AMAB (mean age M= 8.2, with a total range between 5.2 and 10.9). Regarding the sex ratio of
the total sample, 78% were AFAB and 22% were AMAB. AFAB individuals were on average
15 years old (with a range between 11.0 and 18.5), whereas AMAB individuals presented at the
Hamburg GIS at a significantly younger age of approximately 13 years.
Suicidal and nonsuicidal self-harming thoughts and behaviors
Table 2 reports descriptive frequencies for different aspects of STBs according to the CBCL and
YSR parent- and self-reports.
Frequencies of self-harming behavior and suicide attempts
Regarding self-harming behaviors and suicide attempts (Item 18), 2% of the caregivers/parents
reported often and 4% sometimes such behaviors in their children (total: 6%). For adolescents, 9.5%
of the parents reported often, and 20% sometimes reported such behaviors (total: 29%). Examining
adolescents’self-reports, 19% reported often and 26% sometimes such behaviors (any in total:
45%).
Table 1. Sex ratio and age distribution in the total sample, in children (aged 5–10), and adolescents
(aged 11–18).
Total AFAB AMAB Group comparison
tdfp
Total sample
(N= 392)
Gender n (%) 392 (100.0) 306 (78.1) 86 (21.9)
Age M (SD) 14.56 (2.88) 15.02 (2.16) 12.89 (4.20) 4.548 97.954 .000***
Children
(n= 49)
Gender n (%) 49 (100.0) 19 (38.8) 30 (61.2)
Age M (SD) 8.18 (1.91) 9.01 (1.70) 7.65 (1.88) 2.556 47 .014*
Adolescents
(n= 343)
Gender n (%) 343 (100.0) 287 (83.7) 56 (16.3)
Age M (SD) 15.47 (1.51) 15.42 (1.50) 15.69 (1.58) -1.223 341 .222
Note. AFAB = individuals assigned female at birth; AMAB = individuals assigned male at birth.
Group comparison was conducted using two-tailed t-tests. ***p< .001; *p< .05.
Hartig et al. 721
Frequencies of suicidal ideation/thoughts
Regarding suicidal ideation/thoughts (Item 91), none of the caregivers/parents reported often,and
16% reported sometimes suicidal ideation/thoughts for their children (total: 16%). For adolescents, 2%
of the parents reported often, and 18% reported sometimes such thoughts (total: 20%). Examining
adolescents’self-reports, 13% reported often and 25% sometimes suicidal thoughts (total: 38%).
Sum suicidality index: Differences between age and gender groups
Table 3 shows the descriptive results of the SSI measuring total scores of suicidality/STBs, as well
as age, gender group, and parent- versus self-report differences.
According to the evaluation of parent reports, the SSI reported by caregivers/parents for ad-
olescents was M= 0.61 and M= 0.25 for children. The scores differed significantly from each other,
implying that parents reported significantly less STBs for children than adolescents.
Comparing parent-reported outcomes of STBs between AFAB and AMAB children revealed
similar SSI scores for both gender groups. The SSI was M=0.21 for AFAB children and M= 0.27
for AMAB children, showing no significant differences.
Table 2. Parent- and self-reported aspects of STBs in children (aged 5–10) and adolescents (aged 11–18)
according to both CBCL and YSR
Self-harming behavior/suicide attempt (item 18) None Sometimes Often Any total
n (%) n (%) n (%) n (%)
[95% CI] [95% CI] [95% CI] [95% CI]
CBCL parent-report on children (n= 49) 46 (93.9) 2 (4.1) 1 (2.0) 3 (6.1)
87.9–100.0 0.0–9.3 0.0–5.5 0.0–9.3
CBCL parent-report on adolescents (n= 343) 243 (70.8) 67 (19.5) 33 (9.5) 100 (29.0)
66.1–75.7 15.1–23.9 6.9–12.9 6.9–23.9
YSR self-report in adolescents (n= 343) 188 (54.8) 89 (25.9) 66 (19.2) 155 (45.1)
49.4–60.3 21.2–30.9 15.5–23.4 15.5–30.9
Suicidal ideation/thoughts (item 91)
None Sometimes Often Any total
n (%) n (%) n (%) n (%)
[95% CI] [95% CI] [95% CI] [95% CI]
CBCL parent-report on children (n= 49) 41 (83.7) 8 (16.3) 0 (0.0) 8 (16.3)
72.1–94.1 5.9–27.9 0.0 -0.0 0.0–27.9
CBCL parent-report on adolescents (n= 343) 275 (80.2) 61 (17.8) 7 (2.0) 68 (19.8)
76.0–84.2 13.8–21.9 0.8–3.7 0.8–21.9
YSR self-report in adolescents (n= 343) 212 (61.8) 87 (25.4) 44 (12.8) 131 (38.2)
56.4–66.8 21.3–30.6 9.3–15.9 9.3–30.6
Note. AFAB = individuals assigned female at birth; AMAB = individuals assigned male at birth; CBCL = Child Behavior
Checklist; STBs = suicidal and nonsuicidal self-harming thoughts and behaviors; SSI = Sum Suicidality Index; YRS = Youth Self-
Report.
722 Clinical Child Psychology and Psychiatry 27(3)
AFAB adolescents self-reported the highest SSI of all groups (M= 1.24) and showed signif-
icantly higher SSI than AMAB individuals (M= 0.71).
Comparing adolescents’self- and parent-reported SSI scores showed significant differences,
revealing a significantly higher degree of STBs on the SSI for adolescents (M= 1.15) than in reports
made by their respective caregivers/parents (M= 0.61).
Discussion
The current study addressed a gap in the existing literature considering STBs in clinically referred
children and adolescents with GD from the German-speaking part of Europe. The aim was to
examine prevalence rates of STBs or degrees of suicidality and differences between children and
adolescents, gender groups and self-reported versus parent-reported outcomes in a large clinical
sample of children and adolescents with GD. Our findings emphasize the high risk of STBs in both
children and adolescents with GD, reported via both self- and parent-reports. Since information
from both caregivers/parents and the clinically referred youth themselves was obtained for ado-
lescents, this comparison of self-reported and parent-reported outcomes (YSR vs. CBCL) is a
considerable strength of the study.
The present results on STBs reported by caregivers/parents of children aged 5–11 years old (6%
reported self-harming or suicide attempts, and 16% reported suicidal ideation/thoughts on the
CBCL) are in line with a similar study assessing children with GD conducted by Aitken et al.
(2016), who reported approximately 7% and 19%, respectively, for Canadian children aged 6–
12 years old. Holt et al. (2016) underscored these outcomes in another clinical study from the UK by
showing that approximately 15% of their assessed children aged 5–11 years old engaged in suicidal
thoughts, 2.5% in suicide attempts and 15% in self-harm.
Table 3. Comparison of degrees of suicidality/STBs between children (aged 5–10) and adolescents (aged 11–
18) as well as self- and parent-reports according to the sum suicidality index (SSI)
A
.
SSI Group comparison
M (SD) t df p
Age groups (parent-reported SSI, CBCL) 3.468 84.892 .001**
Children (n= 49) 0.25 (0.63)
Adolescents (n= 343) 0.61 (0.97)
Childhood gender groups (parent-reported SSI, CBCL) 0.301 47 .765
AFAB (n= 19) 0.21 (0.54)
AMAB (n= 30) 0.27 (0.69)
Adolescent gender groups (self-reported SSI, YSR) 3.083 90.338 .003**
AFAB (n= 287) 1.24 (1.38)
AMAB (n= 56) 0.71 (1.12)
Self- and parent-reported SSI for adolescents (CBCL vs.
YSR)
9.043 342 .000***
CBCL parent-report (n= 343) 0.61 (0.97)
YSR self-report (n= 343) 1.15 (1.35)
Note. AFAB = individuals assigned female at birth; AMAB = individuals assigned male at birth; CBCL = Child Behavior
Checklist; SSI = Sum Suicidality Index (sum score out of items 18 and 91); YRS = Youth Self-Report.
A
SSI has a range from 0 to 4. Group comparison was conducted using two-tailed t-tests. ***p< .001; **p<.01.
Hartig et al. 723
GD can be exacerbated by puberty, thus leading to more mental health problems. This is in
accordance with the current study, which indicated that adolescents reported even higher degrees of
overall STBs than children. When the percentages of answers rated (1) or (2) were combined, a total
of 45% of the adolescent sample self-reported self-harming or suicide attempts, and 38% reported
suicidal ideation/thoughts (on the YSR) - nearly half of the sample. These numbers are similar to a
recent cross-national study by de Graaf et al. (2020), who found that between 15% and 45% of their
adolescent samples across different clinics in Canada, the Netherlands and the UK self-reported self-
harming or suicide attempts, and 27%–55% reported suicidal thoughts. The results are also in line
with previously reported numbers from a German chart review from the same clinic: Becker et al.
(2014) reported that 40% of their clinical sample had experienced suicidal thoughts, 30% self-
harmed, and 12% had attempted suicide in the past. Similarly, Holt et al. (2016) reported that
approximately 40% of their adolescent sample had thoughts of killing themselves, 44% self-
harmed, and 16% had attempted suicide.
Unfortunately, a distinction between self-harm and suicide attempts was not obtained in the
current study due to assessment method limitations of the CBCL/YSR; therefore, a direct com-
parison with some of the previous studies could not be achieved. When comparing the present
results to findings from a general population sample aged 11–17 years old from Germany; however
(suicidal ideation/thoughts in approximately 4% and self-harming behavior in approximately 3% of
the population; Resch et al., 2008), individuals with a diagnosis of GD showed an increased risk for
STBs compared to the German normal population.
AFAB adolescents presented a higher mean value on the SSI and thus a significantly higher
degree of STBs/suicidality than AMAB adolescents. This finding is in line with previous studies
highlighting possible gender differences between AFAB and AMAB youth and possible conse-
quences for their mental health (Arcelus et al., 2016;de Graaf et al., 2020;Fisher et al., 2017;Holt
et al., 2016;Newcomb et al., 2020;Ream, 2019;Skagerberg et al., 2013;Thoma et al., 2019;
Toomey et al., 2018). Arcelus et al. (2016) specifically observed NSSI among trans youth from the
UK. The authors concluded that, although AMAB individuals might experience more stigmati-
zation and preconceptions, AFAB youth might seem to cope differently with distress, apparently
self-harming without any intention of killing themselves. Therefore, identifying the risks for the
respective gender group and developing distinctive treatment concepts appear to be crucial in order
to support each individual properly.
Furthermore, the present study underscores that caregivers/parents of adolescents with GD are
often aware of the degree of suicidality or distress in their children, but differently than when
addressing adolescents themselves. Since young TGNC individuals likely know best how they are
feeling but might not constantly discuss their worries, family members might not always have
correct insight into what is truly going on and might fail to predict risky behaviors, a result that has
also been reported for the general population of youth in Germany (Resch et al., 2008). On the one
hand, this result is therefore nothing “TGNC specific”but rather is “typical”for the sensitive period
of adolescence. On the other hand, it highlights the need to include caregivers/parents or families in
the treatment progress of youth with GD to facilitate support and mutual understanding (Levitan
et al., 2019).
Limitations
The current study examined clinically referred individuals and so might have underestimated the
true numbers of STBs in the German TGNC population since young individuals not seeking help
because of their GD-related distress were not included. Furthermore, the significant difference in the
724 Clinical Child Psychology and Psychiatry 27(3)
sample size of AFAB (78%) and AMAB individuals (22%) tends to limit the conclusions of the
study. We did not differentiate between possible transgender or nonbinary identities. In addition, the
sample of children was relatively small compared to the adolescent sample, which might reduce
the generalizability of the results.
The evaluation of STBs was based on only two items from the CBCL/YSR questionnaires,
leading to another methodological limitation. Regarding Item 18 from both the CBCL and YSR, no
distinction between a definitive indicator of suicidality, as in “attempting to kill oneself,”and a “self-
harming behavior,”perhaps without any relation to suicidality, could be determined. These two
terms were combined into one item, which did not allow for a differentiation between NSSI and
actual suicide attempts.
Conclusions
As one of the first studies in the German-speaking parts of Europe assessing a large clinical sample
of young individuals with a GD diagnosis, this study adds considerable value to the current state of
the literature. The findings particularly emphasize the need to screen for signs of STBs in TGNC
populations and to provide adequate care that tends toward possible mental health problems and
suicidality in TGNC youth or those with a GD diagnosis. Different prevention approaches exist,
although not specifically for this population (Zalsman et al., 2016). In this age group, the de-
velopment of new technologies using real-life approaches might be a useful target. The present
study does not draw conclusions about the source of suicidality in TGNC youth. However, external
stressors, such as one’s own family and peers, have been identified as key factors in previous studies.
Furthermore, enabling and improving access to care and treatment options for individuals with GD
are essential. Future research is needed to help this population at risk to attend to STBs more
adequately and to prevent suicide attempts. Identification of difficulties from the beginning and
intervening at an early stage are key to the protection of TGNC individuals or those with a GD
diagnosis.
Acknowledgments
We thank all the families who contributed to the study by participating in the first place and providing their
personal information. We also thank all the clinicians and colleagues for their effort they put in the data
collection and their contributions within the interdisciplinary team in Hamburg.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or
publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iDs
Lena Herrmann https://orcid.org/0000-0002-7703-292X
Inga Becker-Hebly https://orcid.org/0000-0002-6007-2247
Catharina Voss https://orcid.org/0000-0002-5039-1949
Hartig et al. 725
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