Demographic and psychosocial factors associated with recent suicidal ideation and suicide attempts among trans and gender diverse people in Australia

Rosenberg S., Callander D., Holt M., Duck-Chong L., Pony M., Cornelisse V., Baradaran A., Duncan D.T., Cook T.

Transgender and gender diverse people have unique risks and needs in the context of sexual health, but little is known about sexual health care for this population. In 2018, a national, online survey of sexual health and well-being was conducted with trans and gender diverse people in Australia (n = 1,613). Data from this survey were analysed to describe uptake of sexual health care and experiences of interpersonal and structural cisgenderism and transphobia. Experiences of cisgenderism and transphobia in sexual health care were assessed using a new, four-item scale of ‘gender insensitivity’, which produced scores ranging from 0 (highly gender sensitive) to 4 (highly gender insensitive). Logistic and linear regression analyses were conducted to determine if experiences of gender insensitivity in sexual health care were associated with uptake and frequency of HIV/STI testing in the 12 months prior to participation. Trans and gender diverse participants primarily accessed sexual health care from general practice clinics (86.8%), followed by publicly funded sexual health clinics (45.6%), community-based services (22.3%), and general hospitals (14.9%). Experiences of gender insensitivity were common overall (73.2% of participants reported ≥2 negative experiences) but most common in hospitals (M = 2.9, SD = 1.3) and least common in community-based services (M = 1.3, SD = 1.4; p<0.001). When controlling for sociodemographic factors, social networks, general access to health care, and sexual practices, higher levels of gender insensitivity in previous sexual health care encounters were associated with a lower likelihood of recent HIV/STI testing (adjusted prevalence ratio = 0.92, 95% confidence interval [CI]:091,0.96, p<0.001) and less-frequent HIV/STI testing (B = -0.07, 95%CI:-0.10,-0.03, p = 0.007). Given the high rates of HIV and other STIs among trans and gender diverse people in Australia and overseas, eliminating cisgenderism and transphobia in sexual health care may help improve access to diagnostic testing to reduce infection rates and support the overall sexual health and well-being of these populations.

Ashley F., St. Amand C.M., Rider G.N.

Kia H., MacKinnon K.R., Abramovich A., Bonato S.

Rationale There is a growing body of research involving transgender (trans) individuals that foregrounds elevated rates of suicidality in trans populations. Although peer support is increasingly studied as a protective factor against suicide among trans persons, the scholarship in this area continues to be limited and has yet to be synthesized and appraised. Objective In this paper, we address this existing gap in the literature by presenting the results of a scoping review of the literature examining the significance and function of peer support in mitigating suicide risk in trans populations. Methods This scoping review is based on an analysis of 34 studies that were included following the execution of a methodical search and selection process. Drawing on scoping review methodology, along with PRISMA-P guidelines, we selected peer-reviewed empirical works, published between 2000 and 2020, which examined relationships between providing, seeking, and/or receiving peer support and suicide risk in trans populations. Results Our findings, which are conceptualized using the minority stress model as a guiding theoretical framework, reveal that while the literature generally substantiates the protective significance of peer support for trans persons, a small body of work also uncovers novel and unanticipated sources of peer support, including social support offered by trans peers online, which are infrequently and inconsistently examined in this body of scholarship. Conclusions Using our appraisal of the literature, we outline the need for future research to further elucidate the significance and function of peer support in protecting against suicide among trans persons. In particular, we discuss the need for exploratory inquiry to inform a conceptualization and operationalization of peer support that more fully and consistently accounts for how such support (including online and community-based support) is sought, received, and experienced among trans persons in the context of suicide.

Lim G., Waling A., Lyons A., Pepping C.A., Brooks A., Bourne A.

Crisis helplines are typically easily accessible and deliver interventions in a timely manner, regardless of geographical location. The efficacy and user experiences of these services are the subject of considerable interest within the field, but the experiences of trans and gender-diverse individuals remain unexplored despite high rates of mental ill health being documented in this population. A total of 134 trans and gender-diverse Australians were surveyed about their experiences of personal crises and of utilising crisis helplines. Within our sample, 84.2% (n = 113) of participants recognised at least one service - however, only 32.8% (n = 44) utilised a service to cope with a personal crisis. Participants cited poor recognition and understanding of the challenges specific to trans and gender-diverse individuals among helpline workers as a primary reason for avoiding these services, and articulated needs which were a poor fit for the one-off intervention model commonly employed by helpline services. In order for helpline services to be viable avenues of support for trans and gender-diverse individuals during a personal crisis, helpline workers must be sufficiently equipped to work with trans and gender-diverse callers and to facilitate their enrolment in 'traditional' mental health services.

Treharne G.J., Riggs D.W., Ellis S.J., Flett J.A., Bartholomaeus C.

Cundill P.

Sequeira G.M., Ray K.N., Miller E., Coulter R.W.

Purpose Transgender youth face significant health disparities and multiple barriers to receiving quality health care. Gender identity disclosure to health care providers (HCPs) is an important step in creating affirming relationships for transgender youth. The objectives of this study were to (1) determine the prevalence of voluntary disclosure and intentional avoidance to HCPs outside of gender clinics, (2) identify factors associated with voluntary disclosure and intentional avoidance, and (3) elucidate strategies to increase comfort with disclosure. Methods A cross-sectional survey was administered to transgender youth aged 12–26 years. Bivariate analyses were conducted using χ2 or Fisher's exact tests. Two logistic regression models for each outcome variable were used to examine factors associated with voluntary disclosure and intentional avoidance. Results Two thirds (65%) of youth (N = 153) identified as transmasculine, and 57% were under 18 years. Three-quarters (78%) had voluntarily disclosed their gender identity to an HCP outside of gender clinic, whereas 46% had intentionally avoided disclosure. Odds ratios (ORs) of ever having disclosed were lower for participants ≥18 years (OR = .33; 95% confidence interval [CI]: .11–.98), those out to fewer people (OR = .12; 95% CI: .02–.81) and out for Conclusion A majority of transgender youth reported having voluntarily disclosed their gender identity to an HCP outside of gender clinic, but almost half reported having intentionally avoided disclosure when they felt it was important. Parental support may play a protective role in mitigating avoidance.

Dolan I.J., Strauss P., Winter S., Lin A.

Ecker S., Riggle E.D., Rostosky S.S., Byrnes J.M.

Ferlatte O., Salway T., Rice S.M., Oliffe J.L., Knight R., Ogrodniczuk J.S.

Valentine S.E., Shipherd J.C.

Transgender and gender non-conforming (TGNC) populations, including those who do not identify with gender binary constructs (man or woman) are increasingly recognized in health care settings. Research on the health of TGNC people is growing, and disparities are often noted. In this review, we examine 77 studies published between January 1, 1997 and March 22, 2017 which reported mental health outcomes in TGNC populations to (a) characterize what is known about mental health outcomes and (b) describe what gaps persist in this literature. In general, depressive symptoms, suicidality, interpersonal trauma exposure, substance use disorders, anxiety, and general distress have been consistently elevated among TGNC adults. We also used the minority stress model as a framework for summarizing existing literature. While no studies included all elements of the Minority Stress Model, this summary gives an overview of which studies have looked at each element. Findings suggest that TGNC people are exposed to a variety of social stressors, including stigma, discrimination, and bias events that contribute to mental health problems. Social support, community connectedness, and effective coping strategies appear beneficial. We argue that routine collection of gender identity data could advance our understanding mental health risk and resilience factors among TGNC populations.

Wolford-Clevenger C., Frantell K., Smith P.N., Flores L.Y., Stuart G.L.

Transgender people are at high risk for suicide ideation, attempts, and deaths compared to the general population. Several correlates of suicide ideation and attempts have been identified empirically to understand this increased risk. However, few attempts have been made to systematically review this literature. Further, a theory to understand and identify targetable factors for intervention has rarely been applied to this population. In the first systematic review guided by ideation-to-action frameworks of suicide, we systematically reviewed the literature from January 1991 to July 2017 regarding correlates of suicide ideation, attempts, and deaths among transgender people. To be included in the review, articles must have been reported in English, reported on empirical data, included a sample or subsample of transgender people, and reported separately on correlates of suicide ideation, attempts, or deaths. Two independent reviewers searched three major databases, references of included articles, and unpublished literature, which produced 45 articles for review. The review suggested that ideation-to-action frameworks would be worth investigating within this population, with attention to sources of psychological pain, social connectedness, and capacity/capability for suicide unique to this population. Additionally, other aspects of cultural identity were often studied (e.g., race, religion), suggesting the need to understand intersectionality of identities among transgender people and their effects on suicide risk. Finally, the review highlighted important limitations of the literature, namely measurement of suicide ideation and attempts and sampling method, which future work should seek to improve.

Suen Y.T., Chan R.C., Wong E.M.

A community-driven survey of 106 transgender people (the first such survey in Hong Kong) showed that: (1) more than half the sample (50.9%) had a university degree or higher qualification; (2) despite this, 43.4% had a monthly income below HK$6,000 (about USD$775); (3) 66% reported "fair" or "poor" quality of life; (4) 67% of the sample (87.1% of respondents aged 15-24 years) had contemplated suicide; and (5) 20.8% of the sample (35.5% of respondents aged 15-24 years) had attempted suicide. It was found that (1) those who were single, had a lower monthly income, and identified as transgender women reported lower quality of life; and (2) those who were younger and on a lower income expressed higher suicidality. The findings suggest that service providers and policy makers urgently need to address the mental health needs of transgender people, particular younger transgender people.

Adams N., Hitomi M., Moody C.

Purpose: This article reports on the findings of a meta-synthesis undertaken on published gray transgender suicidality literature, to determine the average rate of suicidal ideation and attempts in this population. Methods: Studies included in this synthesis were restricted to the 42 that reported on 5 or more Canadian or U.S. adult participants, as published between 1997 and February 2016 in either gray or peer-reviewed health literature. Results: Across these 42 studies an average of 55% of respondents ideated about and 29% attempted suicide in their lifetimes. Within the past year, these averages were, respectively, 51% and 11%, or 14 and 22 times that of the general public. Overall, suicidal ideation was higher among individuals of a male-to-female (MTF) than female-to-male (FTM) alignment, and lowest among those who were gender non-conforming (GNC). Conversely, attempts occurred most often among FTM individuals, then decreased for MTF individuals, followed by GNC individuals. Conclusion: These findings may be useful in creating targeted interventions that take into account both the alarmingly high rate of suicidality in this population, and the relatively differential experience of FTM, MTF, and GNC individuals. Future research should examine minority stress theory and suicidality protection/resilience factors, particularly transition, on this population.

Bouman W.P., Schwend A.S., Motmans J., Smiley A., Safer J.D., Deutsch M.B., Adams N.J., Winter S.

Griffin B.A., W. Hassler G., Sheftall A.H., Ohana E., Ayer L.

Abstract: Suicide is a major public health concern globally, and despite decades of research, there has been a disappointing lack of progress in identifying effective prevention strategies and interventions. We argue over-reliance on traditional statistical significance cutoffs and underreporting of marginal findings may be limiting the clinical benefits of research in the field of suicide prevention and in turn impeding practical progress. The consistent reliance on statistically significant results at p < .05 may limit the visibility of potentially promising results to clinicians making treatment decisions. Expanding awareness of promising interventions – which can then be further scrutinized and subjected to further research – could have an important and needed impact on the field. The American Statistical Association has called upon researchers to view the p-value as continuous, with the call being adopted by leading journals. However, most suicide journals do not have explicit policies around how to use p-values for evaluating the strength of the evidence, and the use of continuous p-values has clearly not been routinely adopted by suicide researchers. We want to call upon suicide researchers to be more open to considering and publishing marginally significant findings that suggest promising trends for suicide prevention strategies and interventions.

Ireland K., Hughes M., Dean N.R.

AbstractBackgroundGender diverse people in Australia have higher levels of psychological stress, suicidal ideation and suicide attempts and have poorer self‐reported health than cisgender people.ObjectivesTo determine if adults who experience gender incongruence have improved health‐related quality of life and mental health with gender affirming treatment (hormone therapy and surgery), compared with no treatment.Data sourcesPubMed, Web of Science, Embase and Psych Info.Review methodsA systematic review of peer‐reviewed publications in English from January 2010 to October 2022. Studies were included where: participants were treated with gender affirming surgery or hormone therapy for minimum 3 months and; validated patient reported outcome measures of health‐related quality of life or mental health were reported. Quality of evidence assessment was undertaken using the Let Evidence Guide Every New Decision evaluation tool.ResultsEighty‐one publications were included for analysis. The systematic review indicated that there were significant improvements in the domains of mental illness, gender dysphoria, body image and health‐related quality of life following gender affirming medical treatment as measured by a variety of patient reported outcomes. Meta‐analysis showed significant improvement in body image (z = 4.47, P < 0.001) and health‐related quality of life for psychological (z = 1.99, P = 0.047) and social relationships (z = 3.09, P = 0.002) following gender affirming surgery.ConclusionsThere is evidence that hormones and surgery as a collective for adults with gender incongruence has therapeutic value and should be considered for funding within Australia's healthcare systems. The development and implementation of patient‐reported outcome tools tailored for purpose (GENDER Q) will facilitate future research.

Worrell S., Bourne A.

Community-controlled organisations provide crucial services to support the health and wellbeing of lesbian, gay, bisexual, trans and gender diverse, intersex, queer and other sexual and/or gender minority (LGBTIQ +) people. A strength of such organisations and their practitioners (many of whom are LGBTIQ +) is their cultural expertise, which can help to identify, understand and address the specific needs of LGBTIQ + clients, including in relation to family violence. While much discussion about standards of care for LGBTIQ + people has focused on a need for mainstream service providers and their non-LGBTIQ + practitioners to become more “culturally competent”, less has considered how clients experience services at community-controlled organisations. In this article, we draw on 19 semi-structured interviews with clients of family violence services at an LGBTIQ + community-controlled organisation in Melbourne, Australia, to explore their perceptions of specialist LGBTIQ + services. Eleven participants were cisgender men, six were cisgender women and two were trans or gender diverse. In terms of sexual orientation, ten self-described as gay, one homosexual, two queer, three lesbian, one bisexual, one asexual and one preferred not to say. Thematic analysis was used to identify patterns of service experience. Our research shows that participants felt that specialist services were most effective when they were informed about, affirming of and focused on the identities and specific health needs of LGBTIQ + clients. Participants had experienced what they perceived to be effective services within the context of LGBTIQ + community-controlled organisations, though felt that “mainstream” service providers were also potentially capable of providing good-quality support. A concerted effort on the part of these providers to embed culturally competent and LGBTIQ + -friendly practices into their services would help them achieve this outcome. Specialist support was most visible in the context of LGBTIQ + community-controlled organisations but also possible in other health and wellbeing settings, which is promising for mainstream service providers and practitioners seeking to provide more inclusive care for LGBTIQ + people. The insight of clients in this research is something that can potentially contribute to further discussion about the continued work both of LGBTIQ + community-controlled organisations and mainstream services.

Nicholas L., Clark S., Falzon C.

AbstractNon‐binary and genderqueer identities are increasingly discussed in public discourse and academia, but there remains a dearth of academic literature centred on non‐binary people's lives and experiences. When non‐binary people are included in research, it is frequently as an additive to explorations of trans identities and subsumed under the trans umbrella or treated as categorically indistinct. Much has been written from a clinical perspective, but the social sciences tend to discuss non‐binary identity conceptually or as a proxy in theoretical arguments. Of the emerging sociological literature on non‐binary identity, much is from the United States or the United Kingdom. Thus, this scoping review engaged with the corpus of research on non‐binary people in “Australia” to consider social change and policy needs. We found much about the negative health impacts resulting from discrimination and barriers, emphasising the structural and systemic nature of the existing gender binary. However, the majority of these papers include a focus on how non‐binary people actively participate in the collective creation of community, identity and safe spaces for affirmation. Resilience, coping strategies and solidarity were key themes and offer important insights into how the barriers identified can be ameliorated.

Grant R., Amos N., Power J., Lyons A., Hill A., Bourne A.

Grant R., Amos N., Lin A., Cook T., Hill A.O., Pang K., Skinner R.S., Carman M., Bourne A.

Grant R., Amos N., Lyons A., McNair R., Power J., Carman M., Hill A., Bourne A.

Grant R., Russell A., Dane S., Dunn I.