Suicide risk and gender affirming care
Suicide risk and gender affirming care
A narrative review
Study under review:
Jackson D. Suicide-Related Outcomes Following Gender-Affirming Treatment: A Review. Cureus. 2023 Mar 20;15(3):e36425. doi: 10.7759/cureus.36425. PMID: 36950718; PMCID: PMC10027312.
Suicide risk is thankfully rare, statistically-speaking — including for trans people; however, because it is rare, it is hard to study and, more importantly, it is very difficult to accurately predict.
The research literature reflects what many trans and gender variant people know intuitively — that trans individuals experience higher rates of mental health issues than the general public. This includes adverse life experiences such as chronic health challenges, trauma, victimization, substance use issues, and social barriers such as housing and employment discrimination. Trans people also report higher rates of suicidal ideation, self-harming behaviours, and suicide than the general public.
Daniel Jackson, a US-based psychiatrist, included 23 studies in a narrative review looking at the relationship between gender affirming care (GAC) and suicide-related outcomes. He reported that the majority of the studies he reviewed made claims that GAC was linked to less suicidality, while two of the 23 studies showed an increase in suicidality following GAC.
In his review, Jackson highlights the difficulty of studying such a heterogeneous group.
Key points:
The lack of high quality studies investigating suicide outcomes after GAC runs counter to claims made by some clinicians and medical organizations that GAC lowers suicide risk.
Given how often advocates of gender affirming care use the risk of suicide to promote GAC, I was surprised by Jackson’s statement that his is the first study to evaluate mental health outcomes following GAC ‘solely from the standpoint of suicidality’.
Jackson identified significant methodological issues with all of the studies he reviewed, such as a lack of measures of statistical significance and effect size, as well as lack of controls for co-occurring psychiatric conditions and substance use.
Many of the studies included in his review also did not take into account the timing of participants’ treatment history (e.g. timing since they received GAC). Ideally, researchers would measure the elapsed time prior to and following GAC — and this time period would be equally long in both directions. Otherwise, he claims, the number of suicide attempts or frequency of suicidal ideation might be falsely lowered.
Some recommendations:
Jackson points out the need for future studies to include data about participants’ psychiatric treatment before and after GAC, as these psychiatric treatments may contribute to lower risk of suicide separate from GAC itself.
He also identifies the need for a more rigorous review of the existing literature, such as a systematic or scoping review.
The narrative review is available for free online.
Resources if you or someone you know is suicidal:
If you are experiencing suicidal thoughts, or you are supporting someone who struggling, the following Canada-based resources can help: