Suicide by Clinic-Referred Transgender Adolescents in the United Kingdom. Michael Biggs. Archives of Sexual Behavior, Jan 18 2022. https://link.springer.com/article/10.1007/s10508-022-02287-7
Introduction: Surveys show that adolescents who identify as transgender are vulnerable to suicidal thoughts and self-harming behaviors (dickey & Budge, 2020; Hatchel et al., 2021; Mann et al., 2019). Little is known about death by suicide. This Letter presents data from the Gender Identity Development Service (GIDS), the publicly funded clinic for children and adolescents aged under 18 from England, Wales, and Northern Ireland. From 2010 to 2020, four patients were known or suspected to have died by suicide, out of about 15,000 patients (including those on the waiting list). To calculate the annual suicide rate, the total number of years spent by patients under the clinic’s care is estimated at about 30,000. This yields an annual suicide rate of 13 per 100,000 (95% confidence interval: 4–34). Compared to the United Kingdom population of similar age and sexual composition, the suicide rate for patients at the GIDS was 5.5 times higher. The proportion of patients dying by suicide was far lower than in the only pediatric gender clinic which has published data, in Belgium (Van Cauwenberg et al., 2021).
Suicidality in Transgender Adolescents
“About half of young trans people…attempt suicide,” declared the United Kingdom Parliament’s Women and Equalities Committee (2015). Similar figures are cited by news media and campaigning organizations. The Guardian reported Stonewall’s statistic that “almost half” of transgender young people “have attempted to kill themselves” (Weale, 2017). “Fifty percent of transgender youth attempt suicide before they are at age 21” stated the mother of the most famous transgender youth in the English-speaking world (Jennings & Jennings, 2016). As a transgender theologian has observed, “the statistic about suicide attempts has, in essence, developed a life of its own” (Tanis, 2016).
Representative surveys of students in high schools provide one source of evidence for this statistic. In New Zealand, 20% of transgender students reported attempting suicide in the past 12 months, compared to 4% of all students (Clark et al., 2014). In the United States, 15% of transgender students reported a suicide attempt requiring medical treatment in the last 12 months, compared to 3% of all students (Centers for Disease Control & Prevention, 2018; Jackman et al., 2021; Johns et al., 2019). In another American survey, 41% of transgender students reported having attempted suicide during their lifetime, compared to 14% of all students (Toomey et al., 2018).
To what extent are self-reported suicide attempts reflected in fatalities? The connection is not straightforward. Respondents who report suicide attempts are not necessarily indicating an intent to die. One survey of the American population found that almost half the respondents who reported attempting suicide subsequently stated that their action was a cry for help and not intended to be fatal (Nock & Kessler, 2006). In two small samples of non-heterosexual youth, half the respondents who initially reported attempting suicide subsequently clarified that they went no further than imagining or planning it; for the remainder who did actually attempt suicide, their actions were usually not life-threatening. To an extent, then, “the reports were attempts to communicate the hardships of lives or to identify with a gay community” (Savin-Williams, 2001). Although such elaborate survey methods have not been used to study transgender populations, there is anecdotal evidence for a similar disjuncture. The pediatric endocrinologist who established the first clinic for transgender children in the United States stated that “the majority of self-harmful actions that I see in my clinic are not real suicide attempts and are not usually life threatening” (Spack, 2009).
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Discussion
How reliable are these estimates? The chief uncertainty about the numerator is whether the fourth death will be ruled as suicide when the inquest is eventually held. It could be speculated that there were further suicides unknown to the Tavistock and to the National Confidential Inquiry into Suicide and Safety in Mental Health. All that can be said is that the single suicide by a GIDS patient from 2014 to 2016 is not out of line with comprehensive mortality data on suicides by transgender adolescents in the United Kingdom which counted five suicides in a longer age range and wider geographical area. The denominator for the annual suicide rate, however, is pieced together from various series and so is inevitably approximate. Statistics from the early 2010s are less reliable, though they make only a small contribution to the grand total; the last three years contribute more than half of the total number of patient-years. The most significant limitation is the lack of information on the age and sex of all the patients who committed suicide.
Direct comparison can be made with the Belgian pediatric gender clinic (Van Cauwenberg et al., 2021). Its annual suicide rate was about 70 times greater than the rate at the GIDS. This is especially puzzling because patients at the Belgian clinic scored better, on average, than those at the GIDS on tests of psychological functioning (de Graaf et al., 2018). The explanation for the huge disparity in suicide is not clear. The Amsterdam’s clinic annual suicide rate was four times greater than the rate at the GIDS. The higher rate is not surprising, however, because the Dutch clinical population was dominated by older adults: the median age at first visit was 25 (Wiepjes et al., 2020). Suicide rates peak in middle age, and so a population of older adults would be at higher risk than a population of adolescents.
The suicide rate of the GIDS patients is not necessarily indicative of the rate among all adolescents who identify as transgender. On the one hand, individuals with more serious problems (and their families) would be particularly motivated to seek referral and more likely to obtain it, and so the clinical subset would be more prone to suicide. One study suggests that a child who frequently attempted suicide was more readily referred to the GIDS (Carlile et al., 2021). On the other hand, young people facing hostility from their families would be less able to seek referral, and this hostility could make them especially vulnerable to suicide.
Taking into account these limitations, the estimated suicide rate at the GIDS provides the strongest evidence yet published that transgender adolescents are more likely to commit suicide than the overall adolescent population. The higher risk could have various causes: gender dysphoria, accompanying psychological conditions, and ensuing social disadvantages such as bullying. Studies of young people referred to the GIDS in 2012 and 2015 found a high prevalence of eating disorders, depression, and autism spectrum conditions (ASC) (Holt et al., 2016; Morandini et al., 2021)—all known to increase the probability of suicide (Simon & VonKorff, 1998; Smith et al., 2018). Eating disorders and depression could be consequences of transgender identity and its ensuing social repercussions, but this is implausible for ASC insofar as it originates in genes or the prenatal environment. From a sample of over 700 referrals to the GIDS in 2012 and 2015, 14–15% were diagnosed with ASC (Morandini et al., 2021). This compared to 0.8–1.1% of students in England (Department for Education, 2012, 2015). The association between autism and gender dysphoria is found in many populations (Socialstyrelsen, 2020; Warrier et al., 2020). Autism is known to increase the risk of suicide mortality, especially in females (Hirvikoski et al., 2016; Kirby et al., 2019; Socialstyrelsen, 2020). To some extent, therefore, the elevated suicide rate for transgender youth compared to their peers reflects the higher incidence of ASC. The same holds for other psychiatric disorders associated with gender dysphoria (Dhejne et al., 2016). Ideally, the suicide rate for patients of the GIDS would be compared to the suicide rate for patients in contact with other NHS mental health services, but the latter rate is not available.
One final caveat is that these data shed no light on the question of whether counseling or endocrinological interventions—gonadotropin-releasing hormone agonist or cross-sex hormones—affect the risk of suicide (Biggs, 2020; Turban et al., 2020). Although two out of the four suicides were of patients on the waiting list, and thus would not have obtained treatment, this is not disproportionate: the waiting list contributed nearly half of the total patient-years.
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