January 19, 2022

Suicide by Adolescents Referred to the World’s Largest Pediatric Gender Clinic

The suicide rate is higher than in the general population but much lower than implied by surveys

Adolescents who identify as transgender are vulnerable to suicidal thoughts and self-harming behaviors. This fact, frequently reported by the news media, is often used as the justification for the rapid provision of "gender-affirming" hormonal and surgical interventions to gender-dysphoric adolescents: “Fifty percent of transgender youth attempt suicide before they are at age 21,” declared the mother of Jazz Jennings, the most famous transgender youth in the English-speaking world. Although the elevated rate of suicidality in trans-identified youth is well-documented, a closer examination of the risk of suicide among reveals a more complex picture.

First off, there are wide variations by country, which remain poorly understood. For example, gender-dysphoric youth in The Netherlands attempt suicide at about 1/3 the rate of the UK's gender-dysphoric youth. Secondly, the estimates collected online from youth themselves tend to be higher than those obtained from more reliable clinic samples. And importantly, the data on suicidal thoughts and behaviors typically does not capture completed suicides, which represents a significant knowledge gap. A recent study by Dr. Michael Biggs fills this gap by calculating the rate of completed suicides among UK's gender-dysphoric youth.  

The new study by Dr. Biggs uses the data from the world's largest pediatric gender clinic, the Gender Identity Development Service (GIDS), to estimate the rates of completed suicides among trans-identifying youth. The United Kingdom has a comprehensive surveillance system for every death classified as suicide or probable suicide and such deaths by patients—even of those on the waiting list—must be reported. In the eleven years from 2010 to 2020, four patients under the care of the GIDS committed suicide, equating to 0.03% of the total. This translates into an annualized suicide rate of 13 per 100,000. For the general population of comparable age (14 to 17 years), the rate was 2.7 per 100,000. Thus, adolescents referred to the GIDS had a significantly higher rate of suicide, 5.5 times greater after adjusting for the clinic’s sex ratio. 

However, this greater risk is not necessarily attributable to transgender identity. Adolescents referred to the GIDS differ in many other ways from their peers of the same age: they are more likely to suffer from depression and to be on the autism spectrum, for example. These conditions increase the risk of suicide. Another recent study revealed that while trans-identifying adolescents' suicidality (including thoughts and behaviors, but excluding completed suicides) is markedly higher than that found in the general population of youth, it is only somewhat higher than in youth referred to mental health services for non-gender-related concerns.

The study found no difference in suicide rates among those on the waitlist compared to those undergoing active care at GIDs. The lack of difference is likely due to the low total numbers of suicides (n=4) recorded. 

SEGM Perspective

Much of the knowledge of suicidality in transgender-identifying youth comes from self-reported online surveys. However, survey data cannot be taken at face value. As demonstrated by prior research on the general public and of non-heterosexual youth in particular, when respondents who affirmatively answer a question on attempted suicide are asked follow-up questions, it turns out that many had not taken life-threatening actions. Moreover, “sexual-minority youths appear more inclined than other adolescents to reply in the affirmative when simplistic suicide attempt research instruments are used” (Savin-Williams, 2001). A recently published article likewise suggests that lesbian, bisexual, and gay youth might be “normalizing suicidality as a way to express distress and cope with life problems” (Canetto et al. 2021). The unreliability of simplistic survey questions make it imperative to collect data on deaths by suicide, as was done by Dr. Michael Biggs (an advisor to SEGM).

The most reassuring finding from this study of suicide mortality is that the absolute risk is low. The proportion of individual patients who died by suicide, 0.03%, is far lower than the proportion of transgender-identifying adolescents who report attempting suicide when surveyed. The finding, combined with the evidence that gender transition may not reduce suicide risk, calls into question the "transition or suicide" narrative promoted by news media and some gender clinicians. The fact that deaths by suicide are rare should provide some reassurance to gender dysphoric youth and their families, though of course this does not detract from the distress caused by self-harming behaviors. All self-harming youth should be carefully assessed and treated with evidence-based suicide prevention protocols, if indicated. 

Given the wide variation in suicidality (thoughts and behaviors) by region, future research should focus on assessing the risk of suicide in trans-identified youth in each specific geography. In addition, given the high rate of co-occurring mental illness in transgender-identifying youth, future research should also focus on comparing suicide rates in trans-identified youth to the rates for patients treated by mental health services for issues other than gender dysphoria/gender incongruence.