Factors Associated with Suicide Attempts Among Transgender Patients across Integrated Health Systems

Background and Purpose: Transgender individuals, or those whose gender identity does not match their assigned sex at birth, have suicide attempt rates that are exponentially higher than rates among the general population. However, very little is known about the unique medical risk and other factors driving such high suicide attempt rates among this population, partially due to the invisibility of non-binary gender identities in electronic medical records and other data sources. The aim of this study was to examine medical factors associated with suicide attempts among a large cohort of transgender patients across three health systems.

Methods: We examined patterns of suicide attempts among patients in the STRONG (Study of Transition, Outcomes & Gender) cohort, a unique study of transgender patients identified between 2006 and 2014 enrolled at three Kaiser Permanente health organizations (Georgia, Northern California, Southern California) (N=6367). Transgender patients were identified using a combination of ICD-9 and ICD-10 codes along with text string reviews of clinical notes and evidence of gender-affirming procedures or hormone therapy. Electronic medical record data included demographics, health system encounters, psychiatric diagnoses, substance use, and use of gender-affirming HT. We compared transgender patients with a suicide attempt to those without an attempt.

Results: The cohort included 2892 transmasculine and 3475 transfeminine patients. Overall, 8.4% of transmasculine and 5.0% of transfeminine patients attempted suicide, as evidenced by an emergency room visit with a self-inflicted injury. The majority of suicide attempts in both transmasculine and transfeminine patients occurred between 11 to 40 years of age.

Psychiatric diagnoses (including anxiety, bipolar disorder, schizophrenia, and ADHD) were higher among attempters than non-attempters. In particular, 97.4% of transmasculine and 96.4% of transfeminine patients who had a suicide attempt were diagnosed with depressive disorders vs. 60.3% and 55.6% of non-attempters, respectively. Alcohol use in transmasculine patients who attempted suicide was substantially more prevalent than it was for non-attempters (76.2% vs. 4.7%). Transfeminine patients who attempted suicide had higher rates of illicit drug use (41.8%) compared to those with no attempt (7.8%). Only 27.82% of transmasculine patients who attempted suicide had used hormone treatment, compared to 54% of transmasculine patients that did not have an attempt. Both transmasculine and transfeminine patients who attempted suicide had higher rates of inpatient, emergency room, and ambulatory encounters compared to those without attempts.

Conclusions and Implications: Overall, suicide attempt rates among transgender patients are very high. Although some risk factors for suicide attempts mirror those of the general population (psychiatric diagnoses, substance use), others – such as hormone therapy use – are unique to transgender patients. Further research should explore the effect of access to hormone therapy on suicide attempt risk. In addition, the high rates of healthcare encounters of all types among those who have attempted suicide suggest that missed opportunities for prevention and intervention exist. Social workers employed in health care settings should advocate for routine depression and suicide risk screening as well as access to gender-affirming hormone therapy for transgender patients.