Mental Health and Transgenderism
being trans aint' easy
Here, in chapter 4.2 of Autoheterosexual: Attracted to Being the Other Sex, I make the straightforward argument that since many mental disorders are highly heritable, it is likely that the high prevalence of mental disorders (and resulting suicidality) among trans people is primarily due to genetic rather than cultural factors.
Trans people are more likely to have mental health problems than people who aren’t trans. They’re also more likely to show suicidal behaviors.
Where does this difference come from? Is it societal? Genetic? Both?
In LGBTQ advocacy, it’s common to fixate on societal mistreatment and its connection to negative mental health outcomes instead of considering inborn factors that may also contribute to poor mental health.
For now, it’s easier to change society than it is to change our genes, so this approach has a certain pragmatic logic to it. Through socially constructing a more perfect society, conditions can improve for sexual and gender minorities (or so the thinking goes).
Among social constructionists, there’s a popular school of thought called minority stress theory which holds that people in nondominant groups experience greater stress due to perceived prejudice, stigma, and discrimination, and that the stress associated with these perceived discriminatory experiences can cause adverse health effects[i].
At face value, this argument seems rather intuitive. It doesn’t take much imagination to see that being part of a nondominant group in society might confer some level of stress or insecurity and perhaps lead to mistreatment.
In my early forays into cross-gender expression, I definitely experienced stress, paranoia, and intense self-consciousness while out in public. Even now, if I go somewhere outside my cozy liberal bubble, I’m usually a little more vigilant about my surroundings.
Perhaps there is reason to worry. A recent study examined signs of minority stress among three generations of American sexual minorities and found that even as society supposedly got more welcoming to LGBTQ people, that cultural change didn’t seem to translate into fewer minority stressors. Younger sexual minorities were more likely to have previously attempted suicide than older ones, and they also reported more psychological distress and everyday discrimination[ii].
Overall, researchers found that little had changed in the metrics they measured. They attributed the overall lack of change to “the endurance of cultural ideologies such as homophobia and heterosexism and accompanying rejection of and violence toward sexual minorities”[iii].
But cultural attitudes toward sexual minorities have gotten way better in the last few generations! If social and cultural influences are the biggest influence on mental health outcomes among sexual minorities, the finding that not much has changed is certainly surprising. If genes play a greater role than culture in mental health outcomes, however, these findings are to be expected.
Genes change very little from generation to generation. Perhaps these researchers found that reported stressors haven’t changed much over the past few generations because genes are actually the primary contributor to mental health outcomes in sexual minorities.
For the genetic explanation to make sense, there would have to be shared genetic contributors to adverse mental health outcomes and nonheterosexual or autoheterosexual orientations. The science is young, but there is some preliminary evidence for this conclusion.
The researchers who wrote the paper referenced above are sociologists, so they didn’t explore the possibility that genes contribute to mental health outcomes of sexual minorities. However, I will.
But first, a little math lesson.
Befriending Numbers
In this chapter, I’ll present a lot of statistics. If you and numbers don’t get along, feel free to gloss over them and not worry about the details too much.
Even if you don’t quite know what the numbers mean, you’ll probably pick up on the general idea that the bigger the numbers are, the stronger the connection is between the things that are being compared.
Most commonly, I’ll compare things using odds ratios and correlations.
Odds ratios are simple: they express the odds of a particular outcome by comparing study participants who have a trait against those who lack that trait. For example, one study showed that trans people are four to six times as likely to have an autism diagnosis compared to people who aren’t trans[iv].
Easy, right?
Correlations are pretty simple to understand, too. The symbol for a correlation is r. It’s always a number whose magnitude is between zero and one. The r says how much one thing moves in relation to another thing—it’s a measure of how much two things are in sync and whether or not they move in the same direction (+) or opposite direction (-).
If r is positive, the two things move up and down in relation to each other. If r is negative, as one thing goes up, the other goes down.
For example, if the correlation between two things is r = 0.2, it means that if one thing moves, the other thing tends to move along with it, but only a fifth as much as the first thing moved. The bigger r is, the more in sync the two things are.
If two variables have a correlation of r = 0.2, the relationship between them is fairly mild. However, small correlations like these are common in sociology research.
Minority Stress Theory: Much Ado About Mild Effects
Studies that provide supporting evidence for minority stress theory typically find fairly modest effects. For example, the correlations between perceived discrimination and various health outcomes in one meta-analysis were quite small, ranging from r = 0.11 to r = 0.18[v].
Although the small correlations in the minority stress model are usually presented as the result of perceived prejudice and discrimination causing mental health problems, some of this small effect could just as well be from the reverse: preexisting mental traits could contribute to more perceived (or experienced) prejudice and discrimination[vi]. Researchers have not yet established the direction of causality in the minority stress model[vii].
To put the smallness of these effects in context, a review of fifty years of twin studies found that psychiatric traits between identical twins had a correlation of r = 0.55, and fraternal twins had a correlation of r = 0.31 [viii]. In fact, for traits in general, identical twins had a correlation of r = 0.64 [ix].
Notice how all these numbers are bigger than the ones from the minority stress study?
Genes are important—the role they play is too big to ignore. At birth, much of our physical and mental destiny has already been determined by our DNA.
Mental Traits Are Highly Heritable
Our genes play a massive role in the types of psychological traits and mental disorders we end up with. They affect our personalities, our general intelligence, and even our politics.
A common measure of how much genes affect traits is called heritability.
Heritability indicates how much the variation in a trait within a population can be attributed to variation in genetic factors rather than to the environment or random chance. To estimate heritability, scientists often compare identical twins to fraternal twins to see how their traits vary in order to figure out how much of their similarity comes from genes and how much from the environment[x].
Every behavioral trait is heritable[xi]. General psychological traits such as the Big Five (openness to experience, conscientiousness, extroversion, agreeableness, and neuroticism) are approximately 50% heritable, meaning that about half their variance in a population is due to variance in genes[xii]. Even social attitudes such as conservatism and authoritarianism are a little over half heritable[xiii], as is self-control[xiv]. General intelligence (IQ) in adults is roughly 80% heritable[xv].
Genetic factors are probably the single biggest contributor to mental traits. This also applies to many mental disorders.
One of the least heritable mental disorders is depression, but 30–40% of variation in depression can still be attributed to genetic factors[xvi]. The heritability of anxiety is similar. Anxiety symptoms and generalized anxiety disorder are about 30% heritable, while panic disorder is around 40% heritable[xvii]. Similarly, obsessive-compulsive disorder and total anxiety sensitivity are both almost 50% heritable[xviii].
Other mental disorders are even more strongly determined by genes. For example, Cluster B personality disorders such as antisocial, borderline, and narcissistic personality disorders are estimated to be 67–71% heritable[xix]. Autism spectrum disorder is somewhere around 80% heritable[xx], as is bipolar disorder[xxi]. Psychotic disorders like schizophrenia and mania are both estimated to be at least 80% heritable[xxii], as is ADHD[xxiii].
Gender-related traits are heritable, but the estimates vary widely. Childhood gender dysphoria has been estimated to be anywhere from 14–84% heritable, and childhood gender-related behaviors have been estimated to be 25–77% heritable[xxiv].
In other words, genes play an absolutely massive role in shaping psychology and behavior. Those who overlook the role of genes will miss the single largest contributor to mental traits and mental disorders.
Nonheterosexuality and Depression Have Shared Genetic Factors
A couple studies have looked into potential genetic connections between same-sex sexuality and depression, and they found a solid association between the two.
An Australian twin study estimated that shared genetic causes accounted for 60% of the shared variance between sexual orientation and depression in nonheterosexuals [xxv].They also found that childhood sex abuse and risky family environment accounted for approximately 9% and 8% of the depression variance, respectively, showing that the social environment had an impact on depression as well[xxvi]. Still, the impact of genes was clearly dominant.
In 2019, a massive genome-wide association study that compared nearly half a million human genomes found associations between same-sex behavior and genes associated with mental traits that tend to worsen mental health outcomes[xxvii].
In males, same-sex sexual behavior was genetically correlated with ADHD (r = 0.27), neuroticism (r = 0.15), and depression (r = 0.33)[xxviii].
In females, same-sex sexual behavior was genetically correlated with ADHD (r = 0.25), anxiety (r = 0.25), bipolar disorder (r = 0.34), autism (r = 0.21), neuroticism (r = 0.22), and depression (r = 0.43) [xxix].
These relationships suggest that being nonheterosexual can make life more difficult—and that some of this increased difficulty stems from genes rather than culture.
While there is certainly more work to be done on the cultural front to make life better for sexual minorities, trying to achieve better outcomes solely through cultural means will inevitably fall short of the utopic goal of equal outcomes. Until genetic technologies are sufficiently advanced and made available to everyone, there will be genetic barriers to equal outcomes between groups of people whose genetic differences lead to consequential differences in mental traits.
As with nonheterosexuals, trans people also have a much higher rate of mental disorders than the broader population. And since genes are major contributors to mental disorders, it stands to reason that societal discrimination can’t account for all of the mental health difficulties that trans people face.
I want to be clear: by bringing up the influence of genetics, I’m not denying that cultural changes can make life better for sexual minorities or gender minorities. There are meaningful solutions outside of gene editing.
Societal discrimination against sexual and gender minorities is a real, well-documented problem. The social environment certainly contributes to the difficulties of being transgender, and I sincerely hope that the cultural project to better incorporate sexual and gender minorities into society will continue to improve our lot in life. Such change is a good thing, and long overdue.
But if culture and society are only part of the picture, then approaches to helping sexual and gender minorities that rely on cultural engineering and unshakeable faith in the power of social construction will inevitably fall short of their goals.
Any realistic analysis must include the contribution of genes. They’re too important to ignore.
Trans People Have High Rates of Mental Disorders
Transgender people are more likely to have previous diagnoses for psychiatric disorders than people who aren’t transgender. Much more likely.
When researchers studied inpatient hospital encounters in the US, transgender patients were found to be eight times as likely as nontransgender patients to have been diagnosed with any psychiatric disorder in the past[xxx]. Previous mental health diagnoses in trans patients were almost four times as likely for anxiety, about 1.5 times as likely for depression, and about 2.5 times as likely for psychosis.
Data from large questionnaire databases has also revealed elevated rates of prior psychiatric diagnoses in trans people. For instance, one study found that in trans people, prior diagnoses were two to five times as likely for ADHD, four times as likely for depression, two to five times as likely for bipolar disorder, and two to five times as likely for OCD[xxxi].
The rates of autism were even higher: trans people were five to six times as likely to have an autism diagnosis as people who weren’t trans[xxxii]. This relationship went the other way as well: people diagnosed with autism were five to six times as likely to be transgender or otherwise gender diverse[xxxiii].
Autism itself is a risk factor for other psychiatric diagnoses. A large meta-analysis found that in comparison to the general public, autistic people are more likely to have ADHD, anxiety, depression, bipolar disorder, schizophrenia, obsessive-compulsive disorder, and sleep-wake disorders[xxxiv]. In particular, ADHD is the most common co-occurring psychiatric diagnosis in adults with autism[xxxv]. The two are highly linked.
Gender transition itself doesn’t seem to be the origin of these higher rates of mental health issues: a 2005 study of the Swedish population found that men who had ever been aroused by crossdressing had about three times the odds of receiving a psychiatric diagnosis in the last year compared to men who hadn’t[xxxvi]. This suggests that autoheterosexuality itself is associated with higher odds of having mental health issues.
The data is clear: trans people deal with mental health difficulties at much higher rates than the broader population. And since many mental disorders are mostly heritable, we cannot attribute trans people’s mental health difficulties to societal conditions alone. The situation is more complicated than that.
Transgender Suicidality
Have you ever heard the statistic that 41% of trans people[xxxvii] have previously attempted suicide?
That study wasn’t a fluke: another large transgender survey with similar methodology found basically the same result: 40% reported a prior suicide attempt[xxxviii].
Given that only about 5% of Americans report a prior suicide attempt[xxxix], does this mean trans people are eight times as likely to attempt suicide as people who aren’t trans?
To explore this question, I will stick to measures of prior suicide attempts. Although this isn’t the only way to measure suicidality, I use prior suicide attempts as a metric here because it’s what studies of transgenderism often use. In addition, measuring the same type of outcome makes it easier to compare the results of different studies.
Estimates of attempted suicide in trans people tend to vary widely, but all are above the levels in the general population. Studies measuring suicidality in gender-dysphoric people have found widely varying rates of past suicide attempts (9–47%)[xl]. Fortunately, studies usually find estimates below 41%.
A study on transgender Virginians found that 25% had previously attempted suicide[xli]. Another study found that 28–31% of trans women in the New York City metropolitan area had a prior suicide attempt[xlii]. Two surveys in the UK found that 21–25% of trans people had attempted suicide more than once, and overall, 35% of them had done so at least once[xliii].
In China, suicidality among trans people is also higher than the general population. At an attempted suicide rate of 16%, Chinese transgender people are about five times as likely as the broader population to have previously attempted suicide[xliv].
In the overall world population, an estimated 2.7% of people have previously attempted suicide[xlv], so these trans suicide rates seem absurdly high by comparison.
It isn’t only gender minorities who have escalated rates of suicide—nonheterosexuals do, too[xlvi]. Among nonheterosexuals, bisexual females are the most likely to have previously attempted suicide[xlvii].
The way researchers find study participants has a huge impact, too: multiple meta-analyses of suicidality in homosexuals have found that community samples result in estimates of past suicide attempts that are approximately double those found in population-representative samples (20% vs. 10–11%, respectively)[xlviii].
If this difference between community samples and population-representative samples applies to trans people, too, it’s good news. Many of the transgender studies I just referenced were community samples (including the one that found a 41% rate), so they might be overestimating suicidality.
Altogether, heterosexuals have the lowest rates of suicide attempts among sexuality- and gender-based identity groups. Homosexuals have two to three times the rates of suicide attempts as heterosexuals, and bisexual females have a higher rate yet. Trans people make suicide attempts at 1.5 to two times the rate of homosexuals.
Although sampling biases may contribute to high reported rates of trans suicide attempts such as the famous 41% statistic, it appears that trans people truly do have the highest risk of suicide among all sexual and gender minority groups.
Transgender Suicidality: More than Gender Dysphoria
What is responsible for the high rate of suicide attempts among trans people? Is it societal discrimination? Gender dysphoria? Mental disorders?
Yes. All of these play a role.
In general, the more mental disorders an individual has, the more likely they are to have made prior suicide attempts or successfully suicided (see Table 4.2.1)[xlix]. Trans people are, at root, people, so it’s likely that the high prevalence of mental disorders among trans people contributes to their high rate of suicide attempts. And since mental disorders are highly heritable, a significant part of this tendency is inborn and independent of society or culture.
Table 4.2.1: Mental health disorders drastically increase the odds of attempted and completed suicide.
As important as genes are, however, society and culture definitely still contribute to transgender suicidality. Not all the potential for suffering is inborn. For example, anxiety and depression contribute to suicidality, yet they’re less heritable than many other types of mental disorders.
The availability of transgender medical care also matters to trans people: many studies show that getting such care is associated with better outcomes among trans people[l].
Personality matters, too. Research on sexual and gender minorities has shown that they have noticeably different rates of past suicide attempts depending on personality traits such as neuroticism, agreeableness, or conscientiousness[li].
In addition, trans people who have previously attempted suicide report that gender issues weren’t the only contributor to their suicidality: in a UK study, 65% of trans people reported that trans-related reasons played a part in their prior suicide attempts, while 61% said that factors unrelated to transgenderism contributed to their prior suicide attempts[lii].
Discrimination and Mistreatment Increases Suicidality
There is a large body of literature suggesting that discrimination harms the well-being of sexual and gender minorities[liii].
By pointing out that suicidality in trans people is not purely a function of gender issues, I’m not saying gender issues are irrelevant. They definitely matter. But how others treat trans people matters, too.
For instance, a study of MTFs in the New York City metro area found that gender-related psychological or physical abuse were both significantly associated with increased suicidality and depression, especially when that abuse happened during adolescence[liv].
A study of transgender Massachusetts residents found a similar association between mistreatment and suicidal thoughts: having been on the receiving end of physical violence, sexual violence, or gender-related discrimination was associated with a higher risk of having contemplated suicide in the past[lv].
Additionally, study participants who had transitioned or were planning on transitioning had a higher risk of prior suicidal thoughts than nontransitioners. Consistent with the general pattern of higher suicidality in females, FTMs were approximately twice as likely to have prior suicidal thoughts for every single one of these risk factors[lvi].
When researchers analyzed results from the massive 2015 US Transgender Survey to examine contributing factors to suicidality, they found the rate of prior suicide attempts differed based on a whole slew of factors and past experiences[lvii]. Many of these decrease well-being in people in general, but some were transgender-specific.
Transgender people with higher income, educational attainment, age, and general health had made fewer past suicide attempts, whereas those with drug use, past arrests, psychological distress, disability, and homelessness had made more past suicide attempts. Sex mattered too: FTMs had more prior suicide attempts than MTFs.
Social rejection also made a big difference. There were higher past suicide attempt rates among trans people who had unsupportive family, classmates, or coworkers, or those who had experienced rejection by their family of origin, intimate partner, child, or religious community.
Trans people who had experienced a professional intervention that attempted to stop them from being trans or change their sexual orientation also higher odds of past suicide attempts. Those who’d been physically attacked, had unwanted sexual contact, or experienced intimate partner violence of any kind all had a higher chance of past suicide attempts, as did those mistreated by police or denied access to restrooms corresponding to their gender identity.
Of the discrimination trans people experienced that they attributed to being transgender, there were four types of experiences that had the greatest impact: being evicted, experiencing homelessness, being physically attacked, and being fired from a job[lviii]. Trans people who had experienced none of these negative events in the previous year had only a 5.1% risk of suicide attempt during that time, whereas those who experienced all four types of discrimination had a 51% risk—a tenfold increase[lix].
The trend is clear: having less money, being younger, and being socially rejected or mistreated for being trans are all associated with higher odds of prior suicide attempts.
In Sum:
Transgender people are much more likely to have previously attempted suicide than the general population. Even if using more conservative estimates, transgender Americans appear to have at least five times the odds of a prior suicide attempt. Trans people in China also have similarly elevated rates of a prior suicide attempts.
Trans people have much higher rates of mental disorders than the general population. They are more likely to have highly heritable mental disorders like ADHD, autism, and bipolar disorder, as well as moderately heritable mental disorders like anxiety, depression, and OCD. Trans identity aside, prior arousal from crossdressing is itself associated with much higher odds of a recent psychiatric diagnosis.
Mental disorders are associated with much higher rates of suicidality among the general population, so it’s likely that transgender suicidality can be largely attributed to trans people’s elevated rates of mental disorders. Since these mental disorders tend to be moderately to highly heritable, a significant proportion of transgender suicidality is probably due to inborn factors independent of societal conditions.
However, societal conditions matter, too. Transgender suicidality is highly linked to social class as well as discrimination for being transgender. The treatment trans people experience certainly influences their mental health outcomes. Genes aren’t everything.
[i] Meyer, “Prejudice, Social Stress, and Mental Health in Lesbian, Gay, and Bisexual Populations.”
[ii] Meyer et al., “Minority Stress, Distress, and Suicide Attempts in Three Cohorts of Sexual Minority Adults,” 10.
[iii] Meyer et al., 15.
[iv] Warrier et al., “Elevated Rates of Autism, Other Neurodevelopmental and Psychiatric Diagnoses, and Autistic Traits in Transgender and Gender-Diverse Individuals,” 6.
[v] Pascoe and Smart Richman, “Perceived Discrimination and Health,” 538.
[vi] Zucker, Lawrence, and Kreukels, “Gender Dysphoria in Adults,” 230.
[vii] Bailey, “The Minority Stress Model Deserves Reconsideration, Not Just Extension.”
[viii] Polderman et al., “Meta-Analysis of the Heritability of Human Traits Based on Fifty Years of Twin Studies,” 704.
[ix] Polderman et al., 704.
[x] Maranges and Reynolds, “Heritability,” 244.
[xi] Maranges and Reynolds, 243.
[xii] Bouchard, “Genetic Influence on Human Psychological Traits,” 150.
[xiii] Bouchard, 150.
[xiv] Willems et al., “The Heritability of Self-Control,” 330.
[xv] Bouchard, “Genetic Influence on Human Psychological Traits,” 150; Bouchard, “The Wilson Effect,” 924.
[xvi] Sullivan, Neale, and Kendler, “Genetic Epidemiology of Major Depression,” 1552; Fernandez-Pujals et al., “Epidemiology and Heritability of Major Depressive Disorder, Stratified by Age of Onset, Sex, and Illness Course in Generation Scotland,” 9; Kendler et al., “A Swedish National Twin Study of Lifetime Major Depression,” 109.
[xvii] Hettema, Neale, and Kendler, “A Review and Meta-Analysis of the Genetic Epidemiology of Anxiety Disorders,” 1568.
[xviii] Stein, Jang, and Livesley, “Heritability of Anxiety Sensitivity,” 249; Mataix-Cols et al., “Population-Based, Multigenerational Family Clustering Study of Obsessive-Compulsive Disorder,” 709.
[xix] Torgersen et al., “The Heritability of Cluster B Personality Disorders Assessed Both by Personal Interview and Questionnaire,” 863.
[xx] Sandin et al., “The Heritability of Autism Spectrum Disorder,” 1183; Tick et al., “Heritability of Autism Spectrum Disorders,” 585.
[xxi] McGuffin et al., “The Heritability of Bipolar Affective Disorder and the Genetic Relationship to Unipolar Depression,” 502.
[xxii] Cardno et al., “Heritability Estimates for Psychotic Disorders,” 166.
[xxiii] Larsson et al., “The Heritability of Clinically Diagnosed Attention Deficit Hyperactivity Disorder across the Lifespan,” 2223.
[xxiv] Coolidge and Stillman, “The Strong Heritability of Gender Dysphoria,” 76.
[xxv] Zietsch et al., “Do Shared Etiological Factors Contribute to the Relationship between Sexual Orientation and Depression?,” 528.
[xxvi] Zietsch et al., 528.
[xxvii] Ganna et al., “Large-Scale GWAS Reveals Insights into the Genetic Architecture of Same-Sex Sexual Behavior.”
[xxviii] Ganna et al., “Large-Scale GWAS Reveals Insights into the Genetic Architecture of Same-Sex Sexual Behavior—Supplementary Materials,” 63,64.
[xxix] Ganna et al., 63,64.
[xxx] Hanna et al., “Psychiatric Disorders in the U.S. Transgender Population.”
[xxxi] Warrier et al., “Elevated Rates of Autism, Other Neurodevelopmental and Psychiatric Diagnoses, and Autistic Traits in Transgender and Gender-Diverse Individuals—Supplementary Materials,” 12–13.
[xxxii] Warrier et al., “Elevated Rates of Autism, Other Neurodevelopmental and Psychiatric Diagnoses, and Autistic Traits in Transgender and Gender-Diverse Individuals,” 3.
[xxxiii] Warrier et al., 3.
[xxxiv] Lai et al., “Prevalence of Co-Occurring Mental Health Diagnoses in the Autism Population,” 6.
[xxxv] Lugo-Marín et al., “Prevalence of Psychiatric Disorders in Adults with Autism Spectrum Disorder,” 31.
[xxxvi] Långström and Zucker, “Transvestic Fetishism in the General Population,” 91.
[xxxvii] Grant et al., “Injustice At Every Turn: A Report of the National Transgender Discrimination Survey,” 82.
[xxxviii] James et al., “The Report of the 2015 U.S. Transgender Survey,” 8.
[xxxix] Kessler, Borges, and Walters, “Prevalence of and Risk Factors for Lifetime Suicide Attempts in the National Comorbidity Survey,” 617; Nock et al., “Cross-National Prevalence and Risk Factors for Suicidal Ideation, Plans, and Attempts,” 15.
[xl] García-Vega, Camero, and Fernández, “Suicidal Ideation and Suicide Attempts in Persons with Gender Dysphoria,” 284.
[xli] Xavier, Honnold, and Bradford, “The Health, Health Related Needs, and Lifecourse Experiences of Transgender Virginians,” 23.
[xlii] Nuttbrock et al., “Psychiatric Impact of Gender-Related Abuse Across the Life Course of Male-to-Female Transgender Persons,” 16.
[xliii] Bailey, J. Ellis, and McNeil, “Suicide Risk in the UK Trans Population and the Role of Gender Transition in Decreasing Suicidal Ideation and Suicide Attempt,” 213; Whittle et al., “Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination,” 78.
[xliv] Chen et al., “Suicidal Ideation and Attempted Suicide amongst Chinese Transgender Persons,” 1131.
[xlv] Nock et al., “Cross-National Prevalence and Risk Factors for Suicidal Ideation, Plans, and Attempts,” 4.
[xlvi] King et al., “A Systematic Review of Mental Disorder, Suicide, and Deliberate Self Harm in Lesbian, Gay and Bisexual People,” 5.
[xlvii] Salway et al., “A Systematic Review and Meta-Analysis of Disparities in the Prevalence of Suicide Ideation and Attempt Among Bisexual Populations,” 14.
[xlviii] Hottes et al., “Lifetime Prevalence of Suicide Attempts Among Sexual Minority Adults by Study Sampling Strategies,” e5; Salway et al., “A Systematic Review and Meta-Analysis of Disparities in the Prevalence of Suicide Ideation and Attempt Among Bisexual Populations,” 14.
[xlix] Kessler, Borges, and Walters, “Prevalence of and Risk Factors for Lifetime Suicide Attempts in the National Comorbidity Survey”; Nock et al., “Cross-National Analysis of the Associations among Mental Disorders and Suicidal Behavior”; Too et al., “The Association between Mental Disorders and Suicide.”
[l] “What We Know | What Does the Scholarly Research Say about the Effect of Gender Transition on Transgender Well-Being?”
[li] Livingston et al., “Sexual Minority Stress and Suicide Risk,” 326.
[lii] Bailey, J. Ellis, and McNeil, “Suicide Risk in the UK Trans Population and the Role of Gender Transition in Decreasing Suicidal Ideation and Suicide Attempt,” 213.
[liii] “What We Know | What Does the Scholarly Research Say about the Effects of Discrimination on the Health of LGBT People?”
[liv] Nuttbrock et al., “Psychiatric Impact of Gender-Related Abuse Across the Life Course of Male-to-Female Transgender Persons,” 18.
[lv] Rood et al., “Predictors of Suicidal Ideation in a Statewide Sample of Transgender Individuals,” 273.
[lvi] Rood et al., 273.
[lvii] Herman, Brown, and Haas, “Suicide Thoughts and Attempts Among Transgender Adults: Findings from the 2015 U.S. Transgender Survey.”
[lviii] Herman, Brown, and Haas, 27.
[lix] Herman, Brown, and Haas, 28.