Transgender and Gender Diverse Patients Are More Likely to Be Victims of Violence, Attempt Suicide or Experience Suicidal Ideation
Researchers from the Health Equity Research Lab at Cambridge Health Alliance analyzed data from the health system’s medical records and found high rates of suicide attempt, suicidal ideation and violence victimization among transgender and gender diverse patients.
CAMBRIDGE, Mass. — A recent study led by researchers at Cambridge Health Alliance’s Health Equity Research Lab and the Harvard Medical School Department of Psychiatry has found that transgender and gender diverse (TGD) patients from an urban safety net health system experienced more suicide attempts, suicidal ideation and violence victimization than other patients in the health system. The study, published in World Medical and Health Policy, adds to the growing literature around mental health for people who are TGD.
Transgender and gender diverse people are people whose gender identity differs from their sex assigned at birth. Routine collection of gender identity is still limited in national surveys and administrative health databases, which has proven challenging for population health and health system research to understand risks and strengths for TGD populations.
This study identified 916 potentially transgender and gender diverse individuals from medical records by using diagnosis codes related to gender affirming care and searching for and reviewing clinical notes for key words related to gender identity from 2008-2019. The researchers then compared the individuals’ health outcomes to 511,026 other patients in the health system.
The identified TGD patients had more suicide attempts (5.2% vs. 0.4%), more suicidal ideation (20.5% vs. 1.8%) and more violence victimization (5.4% vs. 1.7%) than the other patients in the health system. Violence victimization was also independently associated with higher suicide attempt and ideation. However, patients identified as TGD with no documented evidence of violence victimization still had higher baseline suicide attempt and ideation rates than other patients in the health system who had experienced violence victimization. This suggests that violence victimization partially explains, but does not account for, the difference in suicide risk between the two groups.
The elevated risk of suicide attempt and suicide ideation associated with being a person identified as TGD remained, even after adjusting for age, violence victimization, whether someone had Medicaid health insurance, white vs. non-white race, and the interaction between TGD identity and violence victimization. Identified TGD patients also had higher documented rates of depression and anxiety disorders, substance use, and usage of behavioral and physical health services. Some of the higher rates of mental health and substance use diagnoses may reflect the fact that TGD patients are more likely to be screened for these conditions prior to starting certain types of gender affirming care, such as hormones. Other patients in the health system may be much less likely to have been screened for these conditions and therefore less likely therefore to be diagnosed or in treatment.
The authors believe the study findings point to a need for transgender-affirming policies at all levels. Negative experiences such as marginalization, gender-based discrimination and healthcare discrimination are more common among TGD people in comparison to other groups, including within the LGBTQ+ community. The effects of these negative experiences are made worse by experiencing adverse social conditions such as financial instability, homelessness and unemployment, all of which contribute to higher rates of suicidality.
"Cambridge Health Alliance has started training staff to ask about sexual orientation and gender identity,” said study co-author Nathaniel M. Tran. “As a health system, we started to ask every patient about potential social needs like access to food, housing conditions and violent relationships. By routinely asking our patients about these potential areas of need, we can reduce stigma, provide additional support during their visit and connect them with community resources.”
Other institution-level policies such as publicly posting gender identity and gender expression non-discrimination policies, respecting room assignment preferences, and establishing protocols for affirming interactions with transgender and gender diverse patients can lead to more comprehensive care. Additionally, specific training around suicidality prevention and violence risk assessment should be mandatory for medical providers, trainees and non-medical staff interacting with patients.
Study co-author Natalie Bird noted that in addition to reducing barriers for TGD people accessing healthcare, including health insurance and knowledgeable medical providers, “Efforts should be made to identify the unique needs of the TGD population and how those differ among TGD people based on other identities, like race for example. What specific types of concerns might TGD people have which may be addressed by the healthcare community to demonstrate their support? For example, research on the interaction between contraceptive methods and testosterone treatment for people with uteruses.” She said that future studies may want to shed light on areas in which TGD patients have questions.
"Elevated Rates of Violence Victimization and Suicide Attempt Among Transgender and Gender Diverse Patients in an Urban, Safety Net Health System." Ana M. Progovac, Nathaniel M. Tran, Brian O. Mullin, Juliana De Mello Libardi Maia, Timothy B. Creedon, Emilia Dunham, Sari L. Reisner ScD, Alex McDowell, Natalie Bird, María José Sánchez Román, Mason Dunn, Cindy Telingator, Frederick Lu, Aaron Samuel Breslow, Marshall Forstein and Benjamin Lê Cook. World Health and Medical Policy, published online on March 18, 2021.
Cambridge Health Alliance is an academic community health system committed to providing high-quality care in Cambridge, Somerville and Boston’s metro-north communities. CHA has expertise in primary care, specialty care and mental health/substance use services, as well as caring for diverse and complex populations. It includes two hospital campuses, a network of primary care and specialty practices and the Cambridge Public Health Dept. CHA patients have seamless access to advanced care through the system’s affiliation with Beth Israel Lahey Health. CHA is a Harvard Medical School teaching affiliate and is also affiliated with Harvard School of Public Health, Harvard School of Dental Medicine and Tufts University School of Medicine.