Suicidality in trans-identified youth & the question of media ethics: a roundtable discussion

A few weeks ago, the Washington Post published a story about last year’s tragic suicide of a 14-year-old trans-identified teen named Kyler. Although the Post refers to Kyler by male pronouns, according to earlier reports, Kyler identified at other times as genderqueer and nonbinary, preferring they/them as well as he/him pronouns.

By all accounts, Kyler (a natal female) was fully supported by family, support groups, gender specialists, and friends to identify as and embark upon social and medical transition. The reports also indicate that Kyler had a history of self harm and mental health problems, as well as gender dysphoria, which worsened during puberty. Kyler’s death was one of a cluster of three other similarly supported young teens who died by suicide within 5 months of each other in San Diego, CA in 2015. Kyler and two of the other young people attended the same support group for trans youth. The ongoing emotional devastation experienced by parents, families, and friends of these young people is unimaginable.

This terrible cluster of suicides, including Kyler’s, was widely reported last year. Why did the Post publish another story about Kyler more than 18 months later?

The apparent rationale for the new coverage is that Kyler’s mother has brought suit against San Diego’s Rady Children’s hospital where Kyler was admitted as an inpatient under observation for 24 hours due to suicidality. This brief hospitalization occurred 6 weeks prior to Kyler’s suicide.

The suit alleges that some hospital staff discriminated against Kyler by repeatedly referring to Kyler as female. Although Kyler’s mother stated for the record in the Post story that she is not holding the hospital directly responsible for her child’s death, she makes clear that she believes some staff at the hospital caused serious harm by referring to Kyler as a girl and with female pronouns. She stated that Kyler went into a “spiral” after the events at the hospital.

The Washington Post story was picked up very quickly by Pink News and Gay Star News with headlines asserting that Kyler committed suicide “after hospital staff called him a girl.” (Again, Kyler’s death occurred some six weeks after the 24-hour hospitalization.)

One concern raised by the Post article (and the headlines chosen by the news outlets which re-ran the story) is potential suicide contagion, and how this reporting conflicts with well-established ethical guidelines recommended for news organizations. While these guidelines have been in existence for decades, online blogs and social media, along with the relatively recent phenomenon of stories going “viral,” add a layer of complexity to the longstanding ethical dilemma faced by media who report on suicides. Adolescents, who are most vulnerable to suicide contagion, are almost universally denizens of the Internet, and sensationalized accounts of troubled teens killing themselves are all too easy to find nowadays.

Over 20 years ago, the US Centers for Disease Control and Prevention (CDC) published guidelines for responsible reporting about suicide. These guidelines—still relevant decades after they were written–mirror those released in other countries and by other health care and suicide-prevention organizations.

The CDC guidelines make special mention of the vulnerability of young people to suicide contagion:

 One risk factor that has emerged from this research is suicide “contagion,” a process by which exposure to the suicide or suicidal behavior of one or more persons influences others to commit or attempt suicide. Evidence suggests that the effect of contagion is not confined to suicides occurring in discrete geographic areas. In particular, nonfictional newspaper and television coverage of suicide has been associated with a statistically significant excess of suicides. The effect of contagion appears to be strongest among adolescents, and several well publicized “clusters” among young persons have occurred.

The CDC guidelines list a number of things that news organizations should avoid in their reporting of youth suicide. Among them:

…the likelihood of suicide contagion may be increased by the following actions:

  • Presenting simplistic explanations for suicide.

Suicide is never the result of a single factor or event, but rather results from a complex interaction of many factors and usually involves a history of psychosocial problems. Public officials and the media should carefully explain that the final precipitating event was not the only cause of a given suicide. Most persons who have committed suicide have had a history of problems that may not have been acknowledged during the acute aftermath of the suicide. Cataloguing the problems that could have played a causative role in a suicide is not necessary, but acknowledgment of these problems is recommended.

  • Engaging in repetitive, ongoing, or excessive reporting of suicide in the news.

Repetitive and ongoing coverage, or prominent coverage, of a suicide tends to promote and maintain a preoccupation with suicide among at-risk persons, especially among persons 15-24 years of age. This preoccupation appears to be associated with suicide contagion.

Whether intentional or not, the Post (and the other outlets who republished the story), by their choice of headlines as well as their coverage of the mother’s lawsuit, give the implicit message that it was the hospital’s misgendering that was a leading contributor to Kyler’s suicide 6 weeks after the 24-hour hospital stay. (The Post story diverges from a different account published shortly after Kyler’s death, in May 2015, by the Daily Dot, which, quoting friends and Kyler’s mother, explicitly blamed social media online bullying for Kyler’s death. Other reports last year mentioned the online bullying along with the death of family pets as contributing to Kyler’s deep unhappiness.)

The CDC’s ethical-reporting guidelines emphasize that suicide is always the result of many factors, most prominently a history of mental health concerns; and that news stories focusing on a single cause for a suicide could contribute to suicide contagion in young people. In the case of Kyler’s untimely death and the other young people in the San Diego suicide cluster last year, the Washington Post and other news outlets which revived the story this month focused on gender dysphoria and related “misgendering” in their reporting. But there is broad consensus amongst suicide prevention organizations and researchers that the primary factor consistently tied to a desire to take one’s own life is underlying poor mental health.

Even the often-cited Williams Institute survey study of self harming behaviors in gender nonconforming and trans-identified adults notes that a history of mental health problems is the most frequent underlying cause for suicidality; and that the reported rate of suicidal and self-harming behaviors in their survey did not adequately take into account the well-established link between poor mental health and self-harm:

Second, the survey did not directly explore mental health status and history, which have been identified as important risk factors for both attempted and completed suicide in the general population. Further, research has shown that the impact of adverse life events, such as being attacked or raped, is most severe among people with co-existing mood, anxiety and other mental disordersThe lack of systematic mental health information in the NTDS data significantly limited our ability to identify the pathways to suicidal behavior among the respondents.

Many parents who contribute to 4thWaveNow have felt pressured into agreeing to medically transition their children, due in part to the frequent assertion of a direct causal relationship between gender dysphoria and suicidality, and an underlying assumption that medical transition will halt self-harming behaviors. The terrible story of Kyler’s suicide, revived by the Washington Post, has generated a new discussion among us.

We asked three professionals who work with children and families to respond to the Post article. Their responses, in the form of a roundtable discussion, are presented below, and Stephanie, Lisa, and Lane are available to interact with readers in the comments section of this post.


Stephanie Davies-Arai is a parenting consultant and author of Communicating with Kids. She writes a blog for parents at www.stephaniedaviesarai.com and also runs the website Transgender Trend www.transgendertrend.com, a research-based site for parents and anyone seeking information about the current situation in the UK.

Lisa Marchiano is a licensed clinical social worker and a Jungian analyst. She blogs at www.theJungSoul.com and can be found on Twitter @LisaMarchiano.

Lane Anderson (a pseudonym) is a licensed clinical social worker. Currently in private practice, she previously worked in a clinic serving trans-identified youth. Lane is the author of “Exiles in their own Flesh,” in which she chronicles her experience in the adolescent clinic, and her reasons for reluctantly resigning from her position. 


Stephanie: This is a devastating case and difficult to talk about. The suicide of a child is an awful tragedy and a private grief for the parents that you don’t want to step on. We have to talk about suicide, though, if we want to gain more understanding about how to prevent the same tragedy from happening in other families; and I think there are factors in this case which really need examination.

We don’t know all the details of the case, but what we do know is that this child is part of a wider picture of the sudden, unprecedented increase in the number of girls identifying as transgender at puberty/adolescence, many of whom exhibit the same suicidal ideation and similar self-harming behaviours. We also know that one factor discussed as a key risk to transgender youngsters– lack of family support—is absent here: Kyler was fully supported by mom, family, and a support group.

What is striking in this case is the child’s need for validation not only from family and friends, but from adults and the wider society (not normally a concern for teenagers). This begs the question of what messages the child has received about the necessity of having a fragile identity affirmed by strangers in order to construct a healthy sense of self. The dependence on outside confirmation creates a very shaky foundation on which to build the self, and puts a troubled child in a further disempowered and vulnerable position.

The way this case has been reported only reinforces the message to young people (and their parents) from transgender advocacy groups: that being “misgendered” is a devastating attack from which it is hard to recover. The common narrative of “affirmation or suicide” needs to be strongly challenged if we hope to truly support vulnerable young people in building a strong inner sense of self and identity. In transferring the power to outsiders, a child is left helpless and dependent on the whims of other people, on what they are led to believe is a life or death issue.

Lane: Stephanie, yes. Whether or not a prohibition on misgendering becomes the law of the land, it is always a bad idea to teach over-reliance upon the opinions of others, particularly when one’s opinions require the suspension of disbelief within others. We should encourage trans-identified youth to understand that most people will probably have some trouble digesting the whole transgender concept. While it may appear as if people are fully onboard with affirming a person’s self-proclaimed identity, this may be due to fear of being called transphobic. Also, many youth who are hurting for absolutely legitimate reasons may also be deeply attracted or unwittingly drawn to live inside new social categories that mirror their own preexisting inner states of deprivation/alienation–inner states that are enlarged and/or embodied in collective narratives of oppression.

Stephanie: We don’t know the initial causes of this child’s desperate unhappiness, but it seems to me that “gender reassignment” is fast becoming an instant panacea for all the underlying problems an adolescent may be experiencing, which means they are denied the normal level of care and support from professionals to explore and manage these issues. When a condition comes with as devastating a prognosis as “affirmation or die” we really need to be looking at how helpful the sole diagnosis of “gender dysphoria” really is for young people. Otherwise, we will just keep reinforcing the same narrative that many more troubled young people will grow up to believe as truth.

Lisa: You make an excellent point here, Stephanie. The narrative available to gender dysphoric children is one that offers only the direst of consequences – transition or die. Research does not support transition as a panacea for mental health concerns. Indeed, some research suggests that suicide rates remain very high after transition. As a society, we ought to be very focused on finding a range of treatment alternatives to offer to dysphoric young people.

I was deeply saddened to read the story of Kyler’s suicide in the Washington Post. There is no pain more unbearable than losing a child, and losing a child to suicide is unimaginably awful. From the article, we learn that Kyler was experiencing anxiety and depression and was engaging in self-harming behaviors. Kyler killed himself in spite of being accepted by his friends, and having a family fully supportive of transition. The article states that Kyler “went into a spiral” after hospital employees referred to Kyler as a girl. “They were completely traumatizing him,” his mother is reported to have said.

Hospitals have a duty of care for patients in a way that takes into account their needs and psychological state and to act in a way that isn’t detrimental to the patient’s well-being. However, I was disappointed to see the lack of critical thought presented in the Post’s coverage of the lawsuit brought against Rady Children’s Hospital by Kyler’s family. The Post presented only the superficial story, and did not look deeper into the circumstances that caused Kyler to be so vulnerable.

When transgender activists and the media give kids the message that being misgendered is equal to an act of violence, it sets them up for inevitable wounding and disappointment. We cannot control how others perceive us or what they call us. Hospital staff certainly ought to be as gentle and humane as possible with patients in their care. But if kids are taught that they have a right to expect others to address them according to their wishes at all times, they are being given unrealistic expectations about the world.

The Post’s focus on misgendering obfuscates the complexity of teen suicide in general, and Kyler’s situation in particular. There is much we do not yet know about teen suicide, suicide clusters, suicidality, and poor mental health in those who identify as transgender. Approaching the subject in open-minded spirit of inquiry is the only way to begin to unravel these important topics. The Post’s article gives the impression that we know the answers before we have even asked all the questions.

What a frightening vision of the world trans-identifying must teens must have! They are told that that their choices are “transition or die.” Transgender activists online warn them to be perpetually on guard for being misgendered or “dead named,” and fuel fear and unhappiness by stating that these are both “actual violence.” No wonder trans-identifying teens are scared. Yes, scared. In recent weeks, a handful of trans-identifying teens have contacted me, and this has been the common denominator. They are frightened and confused, and want a place to talk about their feelings where these won’t be shamed or disallowed based upon someone’s rigid ideology. At first, I was so surprised to hear how frightened these young people are, but when I thought about it, it made a lot of sense. Transgender ideology has indeed made the world a frightening place, with few options for young people with gender dysphoria.

Lane: Lisa, this is extremely encouraging that the kids were able to talk to you about their fear. Their anxiety is most likely coming from a natural sense that they are being pulled into something much greater than themselves. From my own clinical practice with trans-identified youth, I often had the feeling that many were partially aware of this loss of control. But to acknowledge what is happening would create a cognitive dissonance they are ill-prepared to tolerate. There are no easy answers to the struggles of living, but the trans-narrative that has sprung up from our liquefying culture like some kind of multi-headed hydra is, in fact, presenting itself in a rather threatening way as The Answer. Of course, it is anything but. The fear the children are expressing is actually healthy, because it reveals their ambivalence about—on the one hand–wanting to believe in the infallibility of the trans solution, yet at the same time knowing in some emergent and liminal part of their psyche that such a threatening narrative will require from them personal sacrifices they may not be willing or able to make.

Lisa: The following is a quote from a recent blog post by a “guy called Helen” entitled “A Culture of Fragility,” excerpted with the author’s generous permission. In this piece, Helen astutely points out how transgender ideology results in a self-concept that is volatile, unstable, and fragile. As Helen knows, it is possible to deal with dysphoria and even live as the other sex without subscribing to a harmful delusion that leaves one at the mercy of others’ perceptions of us.


I’m often told that “Dead-naming and misgendering are literally responsible for the deaths of trans people” and I’ve personally known trans people who have committed suicide. I nearly did so myself a few years ago. I know how much these things can hurt. I used to feel devastated, crushed, invalidated and ashamed.

I was lucky though because something changed for me. I started to see gender as being socially constructed and to see how society conflates femininity with being female and masculinity with being male. I came to accept that it’s ok for me to be a male who looks and acts like I do. How there should be no need for anyone to think I’m *actually* female to be a perfectly valid and worthy person as I am. Accepting this meant I no longer had to live with the cognitive dissonance of believing that I’m female whilst knowing that females don’t father children. It meant I was able to let go of the volatile, unstable belief system that, despite objective reality, I have a female brain and that made me female. So now I’m fortunate that I don’t get too upset, or damaged by somebody using my old name or misgendering me because it doesn’t burst my bubble.

People don’t just self-harm or commit suicide because they are dead named. It might be their final straw, but they commit suicide because they are already volatile and unstable. Their self-worth is fragile because it’s based on a view of the world that relies on everybody else seeing you the way you see self and doesn’t provide any coping mechanisms for when people don’t choose to validate your self-perception. This is what transgenderism does to transgender people. I’m not saying it’s OK to dead-name someone or to misgender them on purpose. It’s rude and inconsiderate at best and dangerous at worst. Doing this might indeed be the final straw that pushes someone over the edge and that’s totally not OK. Of course, it’s always important to be aware of the potential repercussions of our actions and be aware that people are fragile. But I truly believe that identity based politics causes as many problems as it solves and the hypersensitivity to dead-naming and misgendering is one of these things. The trans community actively promotes the view that dead-naming is an act of violence and I can’t help but think that this only exacerbates the negative impact on somebody when they hear this.

Whilst we are still fighting for acceptance, we need to survive the battle. Enough people have died, and we, the trans community, need to think about how we instill a culture of strength and pride rather than a culture of fragility.


Lane: The layers of tragedy in Kyler’s story make it extraordinarily treacherous to discuss. Clearly, the loss of a child to suicide is a catastrophe beyond all comparison. I don’t know how anyone’s heart, if it is still beating, wouldn’t leap to console those survivors remaining in the wake of such a devastating loss. Life will never again be the same for the ones who knew and loved this young person, now gone My heart seizes when I consider the child’s pain. For these reasons alone, social discussions of suicide generally do submit to the authority of those who have been most impacted by its effects. To consider the causes of such tragedy through the lens of reason, which would mandate a level of detachment, could be viewed as callous. A child is gone.

Unfortunately, it is likely the extraordinarily sensitive and traumatic nature of the subject may hinder a more thorough investigation of the conditions surrounding it. But absent the permission to honestly explore possible causes of transgender suicide, we will be hard-pressed to reduce its prevalence. Obviously this isn’t a good thing. We certainly need to increase our understanding of the relationship between those who identify as transgender and their rate of suicide. Though research shows a higher prevalence of suicidality in those identifying as a gender other than their biological sex, we don’t conclusively know why.

As effective, evidenced-based solutions to the problem remain frustratingly at large, naturally we cast about for ways to improve the dire situation. Because nobody wants a child to hurt so badly, we may find ourselves rushing to conclusions, and we might hold firmly to what is at best a working hypothesis on grounds of urgency. But the truth is, until we gather more facts, we should be careful not to close the door on deeper investigation. We must also be careful that any conclusions drawn remain free of political and/or ideological motivations.

Stephanie: I think you’ve said it there, Lane: “nobody wants a child to hurt so badly,” and I would add to that (although it goes without saying really), “especially the parents.” If your own child is suffering depression or anxiety, your biggest fear as a parent is that your child could commit suicide; it’s an automatic reaction to go straight to the worst outcome in your head. The problem is that if we react from that fear we can set in stone for the child the seriousness of the condition and compound the helplessness a child feels. We lose our ability to step back and help them find a way to manage their feelings and find their inner strength, because we become too emotionally involved. My first advice to parents about responding to any emotional problems a child is suffering is “don’t catastrophise it” (and my second point is always “I know that’s really difficult”). The problem is, parents of trans-identified kids try to find information about a subject they know little or nothing about, and inevitably come across the suicide narrative which confirms their deepest fears. How hard does that make it for a parent to communicate trust and confidence in their child, how much harder does it make it for them to try to equip the child with tools to manage their feelings and find different, more self-empowering ways of thinking about their problems?

I’d also say that the message that being misgendered can destroy you is the exact opposite of the message parents try to give their kids in any other area of social difficulty, like being called names, left out or bullied for example. In these cases, we want our child to understand that other people’s actions can’t destroy them, they are stronger than that, they will survive, that they can find ways to protect themselves from people who are mean to them. We acknowledge our child’s feelings, but also try to empower them to be resilient and robust in the face of unkind treatment from others, because we know they will inevitably have to deal with these kinds of situations as they grow up in the world. We might also inform the child’s teachers and do our best to stop any bullying, but we don’t give a child the message “this will destroy you” which I think is the message kids are getting from the trans lobby.

Lane: Some would say that it is society’s lack of acceptance of trans people (signified, partially, in the act of misgendering) which fuels the increase in their rates of suicide. But the assumption that oppression or discrimination is entirely to blame for increased suicidal ideation—which, on the surface may seem compassionate–is not necessarily the best way to actually help those identifying as transgender. Attributing the lion’s share of one’s emotional distress to less than optimal conditions in the social environment is not always an effective means of achieving consistent emotional equilibrium.  Believing one can change the world outside the self, in lieu of finding ways to meaningfully or reasonably adapt to a given environment, is a seductive idea. However, problems invariably arise with this tactic, mostly because the social realms/cultures in which we are deeply embedded are designed to provide relative consistency to their inhabitants; they are not designed to change swiftly. Targeting a slow-to-change external realm as the primary means of altering one’s internal state isn’t generally regarded as the most effective intervention for managing mental unrest.

I fear we may be witnessing the unfortunate convergence of a kind of radical activism with mental health treatment. It doesn’t take a rocket scientist to see the potential problems resulting from the collision course of these two disparate paradigms — one focusing on the environment and the other the individual. Social justice activism, the sort seeking to raise awareness and/or fundamentally alter or deconstruct deeply embedded (and often cherished) beliefs about shared reality (such as the existence of biological sex differences), is mentally taxing in the extreme. Such prolonged and dramatic clashing over the nature of our reality is exhausting for adults; it orients them to a life of battle. Without proper reinforcements, engaging in culture wars can fatigue even the heartiest of souls. Imagine such a call to duty and how it is experienced inside the chaotic mind of your average teen, let alone one whose level of internal chaos may be dangerously elevated.

Lisa: This is a good point, Lane. We need to clarify that we are addressing mental health symptoms, i.e., dysphoria, depression, and anxiety. A transgender identity is not the presenting problem. Rather, it is a self-identification whose significance is determined by activism. As clinicians, we need to be careful that we are assessing and treating symptoms according to a mental health model, and not allow treatment to become ruled by concerns that belong in the realm of social justice and activism.

Lane: Consider such a suddenly gender-dysphoric teen wading into the turbulent battlefield of identity politics, just as they embark on the journey of figuring out who they are. They’ve got serious struggles of their own, but instead of dealing with them on a personal level, in a contained manner, on a private stage tailored to their unique needs, these kids now get corralled into the trans narrative and essentially receive their treatment en masse. Instead of sensitive treatment, they get social-justice activism. From a clinical standpoint, this is appalling. This level of activism puts our youth in harm’s way when they are least prepared to withstand the force of such a cataclysm. They are still children. They are too young and inexperienced to see this is a war for which their bodies, their passions, their hopes, their fears and uncertainties have sometimes been exploited for another’s gain.

The Washington Post article emphasizes the origin of transgender angst as issuing from the outside world, as opposed to being localized within the individual. In this way, it also subtly and perhaps inadvertently relocates the transgender individual’s locus of control outside herself rather than within. Much has been written in the psychological literature about the concept of human agency, and its role in healthy emotional development. Encouraging treatments that inhibit individuals from focusing on ways they can manage in the world, such as increasing their tolerance for distress, or not placing undue reliance upon garnering the proper responses from others to maintain emotional equilibrium, is a better way to keep people from sinking into despair. Overdependence upon changing the world instead of growing the self stunts and inhibits the development of self-awareness (one of the foundations of sound mental health). Activism can blind these young people to alternative solutions that don’t serve the mission of the “cause.” Activism encourages the youth to hunt for and then accentuate problems in the external environment that support the activist narrative. In turn, these youth may become increasingly disturbed by viewing their culture in a negative and punitive light.

Teaching impressionable young people that their psychic safety in this world is absolutely predicated upon whether or not others can or will perceive, as well as actively validate, the profound and idiosyncratic fullness of all that they are, is corrupt pedagogy. It is also a devious form of cruelty.  Those who indoctrinate children with these impossible-to-achieve standards spoil a child’s chance of trusting others, for all the child will likely encounter in such a falsely constructed reality are either lies (from the fearful capitulators) or reactive-anger brought on by feelings of defensiveness from those unable to offer anything less than total validation of the activist narrative. Many people do not appreciate being forced by law and public opinion to so swiftly alter their perceptions of reality. Unfortunately, when these people try to defend their reality, they wind up badly injuring transgender children. The life of a child turned poster child/activist is swirling with fear and deception, all the while most everyone on the sidelines, both supporters and detractors, feel they are defending their version of the good.

Stephanie: It’s frightening how we have been manipulated into believing that “affirmation” is the only caring way to respond to a child confused about gender, that it’s what nice people do. People want to be nice and caring. But of course the issues inherent in medical transition—such as sterilization–are not covered much by the media, so people are being given false and misleading information on which to base their views. And no matter how people try, trans people will always be misgendered because when we meet an adult, the first thing we do is distinguish which sex they are. It’s the most ingrained unconscious response from the primitive brain: “Do I want to mate with this person or should I run from them?” These instinctive responses are there for a reason and of course it’s especially crucial for females to make the distinction. We’re very good at immediately quashing those instincts for fear of appearing rude or unfriendly but is it healthy for us to do so? Is it healthy for children to be brought up to immediately suppress instinctive knowledge because that knowledge is “transphobic”? And of course it’s the opposite of the message we give to our teenage daughters, which we hope will keep them safe. We tell them “trust your instincts, they’re often right. If you feel uncomfortable or threatened by someone, go with that feeling and don’t be afraid of looking unfriendly.” This is a very different issue to teaching children about transgender people and the importance of not discriminating against them. It’s teaching children to re-order reality according to a new subjective belief system which they are obliged to believe in, or at least pretend to.

Lane: The implications of what you say here, Stephanie, are huge. It seems we are teaching children to be fearful of their own instinctive responses. This is what is accomplished when we focus children’s attention on how their instinctive responses could hurt someone else’s feelings. This is quite problematic, as our instincts exist precisely to guide us, as well as provide us with a sense of safety in the world. People who do not know how to listen to themselves, who view their own perceptions as mere static and interference to the greater emerging socially-prescribed “truth” are in serious danger of being exploited.

Stephanie: Yes Lane, and I think that’s especially true for girls who are socialised to be nice and think about others’ feelings first; they really don’t want to appear “rude.” It’s a bigger issue for girls and women, who are often treated as if their perceptions are “wrong” so they may have already learned to doubt them – and that’s part of the reason, I think, that we see that the most vocal support for trans people comes from young women — the group, ironically, who are most at risk of being exploited.

Lane: Now that transgenderism has become so visible in the culture people have feelings and opinions about it they need to express — but these questions and concerns are explicitly forbidden.  How can we discuss this topic when our concerns are equated with invalidating another’s reality, even linked to the transgender person’s urge to die? Who wants to bring out that demon or be branded as responsible for the suicide of another?  So we remain silent, even though a paradigm shift this big cannot be truly integrated into the hearts and minds of others if they are deprived of the right to turn the new ideas around a million times in their head. Additionally, besides being actively silenced in this discussion, our healthy skepticism is also elevated due to the sudden and insistent prevalence of transgender issues in the culture. The trans movement’s debut as the new civil rights movement has felt suspiciously orchestrated from without. Those who take note of this are hardly transphobic; our caution more likely indicates we sense something highly unusual is unfolding within our culture; for from the moment we learned of the transgender narrative, it seemed to already be written in stone. How peculiar. Our kids deserve so much more than this new orthodoxy.  Because activism has supplanted true clinical treatment our most vulnerable youth remain bound in this, the latest installment of received wisdom, before which we all seem to have all lost our inalienable right to question.

Self harm & the need for more possibilities for “gender variant” kids

Holidays can be rough for people who are experiencing family discord–or worse, total estrangement from loved ones. A time like Christmas is also particularly hard on those who are depressed or suicidal for any reason. You’re supposed to feel merry and festive, and the discrepancy between the holiday cheer surrounding you and your own feelings of despair can make that misery stand out in relief.

Joel Nowak, who describes himself as a retransitioned man and social work graduate student, authors the blog Retransition. Today, Joel posted a really important letter he received from a reader named Juniper, who talks about the great need that “gender variant” young people have for options and positive role models apart from medical transition.

Juniper shares thoughts similar to my own regarding suicide risk amongst gender nonconforming young people: Maybe some of the increased risk is not necessarily because these kids are prevented from “transitioning” medically for some reason, but more because they feel  it is imperative that they do transition, or risk being consigned to a miserable life. As Juniper explains, these teens perhaps feel trapped by the transition-or-die message that surrounds them:

A young person who is gender-variant may feel that they have few options but to pursue transition or to live inauthentically. People overwhelmingly hear in the media that surgeries and hormones are absolutely necessary for people who are transgender to live meaningful and happy lives.

There is no representation in the media for people who live quite well and enjoy balanced and well-adjusted lives yet radically defy gender stereotypes.

Our story is not told. People like you and I are virtually invisible.

So, what happens to the kid who is questioning their gender? They look into their options and literally see a DEAD END. No matter what they do, no matter how far they go with surgeries and hormones, they cannot change their DNA or their root socialization. How can they be sure that society will change their perception of them? Can they be sure that they will “pass?” Can they be sure that the secret of their sex at birth will ever be exposed?

They hear that it will be difficult to find a life-partner, that the surgeries are prohibitively expensive and that they will never be 100% like other men and/or women. They learn that surgeries and hormones can only do so much.For instance, if they are FtM, it is unlikely that they will ever have a successful “bottom surgery” even after paying $100,000. And if you are 5’1 as a woman … guess what … you will be 5’1 as a man.

They hear from the media that their future is bleak. This is a lot of stress for a young person to handle. They seek support in the transgender community and there is no Transgender “Pride” parade but rather a Trans Day of Remembrance to remind them that suicide and murder are very real outcomes in their community and that they are disproportionately at risk.

Earlier this year, there was a cluster of suicides of trans-identified San Diego teenagers. At least two of them were seen as leaders in the LGBTQ community, and family, teachers, and friends supported them in their transition.

What went wrong? I wrote about this on Tumblr in October:

The fact that their parents and other adults were supportive and helping them along the road to transition should have made them feel better, if transition were the answer to the horrible depression and self harm these kids were obviously experiencing. Being “gender nonconforming” in this day and age is also really stressful. Gay and lesbian kids who aren’t interested in transition are also bullied and some have parents who are not supportive of them stepping outside gender stereotypes.

Suicide contagion is a real, known phenomenon. The press should not be advertising these suicides the way it has been. The fact that several of these kids have stepped into heavy traffic as a way to die also indicates a “copycat” aspect. And FOUR of them in the same city? Someone should be looking into the reasons for this cluster.

I have also long felt that some of the trans-identified kids who are socially transitioning, with an eye towards medical transition, could be made even more depressed when they think their only option is painful, lifelong medical treatments. That they can’t be accepted as the unique and unusual people they are, without having to constantly worry about how they are perceived by others. We are not looking at the full picture with these kids. The assumption that assuming a trans identity is somehow the solution to this terrible problem of teen suicidality is so overly simplified. And the pressure so many kids feel now to claim a certain identity vs. just being themselves with no “identity” required has to add to the despair.

Also this year, the first trans-male high school homecoming king Blake Brockington jumped off a bridge in Charlotte, NC.  Like some of the San Diego teens, Blake was a well respected leader in the Charlotte, NC LGBTQ community.  And in September of this year, another 16-year-old LGBTQ community leader, Skylar Lee of Madison, WI, took their own life.  Skylar had earlier spoken about claiming, then rejecting, a series of gender identities, shifting every two weeks, before “discovering” s/he was trans.

Again, from Juniper in today’s post on Retransition:

No wonder young “transgender” people commit suicide. They are trying to find themselves and figure things out and when they seek help they are told that they have no option but to change themselves if they want to be loved. No one tells them that they are perfect just as they are. No one tells them that there are many ways to live. No one says “Hey, I made it … I am happily married, I have a good life … it will get better … I was a lot like you in High School and I am glad that I kept my body as it is and/or that I learned to love myself for who I am.”

Many people who are diagnosed as transgender may not be aware that there are lots of ways to live outside of the gender lines. More perspectives need to be shared so that young people can decide for themselves what what resonates, and feels right for them.

How else can we reduce the risk? One reader on Tumblr offered some simple but powerful advice  that seems to me compassionate and practical–no matter what your position may be on the wisdom of “transition” or a transgender identity:

The real way to reduce the rate of suicide among transgender teens:

1. Stop telling people that they have to hurry up and transition or they’ll regret it for the rest of their life. They can transition later and have a happy life.

2. Stop glamorizing transgender teens who commit suicide.

3. Encourage them to get good therapy for their problems and think carefully about whether or not they should transition.

4. Encourage them to stay connected to their family, even if their family is skeptical.

I hope everyone reading this can find a way to connect or reconnect with loved ones and family during the coming week–even if it’s just a text message, a Facebook “like,” a quick phone call, or an unexpected hug. I have to believe that most families that may be under stress right now because of something to do with a loved one’s identity or transition status still have some reservoir of good will to tap…even if only a few drops to quench the thirst we all have for mutual understanding and support.

The 41% trans suicide attempt rate: A tale of flawed data and lazy journalists

If there is one constant in reports about transgender people, it’s the prevalence of suicidal intent.  Nearly all media accounts cite an average 41% suicide attempt rate. A Google keyword search for “transgender 41% suicide” results in over 43,000 hits.

Often, the attempted suicide rate is presented in the context of a story about a young person desperately needing to medically “transition” to the opposite sex. Caitlyn Jenner mentioned the 41% when accepting the ESPY courage award last month, and gender specialists like Johanna Olson routinely bring up suicide as a rationale for hormone and surgical treatments.

In every one of the stories I’ve read, the unspoken or explicit assumption is that transition cures suicidality.

A parent reading one of these stories will be terrified. The very notion that a child might attempt suicide is the worst possible nightmare a mother or father could imagine. The message being hammered  over and over again is that we can only save our young people by supporting their transition to the opposite sex, no questions asked, if that’s what they say they want.  Period. End of discussion. (I have personally been accused of contributing to the risk of youth suicide, simply by raising the questions I do in my blogs.)

So where does this 41% figure come from?

Many media accounts don’t cite the source of the 41% number, but this one does: an analysis released in January 2014 by The Williams Institute, in collaboration with the American Foundation for Suicide Prevention. The report, Suicide Attempts Among Transgender and Gender Non-Conforming Adults, drew its data from a 2008 U.S. National Transgender Discrimination Survey of 6456 self-identified transgender and gender non-conforming adults (ages 18+). Of these, 2566 (40%) were biological females at birth. (As always, natal females will be the main focus of my post.)

A suicide attempt rate of 41% is an emergency. Surely the Williams Institute analysis is conclusive enough to warrant the burgeoning number of gender clinics hurrying to diagnose and start “transitioning” young people who identify as transgender? Does the data convincingly show that gender dysphoria is alleviated by “passing” as the opposite gender, and that medical transition lowers suicide rates?

It does no such thing.

The authors of the study were well aware of its limitations, as I’ll show in this post. But you don’t have to take my word for it: read the AFSP/Williams Institute analysis yourself. It’s written in accessible language and is only 18 pages long, much of which is summarized in easy-to-understand tables. This material could be absorbed by even an average journalist, who presumably is paid to be at least marginally interested in the actual findings of the survey. Even a part-time, unpaid, obscure blogger like me can digest it in under an hour.

But it seems the actual “reporters”—even the ones who cite the source of the 41% figure–don’t analyze the report beyond such generalities as: The results are staggering..disturbing…alarming…

Yes, they are. A 41% lifetime suicide attempt rate is horrific, especially when compared to a 4.7% suicide rate for the US population as a whole, and a 10-20% rate for lesbian, gay, bisexual people (these numbers are according to the authors of the survey). What, exactly, does the survey tell us about attempted suicide in the gender nonconforming (GNC) and trans community?  What is causing this high rate of suicidality?  As with most things, the devil is in the details.

I will not attempt to cover all aspects of the Williams Institute analysis in this post, but will highlight a few of the more interesting nuggets of information I gleaned;  in particular, weaknesses and findings that have not been addressed in other accounts I’ve read.

  • The authors note that the survey was flawed because only one binary, Yes/No question was asked: “Have you ever attempted suicide?” More careful and rigorous studies always follow up with in-person interviews, and when self-harming behaviors (not intended to end life) are controlled for, the actual suicide attempt rate is typically halved—meaning the suicide attempt rate could be as low as 20%.
  • The highest suicide attempt rate of all–60+%–was GNC and trans people who self-report a mental disability. No big surprise there; it’s well known that having certain mental conditions is a risk factor for suicidality. But by the authors’ own admission, the survey made no effort to ask for further details about these mental health issues. The status of having a mental condition was self reported, with no corroboration from medical records or a provider. Nor was there any attempt to discover whether the actual rate of mental illness was objectively higher (via diagnosis by a mental health provider) than reported by the subjects.
  • People who had either sought or received transition-related services had a higher suicide attempt rate than people who have not. And the survey did not ask whether suicide attempts occurred before or after services were sought or received.
  • The data suggest that natal females seem not to be helped at all, in terms of self harm, by being either “stealth” trans or passing as male.  (This is the opposite finding from that of natal males.)

Right from the get-go on page 3, under Methods and Limitations, the authors acknowledge the fundamental flaws in the survey. They urge caution in interpreting their findings:

First, the…questionnaire included only a single item about suicidal behavior that asked, “Have you ever attempted suicide?” with dichotomized responses of Yes/No. Researchers have found that using this question alone in surveys can inflate the percentage of affirmative responses, since some respondents may use it to communicate self-harm behavior that is not a “suicide attempt,” such as seriously considering suicide, planning for suicide, or engaging in self-harm behavior without the intent to die …The National Comorbity Survey, a nationally representative survey, found that probing for intent to die through in-person interviews reduced the prevalence of lifetime suicide attempts from 4.6 percent to 2.7 percent of the adult sample … Without such probes, we were unable to determine the extent to which the 41 percent of NTDS participants who reported ever attempting suicide may overestimate the actual prevalence of attempts … In addition, the analysis was limited due to a lack of follow-up questions asked of respondents who reported having attempted suicide about such things as age and transgender/gender non-conforming status at the time of the attempt.

We could stop right here and say the survey’s main data point–the 41%–is worthless. If, in general population studies, it has been shown that, without followup questions, the rate of actual suicide attempts could be artificially inflated to nearly double, the real rate for GNC/trans people could be closer to 20%. In addition, the authors point out that, without some sense of when the self harm took place, there is no way to determine whether identifying as gender nonconforming or transgender was the key factor in the self-harming behavior.

But let’s not stop there. Even if the rate is closer to 20%, that is still unacceptably high. And self harm is a huge problem, whether the actual intent to end one’s life is present or not.

Second, the survey did not directly explore mental health status and history, which have been identified as important risk factors for both attempted and completed suicide in the general population. Further, research has shown that the impact of adverse life events, such as being attacked or raped, is most severe among people with co-existing mood, anxiety and other mental disordersThe lack of systematic mental health information in the NTDS data significantly limited our ability to identify the pathways to suicidal behavior among the respondents.

In other words, the survey is seriously flawed because there is no reliable information about the actual mental health status of the participants; and, since mental health problems are a known self-harm risk, there is no way to accurately figure out whether the suicide attempt rate is as high as it is due to co-occurring mental illness–not necessarily because of  “gender dysphoria.” Further, another high risk factor for suicidality is being physically or sexually assaulted, especially for people with mental health disorders.

So the authors tell us two things: the 41% figure should be interpreted with great caution; and the causes of the elevated self harm/suicide attempt rate (whatever that rate actually is)–the “pathways”–cannot be reliably determined.

Williams Table 12

What about people who have contemplated or received medical transition services? The survey tabulated everything from transition-related counseling to bottom surgery:

Respondents who said they had received transition related health care or wanted to have it someday were more likely to report having attempted suicide than those who said they did not want it. This pattern was observed across all transition-related services and procedures that were explored in the NTDS.

Williams Inst suicide table 5

People who said they “did not want” these services had a lower self-harm rate. Does medical transition, or seeking transition services, decrease or increase suicide attempt rates? We don’t know, because the survey didn’t ask respondents if the self harm occurred before or after such services were soughtas the authors note:

The survey did not provide information about the timing of reported suicide attempts in relation to receiving transition-related health care, which precluded investigation of transition-related explanations for these patterns.

This is very important: I have most often seen the 41% rate mentioned, with no caveats or analysis, to justify young people receiving medical transition services. It’s clear from the authors’ own words that this survey cannot be responsibly used as a basis for the presumption that medical transition reduces self harming behaviors over the lifespan.

And now to one of the more interesting findings in the Williams Institute report:  natal females (in contrast to natal males) who say other people generally don’t recognize them as trans or GNC have the same or higher suicide attempt rate as females who are more often recognized by others.

Williams Table 7

Trans men (FTM) were found to have the same prevalence of lifetime suicide attempts (46%) regardless of whether they thought others can tell they are transgender. … for respondents in the last two gender identity categories – female-assigned cross-dressers and gender non-conforming/genderqueer people assigned female at birth – the prevalence of lifetime suicide attempts was found to be higher among those who said other people “occasionally” or “never” can tell they are transgender or gender non-conforming, compared to those who said that other people “always,” “most of the time,” or “sometimes” can tell. 

And later–buried  in the Executive Summary, we find this:

Importantly, our analyses suggest that the protective effect of non-recognition is especially significant for those on the trans feminine spectrum. For people on the trans masculine spectrum, however, our data suggest that this protective effect may not exist or, in some cases, may work in the opposite direction.

What does it mean to “not be recognized” as transgender or gender nonconforming? It could be one of two things: these natal females “pass” as male, or they are secretly gender nonconforming, perhaps cross dressing at home, in private. But in either case, being stealth or passing doesn’t seem to alleviate the urge to self harm.

I am going to guess that, for at least some of the natal females who answered this survey question, they did interpret  “people can’t tell”  to mean that they usually “pass” as male.  So for at least some of these females,  being perceived as male didn’t help them.  And FTMs, by all accounts, “pass” better than MTFs. Why wouldn’t passing relieve the distress for these female-born people? What is causing the misery in girls and women who are GNC or trans-identified?

If self harm risk remains elevated for many young women, whether they “pass” or not, wouldn’t a more compassionate and prudent approach be to help them–and their families–accept themselves as females who simply don’t fit societal gender norms? Many of these girls, prior to transition, live a lesbian lifestyle (even if they reject the label “lesbian”). How much kinder would it be to help them embrace the only bodies they will ever have, with the sexual preference they have, instead of endorsing extreme interventions that may never resolve their dysphoria?

Elsewhere in the survey, we learn that lack or loss of family support is a big factor in self-harm risk. This seems like a no-brainer. But support for what? Accepting a loved one’s gender expression or identity is not the same as getting on board with hormones and surgery. In fact, by encouraging the idea that they must medically transition (which entails lifelong and sometimes painful interventions) to be happy, might family and gender specialists even be increasing the risk of self harm?

It’s obvious that teens who are gender nonconforming are bullied and rejected because they don’t fit into the stereotypical boy or girl box–however they subjectively identify.  And like all kids, they just want to be accepted. Listen to Ash Haffner, the 16-year-old from Charlotte, North Carolina who died (as Joshua/Leelah Alcorn did) by bolting in front of a moving vehicle in February 2015, writing this days before her death:

if I die…I don’t want to be remembered as the faggot gay girl with all the scars on her arm. unfortunately thats who I am to alot of people. if those people would have just stayed silent and kept their ignorant thoughts in their heads then maybe i wouldn’t have those scars on my arm. maybe. it wasn’t always about what they had in their heads, it was what was inside of mine to. i just didn’t understand why i felt the way i did when i had a decent life. i may have come from a broken family but i always had a roof over my head and a loving mother who fully accepted me for who i was and never stopped trying. she was the only person who never gave up hope on me. but anyway, i don’t want to be remembered as the girl with problems, just remember me as someone who understood and stayed strong for as long as i could.”

Ash’s mother, who, according to media accounts, accepted her child as whatever gender Ash preferred, said:

“She was trying to figure out her identity,” Quick said. “She felt like a boy trapped in a girl’s body. She was caught somewhat in between. People weren’t really giving her the time to figure herself out. … All she wanted was for people to just accept her. Ash started enduring the most bullying when she cut her hair short.”

Ash’s “gender nonconformity”–her short hair, for crying out loud–is what caused the increase in bullying. Isn’t our challenge, as parents, as therapists, as a society, to  support our young people when they step outside stereotyped gender norms? To allow a girl to have a crew cut or wear boxer shorts? For a boy to wear a dress if he wants?


The Williams Institute analysis raises many more questions than it answers. It seems clear that being–or, more precisely, identifying as–some flavor of gender nonconforming or trans is correlated with a high rate of self harming behaviors. Mental health problems, coupled with a history of physical and/or sexual abuse or trauma, are associated with the highest risk of self harm. But judging by the evidence, gender specialists don’t seem to be taking those key risk factors into account when prescribing “transition” as an answer.

Whether the majority of these individuals who have self-harmed will ultimately benefit from medical transition is unknown (and for young people, this will not be known for years, if not decades), but there is absolutely nothing in the Williams survey analysis to indicate that medical transition will decrease suicidal intent or self harm.

In the words of the survey authors themselves:

Well-designed studies that specifically engage the transgender community will continue to be needed to identify and illuminate the health and mental health needs of transgender people, including access to appropriate health care services.

How about including the following things in “appropriate health services” for gender dysphoric young women?

  • family therapy aimed at helping parents and young women come to terms with being “gender nonconforming” women
  • evaluation and therapy for underlying mental health issues apart from gender dysphoria
  • strong female role models for girls and young women that don’t entail conforming to porn star chic
  • support for and acceptance of lesbian identity– especially for girls who don’t look like the gender-conforming, makeup-wearing “lesbians” on the “L” Word

Given the flawed data available to us, the leap in logic to assume the only viable choice is to medically transition or die ought to shame any provider, researcher, or journalist worth their salt. The Williams Institute data, if looked at honestly, should instead spur providers to offer effective psychological health evaluation and treatment for both young people and their families, and the least invasive intervention possible.