Transgender and gender diverse individuals (TGD), those whose gender identity is incongruent with their sex assigned at birth, experience significantly disproportionate rates of minority stress and suicide. While growing, the body of research examining the relationships between minority stress and suicide, particularly within TGD groups, remains in its infancy. Thus, it is imperative researchers identify population-specific factors for the development of effective prevention strategies. Established research in the area of TGD suicide often focuses on adolescents (12-18 years old) or adults (18+ years old), infrequently identifying the distinct group of young adults (18-24 years old). As the adult age group most often demonstrating the highest risk for suicide, young adults cannot continue to be overlooked in suicide research. Further, though many research agendas include the social determinants of health, studies inadequately incorporate measurement of minority stress that is inclusive of the socioenvironmental contexts through which these experiences occur and those contexts most proximal to the individual (family, school, religious/spiritual community, and work). Thus, this dissertation aims to advance the science of suicide among TGD young adults by elucidating the associations of sociodemographic variables, context-specific, and cumulative microsystem minority stress experiences with suicide outcomes.
The goal of the study is to characterize suicidality among TGD young adults using an approach that integrates sociodemographic and minority stress factors with an ecological systems perspective. The primary aims are to: (1) summarize the established relationships between contextual minority stress factors and TGD young adult suicide outcomes, (2a) examine the associations between sociodemographic factors and 12-month and lifetime prevalence of suicidal ideation (SI) and suicide attempt (SA) among TGD young adults, (2b) examine the associations of sociodemographic factors and 12-month SA among TGD young adults with 12-month SI, (3a) examine the associations between context-specific and cumulative microsystem minority stress factors effects and 12-month and lifetime prevalence of SI and SA among TGD young adults, and (3b) examine the associations between context-specific and cumulative microsystem minority stress factors and 12-month SA among TGD young adults with 12-month SI.
To address the first aim, a critical literature review was conducted resulting in 76 included articles. Synthesis of the evidence suggests contextual empirical investigation remains underdeveloped in elucidating the relationships between minority stress experiences and suicide outcomes among TGD young adults. Specifically, religious/spiritual and work contexts have minimal evidence to support clear associations. Further, TGD research continues to require greater awareness and consideration for the heterogeneity within the population to improve the accuracy of evidence as well as better inform suicide risk assessment.
To address the second aim, sociodemographic factors including gender identity, race/ethnicity, sexual orientation, homelessness, and poverty were examined in relation to suicide outcomes using predicted probabilities to estimate comparisons for all levels of the categorical variables. Predicted probabilities were, overall, notably high in value with the probability ranges among SI and SA outcomes being 47 - 94% and 8 – 63%, respectively. Among the five independent variables, gender identity and experienced homelessness demonstrated the most robust findings with significant associations (p < .001) to all suicide outcomes.
To address the third aim, contextualized and cumulative microsystem minority stress experiences were investigated in relation to suicide outcomes using multivariable logistic regression modeling. In all cases, higher minority stress scores were associated with significantly greater odds (p < .01) of all suicide outcomes. Though adjusted odds ratios did not significantly differ from one another, there was variability in which context (family, school, religious/spiritual community and work) had the greatest odds ratio for each outcome. When evaluating cumulative microsystem minority stress by exposures of low, medium, and high, the odds ratios significantly differed from one another. In adjusted models compared to those with low exposure, those with medium exposure ranged from 1.282 – 1.759 times (p < .001) greater risk for suicide. Similarly, those with high exposure ranged from 1.885 – 3.399 time (p < .001) greater risk for suicide compared to those with low exposure.
Findings of this dissertation identify remaining and urgent gaps in the literature on suicide among TGD young adults, contribute important knowledge about suicide risk acuity within heterogenous groups of TGD young adults, and offer insight toward targeted, upstream intervention aimed at reducing suicide risk and mortality. Further, these results can contribute to enhanced suicide risk assessment in clinical and community settings as well as policy advocacy that actively supports mental health equity.