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Transgender and gender non-conforming (TGNC) youth experience severe discrimination which has been linked to adverse mental health outcomes, including an increased prevalence of suicidality and self-harm. Few epidemiological studies have examined this relationship; thus, we studied the relationship between hospitalization for suicidality, self-harm and gender dysphoria in a large, nationally representative database.
We used the 2016 Kids’ Inpatient Database to identify a subset of TGNC youth < 21 years of age captured by the database (using ICD-10 gender dysphoria-related codes). We identified suicidal ideation or suicide attempt using either explicit “suicidality” codes, or one of 355 distinct self-harm codes. Using descriptive statistics, prevalence of suicidality and self-harm was compared between youth with and without gender dysphoria. A multivariable logistic regression model adjusting for individual, admission and hospital-level variables was constructed looking for association between gender dysphoria and suicidality.
The cohort included 3,115,589 subjects, of whom 1,980 (64 per 100,000 admissions) had gender dysphoria. Analysis of demographic variables revealed the gender dysphoria diagnosis group was comprised of a disproportionately lower proportion of non-white, publicly insured, and low median income young adults compared to the entire cohort. Prevalence of suicidal ideation and suicide attempt in the entire cohort was 2%, compared to 35.3% in young people with gender dysphoria. Using the expanded definition of self-harm and attempted suicide, prevalence increased to 44.1%. After adjusting for individual, admission and hospital-level variables, subjects with gender dysphoria had 7.89 increased odds of attempted suicide or suicidal ideation (95%CI: 7.09-8.79).
Using a large and representative database, we found significantly higher prevalence of suicide attempt and self-harm in hospitalized youth with a gender dysphoria-related diagnosis. For youth hospitalized after suicide attempt or self-harm, gender-affirming care and inclusive language is essential to reduce psychological stress secondary to physician-mediated interpersonal discrimination. Importantly, this study only captured TGNC youth with a formal gender dysphoria diagnosis, and not all youth who identify as TGNC have a diagnosis or disclose their identity; thus, the results should not be generalized to the entire population of TGNC youth. Furthermore, there were fewer non-white, publicly insured, and low median income youth with a gender dysphoria diagnosis compared to the entire cohort, which suggests inequities in accessing gender-affirming care among racial minority and economically disadvantaged youth. The results of this study highlight the need for structural interventions and policies to reduce discrimination and improve access to gender-affirming care in order to prevent these adverse outcomes.
Sources of Support
Stoneleigh Foundation, Leadership Education in Adolescent Health.