When Depression Turns Deadly: Society, Suicide and Transgender People
Social and political dysfunction can push transgender people into dark places. They need allies.
Content warning: This article, part of a Wise & Well Special Report, The United States of Depression, contains descriptions of suicidal thoughts and behaviors.
Like other healthcare professionals, I’m trained to think about the worst-case scenario: What’s the most dangerous thing that could be going on with this person? We also have to think about who’s in front of us, and how likely a given problem is for people like them. The top concern I have for young adult patients, and especially young transgender patients, is suicide.
In the college health clinic where I work as a nurse practitioner, I often see young adult patients who identify as transgender. Sometimes they come in to discuss hormone therapy and other gender-related care, but most often, they have the same kinds of health problems as other young adults: minor injuries, infections, and mental health concerns like depression and anxiety.
Depression in particular has me worried. A recurring theme I hear from transgender patients is that they’re scared, sad, and angry — not exactly a recipe for happiness and stability. It’s no surprise that depression is extremely common among this group.
It’s easy to look at news stories about discrimination against transgender people — like laws prohibiting the use of hormone therapy, access to bathrooms, or participation in sports — and feel frustrated (I do). But seeing the impact of this structural violence on individual people hits different. It’s not an abstract political problem. Discrimination against transgender people can endanger their lives.
The grim statistics
The numbers are shocking: 98% of transgender people who have experienced repeated discrimination and violence have thought about suicide, and 51% of them have attempted it, according to the Williams Institute.
On top of that, young queer people want and need help, but they aren’t getting it. The Trevor Project reports that 81% of LGBTQ youth want mental health care, yet only 44% of those wanting care are able to access it.
Sky-high rates of depression and suicidality aren’t an inevitable part of being transgender, though. They are consequences of a brutal political and social environment and a lack of adequate support and treatment.
Hostile rhetoric targeting transgender people has escalated in the political sphere in recent years. There is absolutely zero evidence that transgender people make bathrooms (or sports, or streets, or schools) unsafe, but the facts don’t matter in the culture wars. Repeated media messages suggesting that transgender people are somehow dangerous are politically useful, so they continue. And they turn into policy, too, effectively legalizing discrimination.
Minority stress: The toll of everyday discrimination
The mental health toll of being a political football is striking, especially for adolescents and young adults. Imagine being unable to be honest with your parents at home, then going to school and being aggressively bullied by other students, then coming home and seeing news stories about laws prohibiting people like you from playing sports or using public bathrooms. This isolation and negative messaging creates fertile ground for depression.
We know that health suffers when a person is under chronic stress from discrimination and threats of violence. The minority stress model suggests a reason why: External stress (like bullying and violence) contributes to internal stress (like internalized transphobia and perception of burdensomeness). Internal stress is a major contributing factor to depression and suicide (among other health problems) including in young adults.
Feeling socially excluded and politically attacked can “increase stigma and prejudice and related exposure to minority stress, which contributes to the high rates of substance use and suicidality we see among transgender people,” according to Ilan H. Meyer of the Williams Institute.
A person needs to get their basic safety needs met before they can work on things like intimacy, respect, and self-actualization (classic Maslow’s hierarchy of needs taught in Psych 101). Take away safety, and one has a hard time protecting their mental health, let alone thriving.
Belonging matters
I recently saw a transgender patient we’ll call Milo (names and a few personal details are changed for privacy, but the stories are real). Milo is a transgender man who struggled in high school. He grew up not knowing any other trans people, and he didn’t know how to talk to his parents about who he was. It was really lonely and confusing.
He told me he’d always known that his true identity was as a boy, but he didn’t feel like he could talk to anyone about it. He didn’t know anyone else like him. He read the news about anti-trans laws and felt that he didn’t want to be trans if that’s what it meant. He heard adults make jokes and comments about trans people. He felt like there was nowhere he could go and nowhere he was safe. He worried that he was a disappointment to his family. All this, and he was still in high school.
Milo was severely depressed for years, but he didn’t talk to anyone about it because he was scared he’d be blamed and shamed. He couldn’t get treatment for his depression. In his junior year of high school, he decided he wanted to die.
He didn’t figure out how, though, and he eventually made it to college, where he saw me and got therapy and medication. He met other trans students. He lived in a state that allowed him to update his ID. He started to feel better. And now he’s on track to graduate with a degree in sociology.
This isn’t everyone’s story, but it’s a common one. When people feel safe, they’re able to thrive.
Access to safe healthcare isn’t a sure thing
I recently met a new patient, a transgender woman we’ll call Chloe. She was guarded and on edge the first day she sat in my office, giving one-word answers to my questions and sitting with her arms and legs crossed. The staff at my clinic work hard to provide a welcoming and safe environment, but she wasn’t ready to fully trust me.
It’s no wonder: Most transgender people have had negative experiences in healthcare settings. Sometimes it’s blatant bigotry, but more often, it’s unintentional, born from ignorance. Forms don’t have the correct gender options. Staff use the wrong pronouns. There aren’t bathrooms that are open to any user. All of these seemingly small things, taken together, send the message that it’s not safe here. This happens a lot, both in medical and mental health settings. Getting help is harder than it is supposed to be.
Access to mental health care (like counseling and psychiatric care) is clearly needed, but gender-affirming medical care improves mental health, too. “Improved appearance congruence secondary to hormone treatment is strongly linked to better mental health outcomes in transgender and nonbinary youth,” says Diane Chen, PhD, of Northwestern University.
Gender-affirming care can literally save lives: transgender people who want hormone therapy and/or surgery have fewer suicidal thoughts when they’re able to access these services, according to a report from the Williams Center. Another study published in JAMA Open in 2022 similarly found that gender-affirming medical care was associated with lower odds of depression and suicidality in transgender youth.
Be an ally
Transgender people without supportive families and who live in states with discriminatory laws have more suicidal thoughts and suicide attempts, according to the Williams Institute’s report.
It’s heartbreaking, but it also contains a kernel of good news: It means that we can prevent some of the damage if we can increase support and defeat discriminatory laws. It’s clear that feeling accepted and safe matters to mental health.
You don’t have to be a mental health professional to help make change. Allyship is available to everyone, and it makes a difference. Every opportunity to create a safe and inclusive environment helps. Look for ways to create safety. Advocate for protective, not discriminatory, policies. Challenge misconceptions. Apologize if you make a mistake. Be open to changing your mind.
Some of the transgender college students I see in my clinic come from families and places where they have not felt safe. On campus in a state that’s friendlier to transgender people, they are able, often for the first time, to express themselves fully. Witnessing the transformation of a young person from depressed and scared to healed and happy is powerful.
As Lyric, a young trans woman, wrote in No Pride Without Trans Youth, “It’s getting difficult. We go through stereotypes and discrimination against our transitioning and our gender roles. . . I really just send out hope and pray that those who are having difficulty right now with trying to come out and live their best life, I pray that they find the light one day and they can have peace with being who they want to be.”
This article is part of a Wise & Well Special Report: The United States of Depression. If you or a loved one is depressed, it’s vital to talk about it. Because depression increases the risk of suicide, consider calling the confidential National Suicide Prevention Lifeline at 1–800–273-TALK (8255) for English, 1–888–628–9454 for Spanish, or call or text 988. Global support in 44 languages is available from Befrienders Worldwide.