Factors Associated with Suicidality Among a National Sample of Transgender Veterans

Correlates of past‐year suicidal ideation and lifetime suicide risk among a national sample of transgender veterans were examined. An online, convenience sample of 212 U.S. transgender veterans participated in a cross‐sectional survey in February–May 2014. We evaluated associations between sociodemographic characteristics, stigma, mental health, and psychosocial resources with past‐year suicidal ideation and lifetime suicide plans and attempts. Participants reported high rates of past‐year suicidal ideation (57%) as well as history of suicide plan or attempt (66%). Transgender‐related felt stigma during military service and current posttraumatic stress disorder and depressive symptoms were associated with suicide outcomes as were economic and demographic factors.     

Transgender youth and life-threatening behaviors

Sexual minority status is a key risk factor for suicide among lesbian, gay, and bisexual youth; however, it has not been studied among transgender youth. Fifty-five transgender youth reported on their life-threatening behaviors. Nearly half of the sample reported having seriously thought about taking their lives and one quarter reported suicide attempts. Factors significantly related to having made a suicide attempt included suicidal ideation related to transgender identity; experiences of past parental verbal and physical abuse; and lower body esteem, especially weight satisfaction and thoughts of how others evaluate the youths' bodies. Sexual minority status is a key risk factor for life-threatening behaviors among transgender youth.     

Internalized transphobia and mental health among transgender adults: A nationwide cross-sectional survey in South Korea

Abstract

Introduction: Transgender people are stigmatized in South Korea (hereafter Korea), where cultural expectations of a biologically-based, binary sex and gender system present fundamental challenges to those whose gender identity does not align with their birth-assigned sex. A growing international body of literature implicates gender minority stress as a key contributor to transgender mental health disparities, but little research has been conducted on this topic in Korea. As in other cultural settings, depression and suicidality are urgent public health concerns for transgender people in Korea, primarily for those who have not initiated gender affirming medical treatment (GAMT), such as cross-sex hormone therapy. In the current study, an international and interdisciplinary team of authors apply the lens of gender minority stress to elucidate the relationships between a key facet of gender minority stress, internalized transphobia (ITP), and outcomes of depressive symptoms and suicidality.

Methods: Based on a cross-sectional survey of 207 Korean transgender adults, the current study evaluates the relationships between ITP and depressive symptoms, suicidal ideation, and suicide attempts. ITP was measured with an eight-item, Korean-language questionnaire adapted from the Gender Minority Stress and Resilience Measure through a translation and back-translation process.

Results: Korean trans women and trans men mean (mean age?=?26.4) were included in the analysis, most of whom had at least one experience of any GAMT. The findings of this study show that Korean transgender adults face similar public health concerns such as high prevalence of depressive symptoms, suicidal ideation, and suicide attempts. As predicted, ITP was significantly related to depressive symptoms, suicidal ideation, and suicide attempts.

Conclusion: The authors suggest potential clinical, policy, and research applications, including institutional interventions, to address structural and cultural barriers to optimal mental health and GAMT as well as mental health interventions to reduce Korean transgender people’s internalized negative beliefs about their gender identity.     

Suicide Risk among Lesbian,Gay, Bisexual,and Transgender Military Personnel and Veterans: What Does the Literature Tell Us?

Research suggests that both the military and veteran and the lesbian, gay, bisexual, and transgender (LGBT) populations may be at increased risk for suicide. A literature review was conducted to identify research related to suicide risk in the LGBT military and veteran populations. Despite the paucity of research directly addressing this issue, themes are discussed evident in the literature on LGBT identity and suicide risk as well as LGBT military service members and veterans. Factors such as social support and victimization appear to be particularly relevant. Suggestions are made with respect to future research that is needed on this very important and timely topic.     

Post-Admission Cognitive Therapy for a Transgender Service Member With a Recent Suicidal Crisis: A Case Study of Gender-Affirming Care

While elevated suicide risk in the American military and veteran population has led to the development of targeted interventions, the increased risk of suicidal ideation and behavior among transgender and gender diverse (TGD) Service members requires that interventions address suicide risk within the context of minority stressors and gender-affirming care. This case study presents Jordan (an alias), a transgender Service member who received inpatient psychiatric treatment following a suicide attempt precipitated by distress relating to gender dysphoria, minority status, and associated stressors. Jordan completed Post-Admission Cognitive Therapy (PACT; Ghahramanlou-Holloway, Cox, & Greene, 2012), a cognitive-behavioral intervention targeting suicide risk among military personnel and dependents psychiatrically hospitalized following a suicidal crisis. Within the context of PACT, Jordan’s treatment included identifying and addressing distress related to minority stressors (externalized stigma, internalized transphobia, anticipated rejection, gender concealment) using gender-affirming best practices. Marked changes in Jordan's self-report measures from baseline to follow-up, as well as qualitative changes reported by Jordan, demonstrate that she felt comfortable, safe, and ready to be discharged from the inpatient unit after completing PACT treatment and gaining exposure to the skills necessary to help prevent and/or manage future suicidal crises. Treatment implications and recommendations for addressing suicide risk within the context of gender-affirming care and prevalent minority stressors are discussed.     

History of military service and the risk of suicidal ideation: findings from the 2008 national survey on drug use and health

Studies of completed suicide by history of military service have produced inconsistent findings; no representative population‐based study has compared the risk of nonfatal suicidal behavior among veterans with risk among nonveterans. The objective of this study was to examine whether male veterans of the U.S. military are at heightened risk of suicidal ideation, compared with males who never served in the U.S. military. A total of 17,641 adult men completed the 2008 National Survey on Drug Use and Health (NSDUH). Subjects provided information about history of ever having served in the U.S. armed forces, past suicidal ideation, alcohol and drug abuse and dependence, measures of psychological distress, and sociodemographic data. Overall, men who had ever served in the armed forces were no more likely than men who had never served to report having seriously considered suicide over the prior 12 months. Military status was not differentially associated with other known suicide risk factors assessed by NSDUH, including psychiatric disorders. Our findings suggest that evidence‐based suicide prevention strategies applicable to the general population should be employed to reduce suicide risk among the veteran population as well.     

Risk and Resiliency Factors Influencing Suicidality Among Urban African American and Latino Youth

For decades, suicide rates among minority African American and Latino young people have been stable and, when compared with Whites, relatively low. This is no longer the case, underscoring the need for documenting and understanding the problem of suicidality in this population. We report on the prevalence and predictors of suicidality among 879 urban adolescents in the Reach for Health study. All youth resided in economically disadvantaged neighborhoods; 69% were African American, 16% Latino, and 15% reported mixed or other ethnicity. In the past year, 15% had seriously considered suicide; 13% had made a suicide plan, 11% had attempted suicide at least once, and 4% reported multiple attempts. Risk factors significantly related to suicidal ideation are being female, having basic needs unmet, engaging in same-gender sex, and depression. Resiliency factors include family closeness and, marginally, religiosity. Risk factors related to reports of suicide attempts are being female, being Hispanic, and depression; family closeness is strong resiliency factor. Family composition, ethnic identity, coping style, peer support, and school attachment are not significant correlates of suicidal ideation or attempts.     

Trajectories of Suicide Ideation,Nonsuicidal Self‐Injury,and Suicide Attempts in a Nonclinical Sample of Military Personnel and Veterans

Nonsuicidal self‐injury (NSSI) is a risk factor for suicide attempts, but little is known about NSSI among military personnel and veterans, or about the temporal sequencing of NSSI relative to suicide ideation and attempts. This study evaluates trajectories of suicide ideation, NSSI, and suicide attempts in a sample of 422 military personnel and veterans. Of those with a history of NSSI, 77% also experienced suicide ideation. Suicide ideation emerged before NSSI (67%) more often than the reverse (17%). Of those with a history of suicide attempt, 41% also engaged in NSSI. NSSI emerged prior to the first suicide attempt (91%) more often than the reverse (9%). The length of time from suicide ideation to suicide attempt was longer for those who first engaged in NSSI (median = 3.5 years) compared with those who did not engage in NSSI (median = 0.0 years), Wald χ²(1) = 11.985, p = .002. Age of onset was earlier for participants reporting NSSI only compared with those reporting both NSSI and suicide attempts (16.71 vs. 22.08 years), F(1, 45) = 4.149, p = .048. NSSI may serve as a “stepping stone” from suicide ideation to attempts for 41% of those who attempt suicide.     

The Association Between Gender,Ethnicity, and Suicidality Among Vocational Students in Israel

Gender and ethnicity are significant factors when evaluating suicidal risk, especially among ethnically diverse populations. In the current study we explored the association between gender, ethnicity, and suicide ideation and attempts among Arab and Jewish vocational education and training high school students in Israel. Students (N = 3,554) completed a self‐report survey evaluating suicide ideation and attempts, depression, anxiety, somatization, and sense of belonging. Hierarchical generalized linear modeling indicated that female Arab adolescents had elevated levels of suicide ideation, higher rates of suicide attempts, and greater psychological distress than Arab males and Jewish students. Furthermore, female Arab adolescents were found to be more susceptible to suicide ideation when depression levels were high. These results are discussed in the context of the double‐jeopardy Arab young women face, as members of a minority ethnic group in Israel and their status as women within the patriarchal Arab culture.     

The Association of Multiple Identities with Self‐Directed Violence and Depression among Transgender Individuals

Transgender individuals have a high prevalence of self‐directed violence; however, there is scant literature focusing on their unique experiences. The differences in self‐harm, suicidal ideation, suicide attempt, and depression based on racial/ethnic identity and sexual orientation were examined among transgender individuals. Data were gathered from the Fall 2008 and Spring 2009 National College Health Assessment. Across racial/ethnic identities, greater proportions of transgender students endorsed self‐directed violence than their cisgender peers. Among transgender individuals, sexual minorities were more likely to report suicidal ideation than their heterosexual peers, and racial/ethnic minorities had higher odds of attempting suicide than non‐Hispanic White individuals.     

Suicide Ideation in Female Survivors of Military Sexual Trauma: The Trauma Source Matters

Female veterans who have experienced military sexual trauma (MST) are at elevated suicide risk, yet knowledge is limited regarding correlates of suicide ideation (SI) in this population. MST is associated with a higher risk of posttraumatic stress disorder (PTSD) relative to other trauma types; however, no studies have examined whether experiencing SI differs based on the source of PTSD symptoms (MST‐related, non–MST‐related). Female service members/veterans (SM/Vs; n = 311) who screened positive for MST and reported exposure to a Criterion A event completed an online survey assessing self‐reported demographics, PTSD, depression, the source of their PTSD symptoms, and SI. Ninety‐one (29.3%) reported experiencing current SI, and 223 (71.7%) identified MST as the source of their current PTSD symptoms. Participants who identified MST as the source of their PTSD symptoms were over two times more likely to report SI, compared to those who described non–MST‐related events as the source of their PTSD symptoms. Compared to those who reported the source of their PTSD symptoms as combat‐/deployment‐related, those who identified MST as the source were at least three times as likely to report current SI. Results underscore the importance of efforts to address MST‐related PTSD symptoms when working with female SM/Vs.     

Suicidal Self‐Directed Violence Among Homeless US Veterans: A Systematic Review

A systematic review of the literature was conducted to investigate suicidal self‐directed violence and homelessness among US military veterans, and identify existing suicide prevention strategies. In November 2015, MEDLINE, EMBASE, PsycInfo, CINAHL, Web of Science, Cochrane Library, Google, and Google Scholar were searched. Articles published since 1990 investigating self‐directed violence among homeless veterans were identified. Data were extracted and synthesized qualitatively. Nineteen observational studies were included. Suicide ideation rates were 1.3% (current), 7.0% (past week), 12.1%–18% (past 30 days), and 74% (lifetime). Suicide attempt rates were 0%–6% (past 30 days), 30.7%–31.5% (past 5 years), and 15%–46.6% (lifetime). Death by suicide rate was 81.0 per 100,000. No interventional studies to prevent self‐directed violence among homeless veterans were identified. Homeless veterans are at risk for self‐directed violence, suggesting the need for research to examine preventive strategies. A comprehensive public health approach to suicide prevention needs to focus on vulnerable populations, including homeless veterans.     

State of Innovation in Suicide Intervention Research with Military Populations

A systematic search was performed to identify active, externally funded randomized controlled trials (RCTs) that target suicidal ideation or behavior as a primary or secondary outcome among U.S. military service members, guard–reservists, and veterans. Twenty‐three studies were identified, most funded by the U.S. Department of Defense or U.S. Department of Veterans Affairs. Several innovations were identified based on departures from or modernizations of usual practices and included the targeting of suicide deaths or attempts as primary outcome, delivery of interventions through technology and/or outside clinical settings, and examinations of rarely studied treatments.     

The Associations of Physical and Sexual Assault with Suicide Risk in Nonclinical Military and Undergraduate Samples

The associations of various forms of sexual and physical assault with a history of suicide attempts and recent suicide ideation were studied in two distinct samples: active duty military and undergraduate students. A total of 273 active duty Air Force personnel and 309 undergraduate students anonymously completed self‐report surveys of assault victimization, emotional distress, belongingness, recent suicide ideation, and previous suicide attempts. Among military personnel, rape, robbery, or violent assault was associated with a nonsignificant trend toward increased risk for suicide attempts, whereas physical abuse or battering as an adult was significantly associated with recent suicide ideation. Among undergraduates, unwanted sexual experiences as an adult and physical or sexual abuse as a child were significantly associated with increased risk for suicide attempt, but only unwanted experiences as an adult was significantly associated with increased risk for suicide ideation. Experiencing multiple forms of assault increased risk for suicide attempts and ideation in both groups. Results suggest that different types of assault contribute differentially to suicide risk in military versus undergraduate populations, but experiencing multiple types of assault is associated with increased risk in both groups.     

Effect of Socioeconomic Status on the Linkage Between Suicidal Ideation and Suicide Attempts

Previous suicide attempts are a leading risk factor for completed suicide. To identify specific characteristics of those at high risk for attempts, we investigated associations with socioeconomic status (SES). Data from the 2013 Korean Community Health Survey (KCHS) included adults who reported suicidal ideation (N = 220,245). Attempts in the past 12 months were assessed. Associations of demographic, socioeconomic, and suicide‐related behavioral factors were analyzed using multiple logistic regression. Among those with suicidal ideation, 862 (3.9%) had attempted suicide. After stratification by age and gender, results showed that low education and unemployed young adult men and women had significantly higher rates of attempts. The lowest income level was associated with significantly higher rates of attempts in only young adult women. Among those with the lowest and highest income, the association between ideation and attempts was attenuated, whereas it was enhanced among other income groups.     

Examining the Interpersonal–Psychological Theory of Suicide in an Inpatient Veteran Sample

Suicide among veterans is a pressing public health concern. The interpersonal–psychological theory of suicide proposes that perceived burdensomeness and thwarted belongingness lead to suicidal desire, whereas the acquired capability for suicide leads to suicide attempt in the presence of suicidal desire (Joiner, 2005). Two hypotheses derived from the interpersonal–psychological theory of suicide were tested in 185 veterans (96 women) entering inpatient psychiatric treatment. Burdensomeness and its interaction with belongingness significantly predicted current suicidal ideation. The three‐way interaction between burdensomeness, belongingness, and acquired capability did not significantly predict number of past suicide attempts. Clinical implications and directions for future research are discussed.     

Prevalence of Suicide Risk Factors and Suicide‐Related Outcomes in the National Mental Health Study,Colombia

A community survey in 4,426 adults was undertaken as part of the World Mental Health Survey Initiative reporting the prevalence and risk factors for suicide‐related outcomes in Colombia. Lifetime prevalence estimates of suicide ideation, plans, attempts, and risk factors for suicide‐related outcomes were assessed. Retrospective reports of disorders age‐of‐onset were used to study associations between primary mental disorders and first onset of suicide‐related outcomes. Risks of plans and attempts were highest with ideation early age‐of‐onset and within the first year. The highest risk for ideation and attempt among ideators occurred in the 18–29 age group. After first employment (defined as the first paid job accepted by the respondent) and presence of mental disorders constituted risk factors. Impulse‐control disorders were strongest diagnostic predictors.     

The Longitudinal Association of Being Bullied and Gender with Suicide Ideations,Self‐Harm,and Suicide Attempts from Adolescence to Young Adulthood: A Cohort Study

Longitudinal associations between being bullied during adolescence and suicide ideations, self‐harm, and suicide attempts into young adulthood were examined. A large representative sample was examined in 1998 (N  = 2,464, MA 13.7), 1999/2000, and 2012 to reassess the outcome measures. At all ages, bullied participants showed more suicide ideation, self‐harm, and suicide attempts, regardless of gender. Bullied females showed a decrease in suicide ideation from adolescence to adulthood, while bullied males showed an increase in suicide attempts in the same time period. Being bullied in adolescence strongly predicts suicidal behavior and self‐harm. Preventive efforts might reduce the risk of later suicidality.     

Does Reintegration Stress Contribute to Suicidal Ideation Among Returning Veterans Seeking PTSD Treatment?

Although posttraumatic stress disorder (PTSD) and other psychiatric symptoms are well‐established risk factors for suicidal ideation among returning veterans, less attention has been paid to whether the stress of reintegrating into civilian society contributes to suicidal ideation. Utilizing a sample of 232 returning veterans (95% male, mean age = 33.63 years) seeking PTSD treatment, this study tested whether reintegration difficulties contribute to suicidal ideation over and above the influence of PTSD symptoms, depression symptoms, and potential substance misuse. Logistic regressions indicated that reintegration stress had a unique effect on suicidal ideation over and above PTSD and depression symptoms. Reintegration stress interacted with substance misuse to predict suicidal ideation, such that the effect of reintegration stress on suicidal ideation was much larger for those with potential substance misuse. Exploratory analyses also examined which types of reintegration difficulties were associated with suicidal ideation, and found that difficulty maintaining military friendships, difficulty getting along with relatives, difficulty feeling like you belong in civilian society, and difficulty finding meaning/purpose in life were all significantly associated with suicidal ideation, beyond the effects of psychiatric symptoms and potential substance misuse. Findings highlight the importance of addressing reintegration stress for the prevention of suicide among returning veterans. Implications for treatment are discussed.