Suicide
New papers, old papers, and an enduring myth
I don’t know when I first heard it. Maybe it was in 2020, when I started writing about trans kids for several major media outlets. I’d interview parents who’d say, “I’d rather have a live trans son than a dead cis daughter”—or, of course, vice versa.
Well of course you would, I thought. But…is the choice really that, um, binary? I was in no position to question, when every professional I interviewed repeated the same line. And indeed, many of the kids in question had exhibited suicidal behavior, even if they hadn’t made a real attempt on their own lives. Parents were terrified. Kids were freaked out.
And perhaps more importantly, as parents and some kids told me, clinicians presented gender affirming care as the antidote to this behavior. The clinicians themselves raised the specter of a child or adolescent dying at his or her own hand without medical and psychological interventions. They asserted that affirming the child’s gender identity created a protective shield: gender-affirming care as suicide deterrent.
A new paper from Finland questions the narrative that such interventions are life-saving. The study looked at deaths of adolescents referred for gender issues between 1996 and 2019, comparing the suicide and death rates to those in a control group. Suicide rates in the gender-referred adolescents were higher than the control group, yes. But when they controlled for mental health problems, the differences all but disappeared. That is, kids with mental health issues are at risk for suicidal ideation—whether or not they have gender issues, too.
Indeed, Dr. Hilary Cass warned in her report about youth gender medicine in the UK that “diagnostic overshadowing” (which I wrote about for Unherd) had become a problem: once gender comes into the picture, all other diagnoses are ignored.
When presenting with gender dysphoria (GD) children and young people can experience diagnostic overshadowing where other co-occurring issues can go unaddressed if all professional support is focused exclusively on their gender identity. “In my experience once children express any question about their gender it becomes the central issue and any other mental health issues or psychosocial factors are virtually ignored.” - Pediatrician
Multiple mental health conditions have high rates of suicidal ideation; if not dealt with head on, they will continue to present.
I’ve spent the last six months searching for origins of the ideas, slogans, and talking points of the youth gender culture war, and I haven’t quite pinpointed where “transition or death” came from. (If you have a sense of the first time it was used, please let me know—especially when it comes to kids.) I am aware that many adults coached one another to say this to doctors to get the surgeries and medications they desired. But this suicide narrative about young people was present at the dawn of youth gender-affirming care in this country; Dr. Norman Spack evoked it as a reason to import adolescent transgender medicine to the United States. Early press about the clinic repeated the myth without checking the source, saying that kids had a 50 percent chance of committing suicide before age 20 if they were transgender.
These are statistics that I believe come from anonymous surveys of adult transwomen—that is, extremely biased and low-quality research—and from follow-up studies of those who transitioned in adulthood. Spack and others assumed that the high rate of completed suicide among transitioned adults could be viewed as a control group, even though there was no experimental group that had undergone transition in adolescence to which they could compare it. This was a tremendous ideological leap: the adults did poorly, therefore we must intervene earlier. A premium was placed on passing, assuming that being recognized by strangers as the opposite sex would pave the way to robust mental health.
At the same time, and somewhat in contradiction, this was also the justification for cultural and societal shifts toward creating more tolerance of transgender people. That way, minority stress wouldn’t contribute to poor mental health. But more tolerance would mean less of a need to pass…right?
All of these things happened. We intervened earlier, and our culture shifted massively toward accommodation of the idea of gender identity, which is now enshrined in policy and law. Thus, we should have seen a decrease in suicidal behavior, and evidence that, as activists claim, gender affirming care is “life-saving.”
But the suicide rate reported in the one long-term follow-up paper in the United States is the highest I’ve ever heard of: two out of 315, a fact brushed over in the paper and not reported in the mainstream press. The story that haunts me the most is that of Abigail Martinez and her daughter, Yaeli. Yaeli was removed from the home and placed in foster care because of her mother’s reluctance to psychologically and medically affirm. Eventually, Yaeli medically transitioned, and died by suicide. That story was only reported in conservative media.
We should have seen a series of op-eds questioning gender affirming care as suicide prevention. We did not. The transition-or-death binary lives on, scaring parents into doing things that go against their own instincts, convincing kids that there’s a single pathway leading out of distress.
Dr. Cass explained that there are many pathways to gender dysphoria, and many that could lead away from it. Why won’t the media explain that to people? Why won’t gender-affirming clinicians? “Give me what I want or I’ll kill myself” is a classic abuse tactic, but when have such words been issued by clinicians on behalf of a child?
I think you need to pull back from how this narrative has been used in gender dysphoria and look at the history of "suicide awareness" for adolescents in schools and online. Whether by design or as an unintended consequence, adolescents are learning to understand and equate strong emotional distress with the language of suicidal ideation. We have all experienced deep distress and thought "I don't know how to live through this," "I can't see my way out of this," and "I don't want to live through this" but understood that does not mean we want to die or are suicidal. But now those thoughts are being understood and translated into the language of suicidal ideation, not just for gender dysphoria (where there's a well established script for it) but for ALL adolescent distress. I hear this language used all the time among adolescents and by the adults who think they are supporting them and engaging in suicide prevention. They don't recognize the iatrogenic harm, and this harm is 10x worse in the world of gender identity because of the scripts that have become so inextricably tied to the narrative.
As a side note, the study of 315 adolescents is typical transmedical crap, not worthy of publication in any peer-reviewed journal, much less such prestigious as NEJM. (A study of such quality would NEVER get published in NEJM if it was any other topic). The infamous Diane Enhrensaft and Johanna Olson-Kennedy are two of the authors. Two suicides? No big deal, just look at the ground-breaking 0.5-2 point change in all psych measures over the period of two years! Yeah, there is no control group and it's teens so perhaps they change either way over two years but the study still proves that GAH is effective! We don't know what happened to six kids who dropped out and oh yeah, 11 other participants reported suicide ideation.