Introduction
Suicidality is higher for gender minorities than the general population, yet little
is known about suicidality in disabled or older adult gender minorities.
Methods
This study used 2009–2014 Medicare claims to identify people with gender identity–related
diagnosis codes (disabled, n=6,678; older adult, n=2,018) and compared their prevalence of suicidality with a 5% random non–gender minority
beneficiary sample (disabled, n=535,801; older adult, n=1,700,008). Correlates of suicidality were assessed (via chi-square) for each of
the 4 participant groups separately, and then disparities within eligibility status
(disabled or older adult) were assessed using logistic regression models, adjusting
first for age and mental health chronic conditions and then additionally for Medicaid
eligibility, race/ethnicity, or U.S. region (each separately). The primary hypotheses
were that gender minority beneficiaries would have higher suicidality but that suicidality
disparities would persist after adjusting for covariates. Data were analyzed between
2017 and 2019.
Results
Gender minority beneficiaries had higher unadjusted suicidality than non–gender minority
beneficiaries in the disabled cohort (18.5% vs 7.1%, p<0.001). Significant suicidality predictors in all 4 groups included the following:
age (except in older adult gender minorities), Medicaid eligibility, depression or
behavioral health conditions, avoidable hospitalizations, and violence victimization.
In age- and mental health–adjusted logistic regression models, gender minorities had
higher odds of suicidality than non–gender minority beneficiaries (disabled, OR=1.95,
p<0.0001; older adult, OR=2.10, p<0.0001). Disparities were not attenuated after adjusting for Medicaid eligibility,
race/ethnicity, or region.
Conclusions
Heightened suicidality among identified gender minority Medicare beneficiaries highlights
a pressing need to identify and reduce barriers to wellness in this population.
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to American Journal of Preventive MedicineAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
REFERENCES
- Identifying the transgender population in the Medicare Program.Transgend Health. 2016; 1: 250-265
- Mental health of transgender youth in care at an adolescent urban community health center: a matched retrospective cohort study.J Adolesc Health. 2015; 56: 274-279
- Attempted suicide among transgender persons: the influence of gender-based discrimination and victimization.J Homosex. 2006; 51: 53-69
- Suicide protective factors among trans adults.Arch Sex Behav. 2013; 42: 739-752
- Mental health of transgender veterans in U.S. states with and without discrimination and hate crime legal protection.Am J Public Health. 2016; 106: 534-540
- Factors associated with suicidality among a national sample of transgender veterans.Suicide Life Threat Behav. 2016; 46: 507-524
- The mental health of transgender youth: advances in understanding.J Adolesc Health. 2016; 59: 489-495
- The social determinants of lesbian, gay, bisexual and transgender youth suicidality in England: a mixed methods study.J Public Health (Oxf). 2018; 40: e244-e251
- Mental health of transgender people in Hong Kong: a community-driven, large-scale quantitative study documenting demographics and correlates of quality of life and suicidality.J Homosex. 2018; 65: 1093-1113
- Exploring cross-sectional predictors of suicide ideation, attempt, and risk in a large online sample of transgender and gender nonconforming youth and young adults.LGBT Health. 2018; 5: 391-400
- Suicide and self-harm among sexual and gender minority youth: resilience, coping, and despair.in: Pumariega AJ Sharma N Suicide Among Diverse Youth: A Case-Based Guidebook. Springer, Cham, New York, NY2018: 199-219
- Varied reports of adult transgender suicidality: synthesizing and describing the peer-reviewed and gray literature.Transgend Health. 2017; 2: 60-75
- Cross-national prevalence and risk factors for suicidal ideation, plans and attempts.Br J Psychiatry. 2008; 192: 98-105
- The Report of the 2015 U.S. Transgender Survey.National Center for Transgender Equality, Washington, DC2016
- Prevalence and correlates of lifetime suicide attempts among transgender persons in Argentina.J Homosex. 2016; 63: 955-967
- Impact of social determinants of health on medical conditions among transgender veterans.Am J Prev Med. 2017; 52: 491-498
- Executive Summary.in: The Report of the 2015 US Transgender Survey. National Center for Transgender Equality, Washington, DC2016: 3-17
- Demographic characteristics and health status of transgender adults in select U.S. regions: Behavioral Risk Factor Surveillance System, 2014.Am J Public Health. 2017; 107: 582-589
- Transgender noninclusive healthcare and delaying care because of fear: connections to general health and mental health among transgender adults.Transgend Health. 2017; 2: 17-28
- Suicidal ideation in transgender people: gender minority stress and interpersonal theory factors.J Abnorm Psychol. 2017; 126: 125-136
- Mental health and medical health disparities in 5135 transgender veterans receiving healthcare in the Veterans Health Administration: a case-control study.LGBT Health. 2016; 3: 122-131
- Mortality among veterans with transgender-related diagnoses in the Veterans Health Administration, FY2000-2009.LGBT Health. 2014; 1: 269-276
- Hormone therapy, gender affirmation surgery, and their association with recent suicidal ideation and depression symptoms in transgender veterans.Psychol Med. 2018; 48: 2329-2336
- Suicide rates in five-year age-bands after the age of 60 years: the international landscape.Aging Ment Health. 2016; 20: 131-138
- Suicide in older adults.Psychiatr Clin North Am. 2011; 34: 451-468
- Suicide in older adults: current perspectives.Clin Interv Aging. 2018; 13: 691-699
- Physical illness, functional limitations, and suicide risk: a population-based study.Am J Orthopsychiatry. 2007; 77: 56-60
- Understanding suicide and disability through three major disabling conditions: intellectual disability, spinal cord injury, and multiple sclerosis.Disabil Health J. 2010; 3: 74-78
- Physical and mental health of transgender older adults: an at-risk and underserved population.Gerontologist. 2014; 54: 488-500
- Hate crimes and violence against the transgendered.Peace Rev. 1999; 11: 461-468
- Policy issues affecting lesbian, gay, bisexual, and transgender people in retirement.Generations. 2002; 26: 49-54
- Lesbian, gay male, bisexual and transgendered elders: elder abuse and neglect issues.J Elder Abuse Negl. 1998; 9: 35-49
- Adult development and quality of life of transgender and gender nonconforming people.Curr Opin Endocrinol Diabetes Obes. 2016; 23: 188-197
- Resilience and multiple stigmatized identities: lessons from transgender persons’ reflections on aging.in: Sinnott JD Positive Psychology: Advances in Understanding Adult Motivation. Springer Science+Business Media, New York, NY2013: 247-267
- The health, social care and housing needs of lesbian, gay, bisexual and transgender older people: a review of the literature.Health Soc Care Community. 2009; 17: 647-658
- An invisible population: older lesbian, gay, bisexual, and transgender individuals.Clin Res Regul Aff. 2003; 20: 159-182
- Transgender Medicare beneficiaries and chronic conditions: exploring fee-for-service claims data.LGBT Health. 2017; 4: 404-411
- Identifying gender minority patients’ health and health care needs in administrative claims data.Health Aff (Millwood). 2018; 37: 413-420
- Trends in U.S. emergency department visits for attempted suicide and self-inflicted injury, 1993-2008.Gen Hosp Psychiatry. 2012; 34: 557-565
- Predicting suicidal behavior from longitudinal electronic health records.Am J Psychiatry. 2017; 174: 154-162
- Medicare-Medicaid eligible beneficiaries and potentially avoidable hospitalizations.Medicare Medicaid Res Rev. 2014; 4: 1-13
- Interpersonal trauma and discriminatory events as predictors of suicidal and nonsuicidal self-injury in gay, lesbian, bisexual, and transgender persons.Traumatology. 2011; 17: 75-85
- Longitudinal histories as predictors of future diagnoses of domestic abuse: modelling study.BMJ. 2009; 339: b3677
- Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare.National Academies Press, Washington, DC2003
- Trends in mental health care use in Medicare from 2009 to 2014 by gender minority and disability status.LGBT Health. 2019; 6: 297-305
- Trends in suicide ideation, plans, gestures, and attempts in the United States, 1990-1992 to 2001-2003.JAMA. 2005; 293: 2487-2495
- A risk index for 12-month suicide attempts in the National Comorbidity Survey Replication (NCS-R).Psychol Med. 2006; 36: 1747-1757
- Non-suicidal self-injury in United States adults: prevalence, sociodemographics, topography and functions.Psychol Med. 2011; 41: 1981-1986
- Suicidal behavior in elders.Psychiatr Clin North Am. 2008; 31: 333-356
- The impact of physical, psychological, and sexual intimate male partner violence on women's mental health: depressive symptoms, posttraumatic stress disorder, state anxiety, and suicide.J Womens Health (Larchmt). 2006; 15: 599-611
- Adult suicide mortality in the United States: marital status, family size, socioeconomic status, and differences by sex.Soc Sci Q. 2009; 90: 1167
- Suicide and suicidal behavior.Epidemiol Rev. 2008; 30: 133-154
- Suicide Rates by Males and Females by Race and Ethnicity: United States, 1999 and 2017.Health E-Stats. National Center for Health Statistics, Published June 2010https://www.cdc.gov/nchs/data/hestat/suicide/rates_1999_2017.pdfDate accessed: February 2, 2020
- Suicide mortality in the United States: the importance of attending to method in understanding population-level disparities in the burden of suicide.Annu Rev Public Health. 2012; 33: 393-408
- A conceptual framework for clinical work with transgender and gender nonconforming clients: an adaptation of the Minority Stress Model.Prof Psychol Res Pr. 2012; 43: 460-467
- Discrimination and health in Massachusetts: a statewide survey of transgender and gender nonconforming adults.Fenway Health, Boston, MAPublished 2014http://fenwayfocus.org/wp-content/uploads/2014/07/The-Fenway-Institute-MTPC-Project-VOICE-Report-July-2014.pdfDate accessed: January 25, 2019
- Resilience and collective action: exploring buffers against minority stress for transgender individuals.Psychol Sex Orientat Gend Divers. 2015; 2: 253-265
- Unique challenges of transgender aging: implications from the literature.J Gerontol Soc Work. 2009; 52: 633-646
- Connecting the dots: examining transgender women's utilization of transition-related medical care and associations with mental health, substance use, and HIV.J Urban Health. 2015; 92: 182-192
- American Counseling Association competencies for counseling with transgender clients.J LGBT Issues Couns. 2010; 4: 135-159
- Strength in the face of adversity: resilience strategies of transgender individuals.J Couns Dev. 2011; 89: 20-27
- Individual- and structural-level risk factors for suicide attempts among transgender adults.Behav Med. 2015; 41: 164-171
- Generating a revolution in prevention, wellness, and care for LGBT children and youth.Temp Pol Civ Rights Law Rev. 2013; 23: 331-344
- ‘People have a knack of making you feel excluded if they catch on to your difference’: transgender experiences of exclusion in sport.Int Rev Sociol Sport. 2017; 52: 223-239
- Perceived barriers to mental health services among Canadian sexual and gender minorities with depression and at risk of suicide.Commun Ment Health J. 2019; 55: 1313-1321
- Understanding why patients may not report suicidal ideation at a health care visit prior to a suicide attempt: a qualitative study.Psychiatr Serv. 2019; 70: 40-45
- Managing uncertainty: a grounded theory of stigma in transgender health care encounters.Soc Sci Med. 2013; 84: 22-29
- Trauma in transgender populations: risk, resilience, and clinical care.J Emot Abuse. 2008; 8: 335-354
- Patient satisfaction with transgender health services.J Sex Marital Ther. 2004; 30: 277-294
- The experiences of transgendered persons in psychotherapy: voices and recommendations.J Ment Health Couns. 2009; 31: 264-282
- Gender minority patients: the authors reply.Health Aff (Millwood). 2018; 37: 1014
- Identifying Medicare beneficiaries accessing transgender-related care in the era of ICD-10.LGBT Health. 2019; 6: 166-173
- Estimating the health status of privately insured gender minority children and adults.LGBT Health. 2019; 6: 289-296
- A novel method for estimating transgender status using electronic medical records.Ann Epidemiol. 2016; 26: 198-203
- Racial/ethnic disparities in history of incarceration, experiences of victimization, and associated health indicators among transgender women in the U.S.Women Health. 2014; 54: 750-767
- ICD-11: classifying disease to map the way we live and die. Health Topics - International Classification of Diseases.WHO, Geneva, SwitzerlandPublished 2018 (Accessed July 2019)
Article Info
Publication History
Published online: March 07, 2020
Identification
Copyright
© 2020 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.
