Understanding past experiences of suicidal ideation and behavior in the life narratives of transgender older adults

Abstract

Transgender people (collectively referred to here as trans) experience disproportionate rates of suicidal ideation and behavior (plans and attempts) attributed to complex constellations of structural and individual factors. Interpretive methods in suicide research elucidate and contextualize intricate patterns of risk factors and strategies for recovery. The life narratives of trans older adults offer unique insights into past suicidal behavior and recovery after distress has diminished and perspective has been gained. This study aimed to illuminate the lived experiences of suicidal ideation and behavior in the biographical interviews of 14 trans older adults as part of the project To Survive on This Shore (N = 88). Data analysis was conducted using a two-phase narrative analysis. Trans older adults contextualized suicide attempts, plans, ideation, and recovery as navigating impossible to possible paths. Impossible paths were seen as hopelessness in their life direction, often after a significant loss. Possible paths were described as pathways to recovery from crises. Transitions from impossible to possible paths were narrated as a turning point or moment of strength combined with outreach to family, friends, or mental health professionals. Narrative approaches hold the potential to illuminate pathways to well-being among trans persons with lived experiences of suicidal ideation and behavior. For social work practitioners, therapeutic narrative work around past suicidal ideation and behavior with trans older adults holds promise for suicidal prevention by identifying important supportive resources and previously used coping skills in crises.

Keywords

Trans older adults suicidal ideation suicide attempts narrative analysis

Introduction

The life narratives of transgender people (collectively hereafter referred to as trans) who experience suicidal ideation and survive attempts hold the potential to expand our understanding of the lived experiences of suicidal ideation and behavior (plans and attempts) as well as pathways to recovery. Substantial research has been conducted into correlations and associations of ideation and suicidal behavior among multiple populations (May and Klonsky, 2016), but it has tended to exclude the narratives of people who have survived a suicide attempt, even more so in the trans community (Hjelmeland and Knizek, 2010; Rivers et al., 2018; Williams et al., 2018). Studies examining the lived experiences of sexual and gender minority adults who attempted have used adult narratives of past experiences to conduct in-depth examinations of the perceived context and precipitating factors of the suicide attempts (Rivers et al., 2018; Williams et al., 2018) and resilience strategies leveraged when faced with adversity (Moody et al., 2015). According to Hjelmeland and Knizek (2010), understanding the lived experience of suicidal behavior deepens knowledge of relationships between risk factors because risk factors for suicidal ideation and behavior are often experienced as non-nonlinear, overlapping, or converging at a specific point in time and place in the life course (Hjelmeland and Knizek, 2010). Interpretive approaches give insight into how people who have survived suicidal ideation and suicide interpret themselves, their actions, and the context (Hjelmeland and Knizek, 2010). Therefore, this study examines the lived experiences and perceived circumstances around suicidal ideation and suicide attempts by analyzing the life narratives of older trans adults who have survived these experiences.

Background

Trans people experience high rates of suicidal ideation and behavior (plans and attempts) (Clements-Nolle et al., 2006; McNeil et al., 2017). The estimated prevalence of suicidal ideation among trans people ranges from 45–84% (Adams et al., 2017; McNeil, 2012; McNeil et al., 2017), which is highly disparate from other groups. Approximately 24–48% of trans people have ever attempted suicide compared to 9% of cisgender LGB people and 4% of the general population (Adams et al., 2017; Nock et al., 2009). Theories of gender minority stress posit complex constellations of structural (e.g., discrimination, structural stigma, exposure to gender-related violence) and individual (e.g., anxiety, depression, internalized stigma) factors contribute to increased rates of suicidal ideation and behavior among trans people (Meyer et al., 2008; Perez-Brumer et al., 2015; Testa et al., 2015). However, Nuttbrock et al. (2010) found that suicidal ideation appears to reduce as trans people age and proposed reductions in suicidal ideation may be due to increased coping skills gained while aging, but little knowledge exists on how trans people build these resilience strategies over time (Frimpong et al., 2020; Kidd et al., 2016; Nuttbrock et al., 2010).

Qualitative studies have illuminated important resilience strategies of trans people experiencing adversity, such as pride, advocacy, gender identity exploration, access to services, gender transition, and community connectedness (Ellis et al., 2016; Moody et al., 2015; Singh et al., 2011; Wagaman et al., 2019). Connectedness is considered important for reducing feelings of pain and hopelessness associated with suicidal ideation and behavior (Klonsky et al., 2018). This importance is reflected in trans suicide prevention research findings finding that social support, particularly familial, parental, and institutional support, reduces suicidal ideation and suicide attempts among trans people (Haas et al., 2011; Wolford-Clevenger et al., 2018).

Few researchers have examined the resilience strategies of trans people who have lived experiences of suicidal ideation and behavior (Moody and Smith, 2013; Moody et al., 2015; Rivers et al., 2018; Williams et al., 2018). Mental health and illness narratives of past experiences are thought to illuminate how people make meaning of their experiences and the contexts in which these experiences are embedded (Garro, 2000; Munson et al., 2018). However, there has been little examination of how older adults’ narratives can be used to examine resilience strategies supporting long-term mental health recovery. Thus, this study aims to answer the following questions: How do trans older adults contextualize and ascribe meaning to their past experiences of suicidal behavior? How do these contextualizations and meanings enhance understanding of resilience strategies and long-term recovery?

Methods

To explore how trans older adults contextualize and ascribe meaning to their past suicidal behavior, we conducted a secondary narrative analysis of 13 interviews with trans older adults who had experienced suicidal ideation or behavior earlier in life.

Data source

The data source for this study is a collection of 86 biographical and dialogical in-depth interviews conducted in the United States (with 88 trans and gender-expansive people) from the nonresearch photojournalistic project To Survive on this Shore (https://www.tosurviveonthisshore.com). Interview data were initially identified during the analysis phase of a separate interpretive study on multilevel stigma and trans people’s mental health (Fabbre and Gaveras, 2020). We selected interview transcripts for this secondary data analysis if participants described either a history of suicidal ideation or suicidal behavior as part of their life narrative. Coding of suicidal ideation and behavior was based on definitions from the Centers for Disease Control and Prevention’s (CDC) 2011 Self-Directed Violence Surveillance Uniform definitions and recommended data elements; suicidal ideation was defined as “thoughts of engaging in suicide related behavior” (CDC 2011, p. 90) and suicidal behavior was defined as plans or attempts. In this case, suicide plans were defined as an organized self-initiated thought or action to engage in a suicide attempt that includes a time frame and a method. Suicide attempts were defined as “non-fatal self-directed potentially injurious behavior with any intent to die as a result of the behavior (CDC, 2011, p. 90.)

Interviews were excluded if participants described passive thoughts of death or undetermined acts of self-directed violence defined as when “suicidal intent is unclear” based on the evidence, for example, the statement “going to a very dark place” (CDC, 2011, p. 90). Although there is substantial literature on the significant differences between persons who only experience suicidal ideation and those who experience attempts (May and Klonsky, 2016), we decided to examine both groups to examine the contexts contributing to increased pain and hopelessness, which are considered to increase to both suicidal ideation and attempts (Klonsky et al., 2018; Testa et al., 2015, 2017).

We selected a subsample of 13 interviews with 14 participants (one interview included a couple who were both trans-identified and both had experienced suicidal ideation). All participants in the original interviews we studied identified as trans men or women; no participants who identified as nonbinary or gender-expansive.

Table 1.

Participant demographics (N = 14).

	Sample
Characteristic	N	%
Trans identity
Trans woman	9	64.3%
Trans man	5	35.7%
Non-binary	0	0%
Age
50–55	2	14.2%
56–60	2	14.2
61–65	5	17.0%
66–70	4	20.5%
Race/ethnicity
White/European American	12	85.7%
Latino/Latina	2	14.2%
U.S. geographic location
Northeast	1	7.1%
Midwest	1	7.1%
South	6	42.8%
Southwest	1	7.1%
West	3	7.1%
Northwest	1	7.1%

All participants in the original photojournalistic project signed consent and release forms that their interview and photographs would remain the property of the project cocreators (one of whom is the second author of this article), allowing for use in research and donation to LGBTQIA+ historical archives. Interviews lasted about an hour, and transcripts were deidentified by the second author for use in scientific studies, and the Institutional Review Board at Washington University in St. Louis has approved this project (ID# 201706001).

Data analysis

We used a combination of narrative (Labov, 1997; Riessman, 2008) and thematic analysis (Braun and Clarke, 2006) to (a) organize and identify the narrative bounds of the experience of suicidal ideation and behavior; and (b) apply existing frameworks of gender minority stress and suicidal ideation and behavior to develop themes (Testa et al., 2015, 2017). Narrative analysis was used because participants all shared the collective experience of broaching suicidal ideation and behavior earlier in their lives as a response to the following broad initial questions: “How do you identify today and what are some of the major milestones on the path to this identity, from your perspective?” The interviewers did not specifically inquire about suicidal thoughts, behavior, or mental health history—instead, participants self-initiated discussion of these topics. According to Riessman (2008), broad questions are fitting for narrative research because participants can independently share the stories that are most important to their identity; the broadness and openness of this approach also help to identify similar cases and compare salient and pressing issues from the perspective of research participants. Thus, it is notable that these 14 participants discussed past suicidal behavior as one of the building blocks to their present identity. These participants’ narratives offered both breadth and depth contextualizing suicidal thoughts and behaviors, decision making, and social support (or lack thereof), which gave us confidence that these data were sufficient for robust narrative analysis.

To identify how trans older adults understand and make meaning of their histories of suicidal behavior, we also used the six-element narrative approach to analyzing a specific life event (Labov, 1997; Labov and Waletzky, 1997). This approach is often used to isolate (Mishler, 1986, p. 70) the narrative of a specific and reportable event important to a participant’s biography, which is embedded in a larger interview (Mishler, 1990). According to Labov (1997), a narrative contains six elements: (a) abstract, (b) orientation, (c) complicating actions, (d) evaluation, (e) resolution, and (f) coda or the return to the present; however, not all narratives contain all six elements (Riessman, 2008). Looking for these elements in the narrative of a life event is helpful for understanding the antecedents, contextual factors, and applied meanings of crises and violent events (Riessman, 2008). Life narratives, particularly surrounding violent or traumatic events, are often not told in time order (Labov, 1997; Riessman, 2008); therefore, the narratives were reordered following Riessman’s (2008) expansion of Labov’s approach into time order, when needed. We also created a case summary for each interview to illuminate and compare common narrative structures (Riessman, 2008). All participant names in this paper are pseudonyms.

We then compared the critical elements of each suicide narrative to develop themes across all cases (Braun and Clarke, 2006; Mishler, 1990; Riessman, 2008; Padgett, 2017). We selected thematic analysis because it is flexible, does not have an epistemological home, and can be used with existing theoretical frameworks (Braun and Clarke, 2006). Our coding framework drew upon an adapted measure of gender minority stress (Testa et al., 2015, 2017) to draw out how participants’ narratives reflected their response to gender-based stress.

The thematic coding was conducted by the first and third authors. The development of our findings was an iterative process wherein we reflected and interpreted the comparative structure of the narratives and developed themes reflective of gender minority stress leading to our notion of impossible and possible paths. We think presenting our findings with respect to possibility best captures the essence and structures of the narratives we analyzed. In order to bolster the reflexivity of our analytical process, we also reflected on how our own gender and sexual identities, as well as our varied, lived, and professional experiences impacted the research process. We used critical discussion among team members and analytical memo writing at each stage of the process to incorporate these reflections into our analyses.

Findings

Trans older adults described navigating a turning point from impossible to possible paths in their stories about suicidal ideation or attempts and recovery. These themes were identified through reflection on the common narrative structure across cases and how trans older adults contextualized and applied meaning to their experiences (Riessman, 2008). The trans older adults in our study described contexts of impossible paths experienced prior to suicidal ideation or behavior and suicidal ideation or behavior as a turning point changing the direction of their life course from an impossible to a possible path towards self-actualization, which for many trans older adults was still ongoing.

We defined impossible paths as the feeling of not fitting in, of being stuck, and of there being no possible way forward as an authentic self-actualized person that occurred prior to suicidal ideation or behavior. Within impossible paths, many participants conveyed a past perception that their lives were going in the wrong direction for unknown reasons and expressed hopelessness for a change in trajectory. For many trans older adults, gendered events early in life led to larger questions regarding their life course. The turning point was defined as a moment of clarity or determination to halt ideation or plans to die by suicide combined with a decision to reach out for support. Finally, possible paths were connections to social supports, including family, partners, and mental health providers, and awareness and hope for a full life. Within possible paths, post-suicidal ideation or attempts, trans older adults recounted meaningful relationships built with trans-affirmative mental health service providers and supportive relationships with family and friends who opened up possibilities to access gender-affirming care and learning about their gender identity.

The following case examples exemplify how trans older adults’ stories of suicidal ideation, behavior, and recovery follow the narrative arc of navigating impossible to possible paths. Moreover, impossibility and possibility are experienced in the form of actual and perceived life course paths. Within these stories, suicidal ideation and behavior is a turning point transitioning the narrator from possible to impossible paths, which serve as the push or impetus to seek support altering life course trajectories. In each case, we present highlights from the narrative through which the notions of impossibility and possibility stand out. Cases 1 and 2 present the stories of Miranda and Lydia, which exemplify how trans older adults apply meaning to suicidal ideation and behavior as they transition from impossible to possible paths. Cases 3 and 4 delve further into the contextual details’ impossible paths, and Cases 5–9 detail the trajectories towards self-actualization found in possible paths.

A turning point: How trans older adults apply meaning to suicidal ideation and behavior

Trans older adults attributed their experiences of suicidal ideation and attempts as a turning point towards seeking supports and self-actualization. The following two cases illustrate the common narrative structures trans older adults used to contextualized experiences before suicidal ideation and attempts (impossible paths) and pathways toward recovery and gender-affirming support (possible paths) with a moment of clarity to halt plans to die by suicide as the transition from one to another.

Case 1. Miranda: “And That’s When I Had My Come Back to Jesus Moment”

The case study of Miranda, a 60-year old Latina trans woman living in the Western United States who describes her plan to die by suicide during middle adulthood, illustrates the turning point from impossible to possible paths. Miranda contextualized risk factors associated with plans to die by suicide with relationship loss and questioning why, despite successfully adhering to masculine gender roles, her life was going in the wrong direction. Then Miranda described what she calls her “come back to Jesus moment” during her plan to die by suicide that serves as a catalyst to receiving support and gender-affirming care.

When I wasn’t at work, half the time I was drunk. So after a year, one morning we just met in the dining room, I came out of my room and she [wife] came out hers and she’s like, “I want a divorce.” […] I moved into the [new] house and I just remember being relatively drunk and sitting in my living room at the dining room table and trying to decide if I’m going to shoot myself under the chin or in the side of the head. I couldn’t understand what I had done. I had achieved everything I was supposed to be achieve I was married to a beautiful woman, we had a beautiful house in downtown [City], we both had new cars, I was a respected officer […] . And that’s when I had my come back to Jesus moment […] . Got an intake, got assigned a therapist, and she helped me get onto an antidepressant, she got me back into AA [Alcoholics Anonymous], and after about three weeks, she said “There’s something else going on here that you’re not telling me, you just seem like you’re holding back.” And I said, “Well, a lot of the problems I have stem around the fact that I like to wear women’s clothes.” She took it in stride, and the next time I came in, gave me a referral to go see the Gender Identity Center of [State].

Miranda’s narrative exemplifies the experience of impossibility in one’s life, the power of a turning point in the life course, and seeing and pursuing a new path forward for oneself. Miranda’s story also illustrates how reaching out to a mental health provider is the resolution of this moment of planning to die by suicide. Notably, her therapist probed when she felt there was something Miranda was hesitant to discuss and then provided the appropriate referral to a gender identity center. This process led to Miranda receiving gender-affirmation treatment and developing an expanded social network in the trans community.

Case 2. Lydia and Maggie: “Don’t come home if you lose another job”

Loss and questioning life course direction and the importance of supportive partners and immediate family members were salient themes for many participants. Lydia (68) and Maggie, two trans women, live in the South and are engaged to each other; both related experiences of suicidal ideation and plans as part of their joint interview. In this dialogue, Lydia and Maggie co-construct a timeline of events, including Lydia’s job loss after coming out and Lydia’s plan to die by suicide. In the shared telling of this story, both narratives centered around the turning point when Lydia called Maggie and both of their lives changed:

Lydia: And I tried coming out in one of them because one of the requirements to transition was you’re supposed to live full time, for a year, and when I approached them about it HR was very positive about it but then suddenly the boss threw a fit and all my previous good reviews went out the window and I was just, somebody they didn’t want to have around.

Maggie (finance): She was talking about suicide attempts and one was with a gun. She called me one night, I was still in [Midwestern state] and she was down here, she just got fired from her job, and she said I was told [by exwife] don’t come home if you lose another job. She was sitting in a parking lot. Apparently, I was the last person she tried to call.

Lydia: It was chambered, and I was ready to go. I had gotten six postcards. Final last words, farewell and mailed them.

In their experience, Maggie provides emotional support and offered her a home leading to her moving to the South and begining a new life with her partner Lydia. Lydia’s story also contextualized lived experiences of suicidal ideation and behavior against the backdrop of loss and the importance of supportive connections that are more fully discussed in the following sections.

Impossible paths: Navigating an incorrect life direction

Trans older adults who experienced suicidal ideation or attempts described impossible paths as the feeling as though they did not “fit.” Participants related this feeling of navigating an incorrect life direction at various points in the life course, including adolescence, adulthood, and older adulthood. The following three case studies exemplify how trans older adults contextualize suicidal ideation and behavior across the backdrop of impossible paths. Specifically, they illustrate how experiencing gender norms and oppressive social forces at various points in the life course contributes to creating the impossible paths.

Case 3. Nathan: “I was getting everything I didn’t want”

During adolescence, trans older adults who experienced suicidal ideation or attempts described an awareness that their development was not going in the direction they desired. As Nathan, a 66-year-old White/European American trans man, told his story of a suicide attempt during adolescence:

I snuck it home, it cost me 50 cents […] Yeah, and on the cover was a picture of a 15 or 16-year-old Italian trans boy. They didn’t call them trans boys then. It was a transsexual and we were almost the same age and I knew my puberty was well along and I was getting everything I didn’t want […] . So I shot myself.

It is important to note that in his life narrative, Nathan also chose to describe childhood experiences of sexual abuse, which is also a known risk factor for suicide attempts (McNeil et al., 2017). The conscious choice to share the experience of being abused, unprompted, demonstrates how a narrative account can reveal additional factors that may or may not emerge in telling only the story of a suicide attempt. Nathan was not the only participant who described adverse experiences in childhood. Several participants described experiencing depression, risky substance use, and multiple suicide attempts in adolescence and young adulthood. Narratives such as Nathan’s contextualize the experiences of these risk factors also with feelings that life was not going in the direction one hoped for and seeing no other available options.

Case 4. Damian: “Well, I don’t fit in here, I don’t fit here.”

Damian, a 54-year old Latino trans man, living in the Southwest, in response to a White interviewer asking “Coming from that culture, how did that affect your gender or your understanding of masculinity?” noted,

I’ve always felt that, that I don’t have that machismo that is there [….] [In] the [Southwest region as the] man in the house—you get served, or you do this, and […] I’m not like that. I always thought maybe I was just a little too weak, or something just wasn’t [….] So, it was like, “Well, I don’t fit here, I don’t fit here. What’s next?” You know, it’s […] Thoughts of suicide crossed my mind plenty of times. You know, it’s, I guess I’m a little more balanced, and there’s days that it bothered me. But I have to tell myself, “You can be compassionate, you can be these things and still be very masculine.” But I have a good therapist […] And I have a good wife.

Unlike previous cases, Damien discussed ongoing suicidal ideation after transition in older adulthood and the importance of existing supports such as his wife and therapist, which further illustrates how ongoing questions about fitting within larger cultural and gendered social forces contribute to ongoing thoughts of death by suicide in older adulthood.

Possible paths: New life course pathways

Despite often complex life histories and challenges to mental health, trans older adults described possible paths beginning when they decided to reach for support. Trans older adults in this study described halting plans to die by suicide and recalling a turning point that served as an impetus for seeking support. Case Studies 5–9 illuminate how trans older adults’ personal narratives often feature the recollection of supportive networks and new life course pathways.

Case 5. Chloé: “She was really sharp on trans issues.”

Chloé, a 62-year old White/European American trans woman living in the West, noted support from her wife in her decision to seek mental health services. Chloé described a period when she was afraid to come out, fearing she would lose her job as a teacher and swimming coach, and her wife would leave her. According to Chloé, these fears contributed to depression, and her wife picked up on indications she was having thoughts of suicide and supported Chloé going to a therapist:

Really sharp on trans issues, and I was one of her first clients four years ago. We worked for about a year, and finally, I just realized, and fully realized, it was kind of like a lightbulb that came on, that my identity is one of a female.

Chloé’s case exemplifies the situation faced by trans older adults who do not have an established connection to trans resources or the wider LGBTQIA+ community—immediate family and formal mental health services are among the first resources used at the point of suicidal ideation or attempts.

Case 6. Neil: “I’m like these people are awesome but I’m not like them”

Many participants described accessing supportive resources at crucial points in their lives, which created possible paths to transition and living a fuller and more satisfying life. For example, Neil, a 61-year-old European American/White transman living in the Western United States, described possible paths stemming from the multiple supports he used after leaving a relationship marked by intimate partner violence and multiple suicide attempts:

I actually had three suicide attempts that summer, when I’m trying to figure this out, I came out as lesbian because that’s what I thought I was and I did all the lesbian stuff, and met lesbians at AA, and hung out with them, and I’m like these people are awesome but I’m not like them […] I actually met somebody online in this chat room I went to […] He came up to me as F-to-M and he said “I don’t think you’re a lesbian, I think you’re like me” and then he told me his story and I was like oh my God, that’s me, that’s who I am, so it was just this really incredible night of just wow […] was ready and I moved from back east to back out here where I grew up and went to my sister and asked for help and I started to transition and it changed my whole world.

In his narrative, Neil emphasized how multiple formal and informal supports, including inpatient psychiatry, AA, online chat rooms, and his sister, played a role in opening up new possibilities for himself.

Case 7. Matthew: I’ve found that being myself is what keeps me alive

Community engagement played in participants’ pursuit of possible paths. One participant, Matthew, a 60-year-old White/European American trans man living in the Northwest, found engaging in the community, learning about his own gender identity, and sharing it with others as protective against suicide. In the following account, Matthew narrated his experience of suicidal ideation around the time of his transition and how his relationship with his mother, learning about trans issues and working with the community kept him going: “So I was like, ‘I might as well do something useful for people, if I don’t feel useful for myself, I’ll try to be some sort of service to the world.’ That’s what got me going on it.” Matthew detailed a history of substance use disorders, homelessness, and multiple periods of suicidal ideation throughout his life before and after his gender transition. In another account from his interview, Matthew described how self-acceptance and self-actualization are what make a possible path forward a reality for trans people who survive suicidal ideation or attempts:

I’ve found that being myself is what keeps me alive. If I’d given in and gone the way of making myself socially acceptable, it would have killed me […] For me, being this outsider is what kept me alive […] I suppose it’s a way of self-love, but I think also self-actualization.

Matthew, similar to other participants, often described the concept of self-authentication as an essential aspect of pursuing their self-directed lives. Settling into self-directed lives, living authentically, and making close connections were most often the resolution to the narratives provided by these participants, which often began as a description as a period of navigating oppressive social forces, adversity, and loss.

Discussion

By leveraging the narratives of suicidal ideation and suicide attempts by trans older adults, this study illuminates important contextual details of the circumstances surrounding this period of crisis and resolution. Importantly, trans older adults shed light on the role and source of social support during the resolution of suicidal ideation or behavior and their pathways to mental health and gender-affirming treatment. Furthermore, these narratives show how confronting oppressive gender norms and nurturing meaningful social connections contributes to living a fulfilling life.

The way trans old adults told their stories is similar in structure to other illness narratives. According to Garro (2000, p. 70) the process of “talking about illness […] individuals remember, drawing on their experiences and knowledge to link the past with the present concerns and future possibilities.” The purpose of narrative analysis in mental health research is to consider how participants relate their experiences to develop contextual knowledge (Garro, 2000; Munson et al., 2018; Narendorf et al., 2015). Impossible paths contextualize experiences of suicidal ideation and behavior across a backdrop of gendered stress and hopelessness of future possibilities, whereas possible paths contextualize the resources leverage to build connections and increase knowledge of gender identity.

Narrative analysis aims not to measure the “accuracy” of the recollection (Garro, 2000); however, it is notable that trans older adult participants related experiences reflective of the wider literature of complex constellations of risk factors associated with high rates of suicidal ideation and attempts among trans people (Bailey et al., 2014; Clements-Nolle et al., 2006; Dickey and Budge, 2020; McNeil et al., 2017; Nuttbrock et al., 2010; Wolford-Clevenger et al., 2018). Further, the combination of internal strength, gender affirmation, and social support reflects findings from a qualitative study that developed a thematic mapping of the suicide resilience among a national sample of Canadian trans adults (Moody et al., 2015). Additionally, the findings reflect previous on studies resilience strategies for trans people experiencing adversity in the U.S. not specific to suicidality (Singh et al., 2011; Wagaman et al., 2019). These findings point to the usefulness of narrative analysis to leverage the knowledge and perspectives of trans elders.

Limitations

This study has several limitations that should be taken into consideration when interpreting our findings. Narratives were selected from a group of participants willing to have their portrait photograph included in a book and their biographical interviews shared with LGBTQIA+ archives for future research. Thus, we may have missed perspectives from people who did not feel supported enough to share their life narratives or actively in crises. Participants who told stories of suicidal ideation and behavior in this sample were engaged in a self-initiated retelling of their mental health narrative, which involved the deliberate choice of reconstruction and choosing pieces of their lives to narrate to others (Riessman, 2008). Each narrative telling was unique, so some aspects of lived experiences may have been emphasized or left out of the recorded interviews. Our findings are meant to provide insight and conceptual tools for expanding understandings of suicidality in trans people’s lives.

The majority of this sample was White/European American and did not represent the 22% of African American interviewees or 2% of American Indian/Alaskan Native interviewees in the original project. It is possible that discomfort or stigma with discussing topics related to suicide, comfort with discussing suicide among White/European American interviewers (the cofounders of To Survive on This Shore are both White), or differences in suicide rates could all have contributed to this lack of representativeness. There are significant gaps in knowledge regarding suicidal ideation and attempts among trans people of color (Wolford-Clevenger et al., 2018). In addition, we did not apply an analytical lens to this project that might have delved deeper into the roles of age, geographic region, or race and ethnicity in these experiences and narratives. This study is also not representative of the eight nonbinary or gender-expansive people who participated in the original project. Both these gaps exist within a broader gap in knowledge on suicidal behavior among trans people and draw attention to the importance of considering trans people as a heterogeneous group within suicide research (McNeil et al., 2017; Wolford-Clevenger et al., 2018).

Our analysis included participants who expressed suicidal ideation and those who attempted suicide. A substantial literature has identified significant differences in risk factors for suicidal ideation and transitioning to attempts (May and Klonsky, 2016). However, pain, hopelessness, and the protective nature of connectedness are experienced by members of both groups (Klonsky et al., 2018). This study focused on using narrative analysis to identify contexts giving rise to suicidal ideation and behaviors, therefore, identifying factors contributing to transition from ideation to plans to attempt, such a capability (Klonsky et al., 2018) was outside the scope of this study. It is important to note trans older adults in this study described a continuum of past suicidal ideation, plans to die by suicide, and attempts, including three cases in which participants described plans or attempts with high lethality, e.g., using firearms. Thus, this study echoes previous calls for attention to the dearth of literature on suicide outcomes among trans people and reflects an urgency to examine the transition from ideation-to-attempts among trans people to develop informed suicide prevention interventions (Abramovich and Cleverley, 2018; Dickey and Budge, 2020).

Implications

Our study emphasizes the usefulness of a narrative approach for deriving insight into trans people’s experiences of suicidality and as an example of how to enhance data collection in suicide research moving forward. This was a secondary analysis of narratives generated without the direct intention to collect suicide or mental health stories. Future research in this area could proactively elicit the narratives of trans people who have experienced suicidality with a more systematic approach. Specifically, purposive sampling and questions focused on gender-related stress and recovery of trans survivors hold the potential to build a broader understanding of the way trans people see their struggles and paths to recovery.

The perspectives of older adults, who have a valuable perspective at a later point in the life course, highlighted the importance of connecting to trans-affirming support for nurturing their possible paths. This implies that social workers have a tremendous opportunity to expand trans-related knowledge and guidance for care in many “mainstream” service settings such as community mental health clinics or primary care. Increased affirmation of trans people and knowledge about their experiences could mean that the first point of contact in a service network holds the potential to interrupt suicidality for this group of people. We learned in this study even if services are not primarily geared towards the trans community, they have a tremendous impact. In narratives such as Miranda’s, participants questioned why they felt so bad despite following gendered norms in young and middle adulthood and did not identify as trans before reaching out to a mental health service provider. Miranda’s case highlights the importance of a trained community mental health provider’s ability to provide gender-affirming care and referral to appropriate services.

Social workers can support trans people of all ages by encouraging the sharing of life narratives surrounding suicidal ideation and attempts, and thus help address the pain of experiencing impossible paths and be part of facilitating possible ones. Relationships between social workers and clients often involve the cocreation of a mental health narrative (Lysaker et al., 2002). Assisting clients to develop mental health narratives around suicidal ideation and attempts is thought to build confidence in communicating one’s mental health history with other providers, family, partners, and friends (Lysaker et al., 2002; Munson et al., 2018). Among trans people, narrative therapy may help reduce internalized stigma from oppressive social forces and increase pride in gender identity (White Hughto and Reisner, 2018). Furthermore, some trans older adults feel that sharing their life narratives with younger trans people reduces internalized stigma and enhances their meaning-making around difficult experiences (Fabbre and Gaveras, 2020).

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Eleni Gaveras’ contribution was supported by Grant# T32MH019960 from the National Institute of Mental Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Mental Health or the National Institutes of Health.

ORCID iD

Eleni M Gaveras

References

Abramovich

Cleverley

(2018) A call to action: The urgent need for trans inclusive measures in mental health research. Canadian Journal of Psychiatry. Revue Canadienne de Psychiatrie 63(8): 532–537.

Adams

Hitomi

Moody

(2017) Varied reports of adult transgender suicidality: Synthesizing and describing the peer-reviewed and gray literature. Transgender Health 2(1): 60–75.

Bailey

Ellis

McNeil

(2014) Suicide risk in the UK trans population and the role of gender transition in decreasing suicidal ideation and suicide attempt. Mental Health Review Journal 19(4): 209–220.

Braun

Clarke

(2006) Using thematic analysis in psychology. Qualitative Research in Psychology 3(2): 77–101.

Clements-Nolle

Marx

Katz

(2006) Attempted suicide among transgender persons: The influence of gender-based discrimination and victimization. Journal of Homosexuality 51(3): 53–69.

Dickey

Budge

(2020) Suicide and the transgender experience: A public health crisis. The American Psychologist 75(3): 380–390.

Ellis

Bailey

McNeil

(2016) Transphobic victimisation and perceptions of future risk: A large-scale study of the experiences of trans people in the UK. Psychology & Sexuality 7(3): 211–224.

Fabbre

Gaveras

(2020) The manifestation of multilevel stigma in the lived experiences of transgender and gender nonconforming older adults. The American Journal of Orthopsychiatry 90(3): 350–360.

Frimpong

Rowan

Williams

, et al. (2020) Health disparities, inpatient stays, and emergency room visits among lesbian, gay, and bisexual people: Evidence from a mental health system. Psychiatric Services (Washington, D.C.) 71(2): 128–135.

10.

Garro

(2000) Cultural knowledge as resource in illness narratives. In: Mattingly

Garro

(eds) Narratives and the Cultural Construction of Illness and Health. Berkeley: University of California Press, pp. 70–87.

11.

Haas

Eliason

Mays

, et al. (2011) Suicide and suicide risk in lesbian, gay, bisexual, and transgender populations: Review and recommendations. Journal of Homosexuality 58(1): 10–51.

12.

Hjelmeland

Knizek

(2010) Why we need qualitative research in suicidology. Suicide & Life-Threatening Behavior 40(1): 74–80.

13.

Kidd

Howison

Pilling

, et al. (2016) Severe mental illness in LGBT populations: A scoping review. Psychiatric Services (Washington, D.C.) 67(7): 779–783.

14.

Klonsky

Saffer

Bryan

(2018) Ideation-to-action theories of suicide: A conceptual and empirical update. Current Opinion in Psychology 22: 38–43.

15.

Labov

(1997) Some further steps in narrative analysis. Journal of Narrative and Life History 7(1–4): 395–415.

16.

Labov

Waletzky

(1997) Narrative analysis: Oral versions of personal experience. Journal of Narrative and Life History 7(1-4): 3–38.

17.

Lysaker

Clements

Plascak-Hallberg

, et al. (2002) Insight and personal narratives of illness in schizophrenia. Psychiatry 65(3): 197–206.

18.

May

Klonsky

(2016) What distinguishes suicide attempters from suicide ideators? A meta-analysis of potential factors. Clinical Psychology: Science and Practice 23(1): 5–20.

19.

McNeil

Bailey

Ellis

(2012) Trans mental health and emotional wellbeing study 2012. Available at: www.scottishtrans.org/wp-content/uploads/2013/03/trans_mh_study.pdf (accessed 23 September 2021).

20.

McNeil

Ellis

Eccles

FJR

(2017) Suicide in trans populations: A systematic review of prevalence and correlates. Psychology of Sexual Orientation and Gender Diversity 4(3): 341–353.

21.

Meyer

Schwartz

Frost

(2008) Social patterning of stress and coping: Does disadvantaged social status confer more stress and fewer coping resources? Social Science & Medicine (1982) 67(3): 368–379.

22.

Mishler

(1986) The analysis of interview-narratives. In: Narrative Psychology: The Storied Nature of Human Conduct. Westport: Praeger Publishers, pp. 233–255.

23.

Mishler

(1990) Validation in inquiry-guided research: The role of exemplars in narrative studies. Harvard Educational Review 60(4): 415–442.

24.

Moody

Smith

(2013) Suicide protective factors among trans adults. Archives of Sexual Behavior 42(5): 739–752.

25.

Moody

Fuks

Pelaez

, et al. (2015) “Without this, I would for sure already be dead”: A qualitative inquiry regarding suicide protective factors among trans adults. Psychology of Sexual Orientation and Gender Diversity 2(3): 266–280.

26.

Munson

Narendorf

Ben-David

, et al. (2018) Integrated, overwhelmed, and distanced: Narratives of mental health among young adults with prior public system involvement. Journal of the Society for Social Work and Research 9(3): 413–430.

27.

Narendorf

Munson

Floersch

(2015) Perspectives on psychotropic medication treatment among young adults formerly served in public systems of care: A thematic and narrative analysis. Journal of the Society for Social Work and Research 6(1): 121–143.

28.

Nock

Hwang

Sampson

, et al. (2009) Cross-national analysis of the associations among mental disorders and suicidal behavior: Findings from the WHO World Mental Health Surveys. PLoS Medicine 6(8): e1000123.

29.

Nuttbrock

Hwahng

Bockting

, et al. (2010) Psychiatric impact of gender-related abuse across the life course of male-to-female transgender persons. Journal of Sex Research 47(1): 12–23.

30.

Padgett

(2017) Qualitative Methods in Social Work Research. 3rd ed. Thousand Oaks: Sage Publications.

31.

Perez-Brumer

Hatzenbuehler

Oldenburg

, et al. (2015) Individual- and structural-level risk factors for suicide attempts among transgender adults. Behavioral Medicine (Washington, D.C.) 41(3): 164–171.

32.

Riessman

(2008) Narrative Methods for the Human Sciences. Thousand Oaks: Sage Publications.

33.

Rivers

Gonzalez

Nodin

, et al. (2018) LGBT people and suicidality in youth: A qualitative study of perceptions of risk and protective circumstances. Social Science & Medicine (1982) 212: 1–8.

34.

Singh

Hays

Watson

(2011) Strength in the face of adversity: Resilience strategies of transgender individuals. Journal of Counseling & Development 89(1): 20–27.

35.

Testa

Michaels

Bliss

, et al. (2017) Suicidal ideation in transgender people: Gender minority stress and interpersonal theory factors. Journal of Abnormal Psychology 126(1): 125–136.

36.

Testa

Habarth

Peta

, et al. (2015) Development of the gender minority stress and resilience measure. Psychology of Sexual Orientation and Gender Diversity 2(1): 65–77.

37.

Wagaman

Shelton

Carter

, et al. (2019) “I’m totally transariffic”: Exploring how transgender and gender-expansive youth and young adults make sense of their challenges and successes. Child & Youth Services 40(1): 43–64.

38.

White Hughto

Reisner

(2018) Social context of depressive distress in aging transgender adults. Journal of Applied Gerontology : The Official Journal of the Southern Gerontological Society 37(12): 1517–1539.

39.

Williams

Frey

Stage

, et al. (2018) Exploring lived experience in gender and sexual minority suicide attempt survivors. The American Journal of Orthopsychiatry 88(6): 691–700.

40.

Wolford-Clevenger

Frantell

Smith

, et al. (2018) Correlates of suicide ideation and behaviors among transgender people: A systematic review guided by ideation-to-action theory. Clinical Psychology Review 63: 93–105.