To distinguish from academic information regarding suicide, certain content has been ITALICIZED to indicate information about suicide more descriptive and personal in nature.
If you or someone you know needs support, please visit: https://www.outyouth.org/help for resources or contact the National Suicide Prevention Hotline at 1-800-273-8255
by John Oeffinger
The signs were there. Firemen milling in the front yard with no house fire to fight. Two police vehicles arriving shortly after – no lights or siren. Then the EMS ambulance arriving silently with no urgency to enter the home. Neighbors in their front yards watching and texting while the crime scene van pulls up. Wondering what could have happened in this quiet neighborhood. And yet, all of the signs were there. Almost exactly how they had played out in my mind too many times to count. I knew someone had just committed suicide. My heart tightened as I watched and heard the family try to make sense of this horrible event. Did they see the warning signs? What are the warning signs? Did the person reach out for help?
My suspicion, this person kept their thoughts compartmentalized like I did fifty-three years ago. I failed in my three attempts to kill myself in 1968. No one knew until forty-eight years later when my organization’s CEO, a social worker, made it safe for me to bare my thoughts over dinner — to give context for a new project’s importance. Thankfully, I had learned that the sun can shine the next day, and the next. The mental guardrails I developed over the years have kept this darkness at bay. Now, my ability to talk about suicide and suicide ideation helps as well. My hope is this blog post will assist at least one other person in working through that isolated, dark, and desperate place with no seeming way to escape. Suicide is not painless. Suicide does bring on many changes.
September is Suicide Prevention Awareness Month — a time to raise awareness on this stigmatized, and often taboo, topic. In addition to shifting public perception, the National Alliance on Mental Health uses this month to spread hope and vital information to people affected by suicide.
HuffPost published I was a gay boy who tried to kill myself. Now I know it wasn’t my fault written by my colleague and friend Dr. Phillip Schnarrs. Phillip describes a 2018 community assessment’s finding that 25% of LGBTQ+ adults thought about suicide at least one day during the previous week. One in four people. In the Austin area.
The Trevor Project found 42% of their respondents “seriously considered” ending their life by suicide last year. More than half of the transgender and non-binary people considered suicide. “Crucially, the survey uncovered further disparities in mental health along racial lines. Twelve percent of white respondents said that they had attempted suicide in the past year, whereas Black and multiracial youth had both attempted suicide at nearly twice the rate — 21%. Furthermore, as many as 31% of ‘Native/Indigenous’ survey participants reported having attempted suicide in the last year. Finally, 18% of Latinx youth and 12% of ‘Asian/Pacific Islander’ youth reported having attempting suicide in the same time period.”
2021 has also been the worst year for LGBTQ+ state legislative attacks across the country. In Texas, an unprecedented number of anti-LGBTQ+ bills, especially bills targeting transgender children, have been filed. “These bills represent a cruel effort to further stigmatize and discriminate against LGBTQ+ youth across the country,” states Equality Texas. Every time anti-LGBTQ+ bills are debated in Texas, we see spikes in kids in crisis. The Trevor Project has confirmed this spike in its crisis hotline from Texas area codes. Our LGBTQ+ youth, especially our transgender and gender diverse youth, are at serious risk of doing harm to themselves, or worse, thinking about suicide as an exit path.
There is hope.
The LGBTQ+ community, parents, and allies are rallying to support our youth. One example is TransFORWARD: Texas Transgender Health, a collaboration between Texas Health Institute and Equality Texas Foundation. TransFORWARD seeks to inform clinicians and policy makers on what competent and necessary healthcare looks like for transgender and gender diverse people. The collaboration was created to improve the lives of transgender and gender diverse people. The long-term goal is to reduce suicide attempts and suicide ideation.
Improving the lives of transgender and gender diverse people using a patient-centered approach is a 3-step process. First, we must build research capacity for patient-centered outcomes research and comparative effectiveness research. Second, we need to do research that is patient driven and includes transgender and gender diverse stakeholders in leadership positions. Third, research results should be disseminated and applied to clinical practice and health policy.
Step 1 — Building Research Capacity
TransFORWARD: A Statewide Transgender-Powered Research Collaborative in Texas was recently completed. The thirty-five month project identified patient-centered outcomes research priorities and was funded by the Patient-Centered Outcomes Research Institute (PCORI EA #10671). Close to three hundred Texans were engaged in the research capacity-building effort. Transgender community members, physicians, clinicians, and researchers were engaged in eight regional summits to identify research priorities. Twenty Project ECHO virtual meetings started identifying how trans people are coping with the COVID-19 pandemic. Mental health, housing, and employment sessions surfaced emerging topics requiring research to better understand the long-term effects of COVID-19. These sessions also reinforced the value of personal narratives and speaking up to shine a light on important subjects. I truly admired the sharing of deeply personal information which inspired this post.
TransFORWARD participated in a 2020 PCORI Virtual Annual Meeting Breakout Session Building Research Capacity to Address Disparities Faced by Transgender Individuals. PCORI recognizes that transgender individuals have a higher prevalence of HIV and STIs, violence victimization, mental health issues, suicidal ideation, and suicide than cisgender individuals do. TransFORWARD was one of three highlighted projects representing PCORI-funded engagement awards intended to address health disparities and build the capacity to promote comparative effectiveness studies with transgender populations. Each of the projects discussed the unique health disparities that transgender individuals face, shared lessons learned, and discussed future directions in transgender and health services research.
One of PCORI’s goals is to reduce the seventeen years it takes from a patient identifying a research topic to applying the evidence-based data through clinical application. The process begins with building a foundation or patient-centered outcomes research capacity. Creating a statewide transgender-powered research collaborative in Texas is TransFORWARD’s first step.
Step 2 — Creating Research Projects
The second step in the three-step process is creating research projects and developing evidence-based data. In this case, topics prioritized by transgender people. Suicide intervention is one of those crucial priorities for transgender and gender diverse people. Transgender and gender diverse young adults have higher rates of depression and stress and are at greater risk of suicide compared with other young people. These stigma-related stressors increase mental health risk factors, such as depression and anxiety, that heighten vulnerability to suicide attempts. TransFORWARD’s leadership team presented our work on the importance of addressing suicide attempts and ideation during a mini-symposia at the World Professional Association for Transgender Health (WPATH) 26th Scientific Symposium.
Suicide is also an important public health issue. The Centers for Disease Control and Prevention list three items as part of suicidal behavior. Suicidal ideation is thinking about ending one's life. A suicide attempt is a non-fatal suicidal behavior. A suicide ends one's life. Different communities are affected differently such as veterans and mothers during pregnancy and after childbirth. Part of public health’s broad view is an emphasis on population health—not just the health of individuals. While suicide is often thought of as an individual problem, it actually impacts families, communities, and society in general.
Suicide is the second leading cause of death in the United States among youth. PCORI’s Board of Governors recently approved four culturally adapted youth suicide intervention awards. Suicide attempts are much higher for LGBTQ+ young adults than non-LGBTQ+ peers. Preventing Suicide among Sexual and Gender Diverse Young Adults in Primary Care in Texas, was awarded to one of TransFORWARD’s partners, UT Southwestern Medical Center. The five-year effort capitalizes on the medical center’s experience and that of The University of Texas at Austin’s Dell Medical School and Steve Hicks School of Social Work.
Asking about depression when they see a physician or other healthcare professional may help identify young adults who may have thoughts of suicide (suicidal ideation). There is little research indicating which intervention works best for the community. Currently, physicians and other healthcare professionals do not know which is the best intervention to use, especially in the primary care setting.
Dr. Elizabeth Arnold will lead the project whose aim is to reduce suicide among LGBTQ+ young adults. Two current “emergency room” interventions will be culturally adapted for the primary care settings. The first phase will collect information on the needs of LGBTQ+ young adults regarding suicide prevention and mental health. A pilot project then a larger study will be collected in different primary care settings. The goal is to see which intervention works best to decrease thoughts about suicide and other factors related to suicide.
Dr. Phillip Schnarrs, at The University of Texas at Austin’s Dell Medical School serves as co-principal investigator. Dr. Lauren Gulbas at the The University of Texas at Austin Steve Hicks School of Social Work is a Co-Investigator. TransFORWARD’s partner Out Youth will provide MSW Interns to help with the project in the Austin area. TransFORWARD will assist with the patient-engagement plan.
I am personally very excited about this research project. The $5.4 million award over 5 years can break new ground in LGBTQ+ suicide intervention. My personal belief is peers, quite possibly peers who have attempted suicide or have suicide ideation, are more likely to recognize signs and may be a “trusted friend” capable of intervening. This project includes “Youth-Nominated Support Team for Suicidal Adolescents.”
This gives me hope that we may be able to advance to Step 3 and apply the evidence-based data to clinical practice and health policy sometime in the future.
The Institute of Medicine states it takes 17 years from when a patient identifies a research idea or topic to move evidence-based research data into practice. This month we celebrate our 3rd year in taking these three steps as we help enter Step 2 with this important suicide intervention award.
One of my siblings said, “John, I never knew” when I told him about my failed attempts a half-century ago. My response was, “you were never supposed to know.” Not because I was ashamed, I was, but because I didn’t want family to intervene. I didn’t want family and friends to become concerned about my mental health. I still don’t for the most part. That said, I have learned to lean on or listen to four people (K, A, S, and P). Taking their thoughts together I have changed the way I think about suicide. I realize I have more to live for than the alternative. Intuitively, I knew this standing on that rickety chair in the woods so very long ago. The mental picture of my mother having to deal with my death helped me loosen the rope, step down, and realize I could have a future. My mother, who I still dearly miss, was 16 when her father committed suicide. I didn’t want to put her through that again when I was 16.
Watching the crime scene unit pull away from the curb reinforced something I think about often. It’s on my mind as I try and put these words to paper. It’s family members, especially immediate family members, and friends who are left to wonder why. Writing a note does not explain the desperation. The isolation. The mask over not letting anyone know what is racing through your mind. I felt pain and grief watching as a bystander. For the family now trying to understand. For the person who took the action to end their life. Reflecting on this has reinforced why the work we do try to improve transgender and gender diverse lives, the LGTQ+ community, and people and their families dealing with suicide or suicide attempts is important. I do have hope. I do know that the sun will rise tomorrow. And the next day. My hope is this suicide intervention project will help LGBTQ+ youth see that the sun is going to shine if they take that step into the light.
If you or someone you know needs support, please visit: https://www.outyouth.org/help for resources or contact the National Suicide Prevention Hotline at 1-800-273-8255