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Suicide and Suicidal Behavior among Transgender Persons
H. G. Virupaksha, Daliboyina Muralidhar, and Jayashree Ramakrishna1
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Background:
Suicide rate and suicidal tendencies among transgender persons are considerably high compared to general population. Hence, this review is an attempt to understand the issues around the suicide and suicidal behavior among transgender persons.
Methodology:
The literature search conducted using three sources, i.e., electronic databases (PubMed, ProQuest, Google Scholar, PsycInfo), manual search (library catalog), and gray literature (consultation with experts).
Results:
The suicide attempt rate among transgender persons ranges from 32% to 50% across the countries. Gender-based victimization, discrimination, bullying, violence, being rejected by the family, friends, and community; harassment by intimate partner, family members, police and public; discrimination and ill treatment at health-care system are the major risk factors that influence the suicidal behavior among transgender persons.
Conclusion:
In spite of facing a number of hardships in their day-to-day life, the transgender community holds a number of resiliency factors. Further, this community needs to be supported to strengthen their resiliency factors and draw culturally sensitive and transgender-inclusive suicide prevention strategies and increase protective factors to tackle this high rate of suicidality.
Key words: Suicidal behavior, suicide, transgender persons

INTRODUCTION
Suicide is a complex behavior which results from the complicated interaction of biological, psychological, cognitive, and environmental factors.[1] Suicide rate and suicidal tendencies among transgender community have been reported to be high compared to general population.[2,3,4,5] The suicide rate among transgender individuals in India is about 31%, and 50% of them have attempted suicide at least once before their 20th birthday and 40–50 persons commit suicide every year in Karnataka state alone.[6] However, the exact prevalence of completed suicide among transgender persons remain undocumented; the gender-based discrimination has prevented them by obtaining education, livelihood, and housing because of which they are living in slums and have to resort to begging and sex work; this pitiful conditions lead them to breakdown further and end their life in suicide.[6] The high prevalence of depression and suicidal tendencies among transgender persons seems to be highly influenced by societal stigma, lack of social support, HIV status and violence-related issues which require further thorough investigation and necessary mental health counseling, crisis management, addressing drug abuse, providing them livelihood opportunities, and so on as part of the intervention.[7]

METHODOLOGY
The literature search was carried out mainly using three sources, namely, search in electronic databases (PubMed, Google Scholar, PsycInfo, ProQuest), manual search (library catalog) at the library of the National Institute of Mental Health and Neuro Sciences (NIMHANS), and gray literature (consultation with experts). To extract the related studies, the search strategies (key words) used for both electronic database and manual search are “Transgender and Suicide,” “Hijra and Suicide,” “Sexual minorities and Suicide,” transgender and Self-harm,” “Transgender and Suicide Prevention,” “Transgender and Suicide Prevention Intervention.” The author selected 21 research studies including reports and documents as part of the search in electronic databases. These studies selected based on their relevance to the current title of the review and their availability with full text freely online.

As part of the manual search (library catalog), the author could get three dissertations relevant to the title of the review, submitted to NIMHANS. All these studies and dissertations are published or submitted between 2005 and 2015.

As part of gray literature, the author consulted the Director of Karnataka State Women Development Corporation, Bengaluru, the Key persons of nongovernment organizations (NGOs), i.e., Initiatives for Development Foundation (IDF), Sangama, Samara, Jeeva, and Aneka. The author consulted the key persons who gave oral consent and discussed the subject and note down the key points with their permission. The discussion mainly focused on the services available at these organizations for transgender persons which may influence the suicidal behavior of the transgender community directly or indirectly.
This review is part of an ongoing Ph.D research program which has obtained the approval by the NIMHANS Ethics Committee, No. NIMH/DO/ETHICS SUB-COMMITTEE 18th MEETING/2014, dated September 19, 2014.

RESULTS
Prevalence of suicide and suicidal behavior among transgender persons
The suicidal behavior and suicide attempt rates are reported to be significantly high among transgender persons compared to general population across the countries. Thirty-one percent of transgender persons in India end their life by committing suicide, and 50% of them have attempted for suicide at least once before their 20th birthday;[6] however, the exact prevalence of completed suicide among transgender persons in the country remain undocumented.[6] Forty-one percent of the transgender persons in the United States attempt for suicide at least once in their life.[8] In San Francisco, the prevalence of attempted suicide among transgender persons is 32%, among young age (<25 years) it is 50%.[9] Suicidality and self-harm behavior are serious problems among sexual minorities in Japan.[10] Transgender persons are at higher risk for suicidal ideation and suicide attempts at Virginia.[11] Fifty percent of transgender persons in Australia have attempted suicide at least once in their lives.[12] In England, 48% of the transgender young people had attempted suicide at least once in their lives.[13] The prevalence of suicide remains high among transgender persons irrespective of disclosing their transgender status to others and undergoing sex reassignment surgery.[8]

The self-harm behavior among sexual minority including transgender persons is equally serious and impactful as suicidality; the forms of self-harm committed by the respondents are cutting on the wrists and other areas of the arms, burning oneself, pouring gasoline on oneself but not igniting it, hanging oneself, breaking glasses, cups and other objects on one's head, fists and body, banging one's head against the wall, excessive drinking, eating and drug use, harmful sexual behavior, joining crime, street gang and violent activities to purposefully drop-out from the life and society, etc.[10]
Living conditions and salient features of the transgender persons
Rejection and lack of support from the families and society, gender dysphoria associated with extreme stressful experiences, child sexual abuse, early discontinuation of schooling, forced marriages, lack of livelihood opportunities, sexual and financial exploitation by the partner and police and rowdies, and lack of legal measures for protection are some of the characteristics of transgender persons.[14] About 62% of the transgender respondents are either have problems with their family members, or they do not have any contact with their family members hence, they are living away from their families; they left their families because of ill-treatment, being not accepted as transgender persons and being felt embarrassed to live in the community; 56% of them have discontinued their education at either primary level or secondary level; majority of the transgender persons have opt sex industry and begging for their survival; 54% of them have the habit of consuming alcohol.[15] Fourteen percent of the transgender persons consulted mental health professionals for their gender dysphoria mostly because they were referred by the general physicians and rest of the respondents have sought help at traditional healers and transgender community leaders; 31% and 15% of the transgender persons are at high risk for tobacco and alcohol abuse, respectively, and 26% of them are have severe depression.[14] The transgender persons are forced to go out of their family and community; they are refused from education, employment and getting a house for rent; they stay at slums and many people under the same roof; they are ill-treated at health-care centers.[16] All the transgender persons are belong to lower socioeconomic status[17] have high level of perceived stigma,[18] have poor social support from family, friends and significant others, and their level of perceived stress is high.[19]
Risk factors of suicide and suicidal behavior among transgender persons
The studies have identified a number of risk factors for the high rates of suicide and suicidal behavior among transgender persons. The discrimination of the transgender persons in the society has prevented them from obtaining an education, job, and housing because of which they are living in slums or street and have to resort to begging and sex work;[10] this pitiful conditions have lead them to breakdown further and end their life in suicide.[6] Stigma, discrimination, and violence against transgender persons occur across multiple social and institutional contexts; they are verbally harassed, physical and sexually abused[11] and blackmailed by the police and rowdies; rejection, hateredness, verbal and physical abuse from friends and family members, stigmatization, refusal of services, and derogatory labeling at health-care system, etc., have lead them to lose interest in day-to-day activities; the risk of HIV and HIV status increase their psychological distress, and they express thoughts of committing suicide.[17] The suicidality among sexual minority community is associated with poor mental health condition in forms of mental illness,[20,21] psychological pain, emotion fatigue, and low self-esteem; life being hard, being confused about one's sexuality or difficulty in accepting it, not being able to disclose one's sexuality,[8] bullying, history of forced sex, gender-based discrimination, and victimization[9] and isolation are the other reasons for suicide among this population.[10] Lesbian, gay, bisexual, and transgender (LGBT) assault hate crimes at the neighborhood are an additional sociocontextual risk factors for suicidal ideation and attempts among sexual-minority adolescents.[22]
Transgender persons being in adolescents and being in their early 20 s and having history of suicide attempt,[21] those who work in the Bar, entertainment and sex industries, survivors of violence perpetrated by intimate partners or family members, are potentially in higher risk for suicidality.[10] Neither reporting the thoughts and behaviors of suicide and self-harm nor seeking help is common among sexual minorities.[10,11,14]
The final triggering factors
The psychological autopsy of the completed suicides among transgender persons has revealed that the factors such as break-up of love relationship initiated by the partner (64.3%), serious altercations with family members (14.3%), refusal of gender/sex reassignment by the family members (9.5%), financial problems (9.5%), being diagnosed with HIV positive in the past few days/weeks (2.4%) have triggered the act of suicide among the victims.[14]
Resiliency factors and protective factors among transgender persons
The research studies have tried to explore the resiliency factors which are helping the transgender community to bounce back and continue living even with a number of hardships and adverse conditions in their day-to-day living. The transgender persons have overcome from the above-mentioned situations using at least one of the coping mechanisms or having certain personal qualities such as assertive communication, self-advocacy, spiritual coping, honesty, integrity, avoidance, physical or verbal aggression, help seeking, being future-oriented with having personal goals, being outspoken, strong, friendly, outgoing, independent, determination, etc.[23] The transgender persons who have income of >10,000 Dollars and being educated at higher level,[8] employed in the mainstream jobs other than sex work and begging,[19] optimistic, having perceived social support from family, emotional stability, and child-related concerns[24] have shown better self-esteem and resiliency level. Social support from family is found to be general protective factor which is associated with reduced risk for lifetime suicide attempts among transgender persons.[21]
Suicide prevention among transgender persons
The National Centre for Transgender Equality provides information on services available for suicide prevention in the United States that includes national suicide prevention helpline (24 × 7, toll free), LGBT national hotline and the Trevor Project which provides telephonic, online, E-mail peer counseling, crisis intervention and online materials, and information about suicide and help.[8] The most of the programs related to LGBT youth under Trevor project deal with the issues such as school safety, health promotion, prevention of violence, harassment and discrimination, civil rights, peer education, emergency support, HIV and AIDS prevention and offer services in terms of training in life skills, enhancing peer relationships, connecting LGBT youth with supportive adults, helping parents and teachers to provide support to the LGBT youth, in-school workshops, educational materials, online educational resources for youth, and advocacy for public policy to reduce LGBT stigma.[25,26]
The NGOs such as Sangama, Samara, Jeeva, Aneka, IDF and the Karnataka Women Development Corporation of Bengaluru, Karnataka, the organization Sahodari in Tamil Nadu, The Humsafar Trust in Maharashtra, and so on organizations are providing services in terms of crisis intervention services, helpline services, clinical services, information and referral services, Legal and advocacy support, drop-in-centers, alternative employment services and financial assistance, soft-skills training, self-help group formation, assistance in availing ration card, election ID card etc., creating awareness through workshops, lobbying with media to create awareness among families to increase the acceptance of transgender children, telecasting programs through community radio, developing films and videos, screening the documentaries and films, self-esteem and resilience building services, organizing health camps to provide general health and mental health services, medical services, entertainment, competition and library services, organizing seminars, discussions, and so on services to the sexual minority community at locally.
Although these services explicitly do not focus on suicide prevention, they contribute enormously in enhancing the resiliency factors and protective factors among transgender persons.
Suicide prevention – the recommendations
The interventions and programs to enhance protective factors and resiliency factors are as important as programs for risk reduction; these interventions should be delivered through cultural competence approach[25,27] and should be more LGBT inclusive[26] which help an agency, system, or a professional to work effectively in cross-cultural situations.
The suicide prevention interventions and programs for all youth can also be implemented for LGBT individuals mainly in three settings, schools (suicide awareness curricula), communities (gate-keeper training) and health-care system (screening) and crisis centres, hotlines, and risk reduction which can include restricted access to lethal means, media training, and youth life-skills training also can be part of it.[7,25] Community awareness campaigns, discrimination and hate crime legislations, culturally and age appropriate suicide prevention interventions[28] including peer-based outreach, counseling and referrals,[9] targeting the institutions such as schools, family, community, health-care system,[25] police and judiciary,[11] effective treatment for symptoms of hopelessness, depression, conduct disorder, family-based interventions to enhance the support and reduce the victimization,[21] effective intervention in addressing high rates of HIV infection, multiple and complex high-risk behavior and comorbid conditions,[27] addressing sociocultural factors such as LGBT assault hate crimes at the neighborhood[22] providing educational and resource materials on LGBT suicide to the LGBT organizations and encourage these organizations to consider suicide prevention at their organizations' mission and activities,[26] all these would help in achieving increased societal acceptance of the transgender community and decreased gender-based prejudice and also in the promotion of mental health and reduction of suicidal risk among transgender community.

CONCLUSION
The current review covers research studies from electronic database and manual search and also supplements information with gray literature. The review has included important studies conducted across the countries and through more light on issues and situations surrounded suicidality and suicidal behavior among transgender persons, and the efforts are taken to address the same across the countries and in the Indian context. The transgender community is highly vulnerable for suicidality and suicidal behavior which is a challenging phenomena for the governments and organizations globally. However, the countries like the United States are trying to address the same at national level but in the Indian context, a lot of ground work should happen. The involvement of government, policy, institutions, organizations, public, along with the involvement of transgender community is required.
The transgender community is one of the difficulties to reach population having its own cultural background requires understanding and interventions with culture-specific, sensitive, and transgender-inclusive approach. The review recommends the interventions to be drawn simultaneously for suicide risk reduction and enhance the protective factors and resiliency factors at the same time.
Financial support and sponsorship
This article is part ongoing Ph.D research work and the study has been funded by University Grants Commission as part of Junior Research Fellowship.
Conflicts of Interest
There are no conflicts of interest.

Acknowledgments
The authors are very much thankful to the key informants of the NGOs and the Director of Karnataka State Women Development Corporation, Bengaluru, who cooperated to share the information and support this study.

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