In the midst of a slew of anti-trans legislation proposed earlier this year, Spencer Cox, the Republican governor of Utah, made an impassioned plea to his state’s legislature as he tried to veto a bill that would bar trans youth from competing in girls’ sports. “I want them to live,” he wrote of the trans athletes in his state, in reference to the astronomical rates of suicide attempts among the trans community. Multiple surveys have estimated that about 40 percent of trans people may attempt suicide in their lifetimes; among the general public, this figure is around 5 percent.
But despite the governor’s veto attempt, the Utah bill passed, as have a few across the country that ban gender-affirming medical care for kids and teens. Many other such bills are currently in the works. These treatments—principally drugs that delay the onset of puberty, and hormone treatments such as testosterone and estrogen—help trans people achieve the bodies and appearances that feel right to them. Experts worry that the bans will have catastrophic effects. “Youth will die,” says Dallas Ducar, CEO of Transhealth Northampton, a medical center in Western Massachusetts that provides gender-affirming health care services.
Because such treatments for adolescents are relatively new, and access to them is limited, the pool of studies about their mental health effects is both small and recent. But WIRED spoke with half a dozen academics who have published studies on transition and suicidality in peer-reviewed journals, and they all agree—gender-affirming medical care seems to lower that risk among trans youth. There’s no single study that proves it once and for all, no clincher that can summarily end every argument. Researchers say they can’t ethically pursue the kind of randomized control trial that’s the gold standard for most medical research: That would involve giving a placebo to a person in a potentially dangerous situation. Still, as a whole these studies tell a consistent story, one robust enough to convince their authors of the vital importance of these medical treatments. “All the data that we have at this point suggests that they decrease suicidality,” says Jack Turban, an incoming assistant professor of child and adolescent psychiatry at the University of California, San Francisco.
Research in this area can be tricky because it deals with small numbers: Trans people are a minority of the population, and those who receive gender-affirming treatment as minors are an even tinier subset. Some of those minors may receive puberty blockers, others only get hormones, and some get both. Gathering enough participants to obtain statistically significant results takes a lot of time and money.
Studies limited to people who have attempted suicide would be smaller still. So researchers often focus on suicidality, a term that captures a wide range of behaviors, including thinking about ending one’s life. Critics have contended that this research doesn’t show evidence of a crisis—after all, thoughts are not actions. But ideation is a strong predictor of attempted suicide, and a “marker of really severe psychological distress,” Turban says. And, because it’s more common, it’s easier to study.
To do that, researchers have two primary tools at their disposal. The first is the longitudinal study, which tracks individuals over a period of time to evaluate the efficacy of a medical intervention. In the trans health care context, these studies typically start in the clinic: Patients who want to pursue a particular intervention will get recruited for the study, and then researchers will follow them over the course of their treatment.
One such study followed 47 adolescents in Missouri and found significant decreases in suicidality after three or more months of hormone treatment. A Finnish study that looked back at the medical charts of 52 adolescents also found significant reductions in suicidality after hormone treatment. And another longitudinal study reported less suicidal ideation in its subjects after treatment, although the number of people reporting any suicidal ideation at all was too small for the results to be statistically significant. Several more longitudinal studies have observed improvement in depression symptoms after treatment, although these did not evaluate suicidality directly.
Longitudinal studies are common tools, and they have some advantages. By comparing an individual to themselves, researchers can control for factors like age, socioeconomic status, and parental support. But these studies also have downsides. Following up with subjects is expensive, so the sample sizes can be small, and time frames are limited—typically several months or a year. The lack of a control group is the studies’ biggest shortcoming, though. There’s no way of knowing what would have happened to these people in the absence of gender-affirming care; perhaps their mental health would have improved anyway. This is particularly plausible if seeking care is associated with other beneficial experiences, like coming out or starting talk therapy.
So researchers also deploy their second tool: cross-sectional studies, which take a snapshot—a “cross-section”—of what a group of people is experiencing at a given point in time. In a group of trans people, some will have had gender-affirming medical care and some will not. Comparing the mental health of people who received that treatment with those who wanted it but didn’t get it can give scientists an idea of its benefits.
Recently, a few cross-sectional studies using data from surveys of tens of thousands of trans adolescents have tried to pin down these effects. One, led by Turban, used data from the 2015 US Transgender Survey and found that participants who wanted—but had not received—puberty blockers reported significantly more suicidal ideation than those who received them, although it’s unclear if that ideation occurred before or after they would have received treatment. Another Turban-led study using the same survey data found that hormone treatment at any age was associated with significantly lower odds of suicidal ideation in the year before the survey, although no difference was observed for suicide attempts. And a study by The Trevor Project, a charity that works to prevent suicide in queer youth, examined hormone treatment data from a 2020 survey of trans adolescents and young adults. Rates of depression were significantly lower among those who had received hormone therapy, and rates of having attempted suicide trended lower, though the difference was not significant.
This sounds promising, but just like the longitudinal studies, the cross-sectional studies have limitations: People who receive gender-affirming health care likely had more parental support and better mental health in the first place.
To account for this possibility, both Turban and the Trevor Project study authors controlled for levels of parental support in their analyses. Accounting for someone’s mental health when they started treatment is a bit trickier: Mental health has numerous dimensions, and participants who are many years into treatment may find it difficult to recall exactly how they felt years ago. In his paper on hormone treatment, Turban took a step toward addressing this issue by focusing on people who had reported suicidal ideation in their lifetime, but not in the past year. That way, he was looking specifically at people whose mental health had improved, and not at those who had always had good mental health. This sort of improvement was significantly more likely for people who had received gender-affirming hormones as an adult, and it approached significance for those who received hormones at ages 16 or 17.
Ultimately, longitudinal and cross-sectional studies have opposing strengths and weaknesses: The former explicitly analyze baseline mental health, and the latter have control groups. Each fills in the other’s gaps, and together they tell a coherent story. “The best approach is not for everyone to do the same thing, but for different researchers to examine it from different angles and really have that accumulation of evidence,” says Amy Green, lead author of the Trevor Project study and head of research at Hopelab, which designs technologies to improve youth health and wellness. “That makes the research stronger than any one of those studies could ever do.”
Granted, there is one research tool that would do away with these limitations: a randomized control study, in which patients seeking gender-affirming care would be arbitrarily assigned to receive either treatment or a placebo, to avoid any systematic differences between the two groups. “That’s the gold standard for understanding causality,” says Jaclyn Hughto, assistant professor of behavioral sciences and epidemiology at Brown University. But that would require denying some patients care. And when there are solid indications that the care may be effective—not only for preventing suicide, but also for ameliorating other mental health concerns like depression—such studies may not be considered ethical.
Not having a randomized control study may not be optimal, but it’s far from unusual. There was never one to test whether cigarettes are dangerous, Green points out, and yet no one today disagrees that they are. The danger of stomach-sleeping for babies was never tested using a randomized control trial, but experts universally recommend that babies should sleep on their backs. For similar reasons, mask-wearing for Covid-19 prevention was never tested with a randomized trial. And in urgent situations, like the AIDS crisis and Covid pandemic, scientists often forgo the absolute best standards of evidence in order to get promising treatments to patients, by, for example, testing drug candidates head-to-head instead of against a placebo. “In times of crisis like this—and the suicide rate among trans youth is at a crisis level—we’re willing in science to use our best available evidence to make decisions,” Hughto says.
Plus, a placebo-controlled trial might not be practical: If the treatment is already available, why would anyone opt into a study where they might not get it? Covid drug trials are having trouble recruiting participants for this precise reason. Researchers also typically try to ensure that trial participants don’t know whether they’ve been assigned to the untreated group. But in the case of hormones, whose effects are fast and obvious, such blinding would be impossible.
Getting gender-affirming health care as an adolescent is already challenging—people must navigate lengthy waiting lists, insurance denials, and other hurdles. And for tens of thousands of trans youth, it may soon be getting much more difficult. This year, over a hundred pieces of anti-trans legislation, most targeted at young people, have been introduced in US state legislatures. Sebastian Barr, a psychologist and researcher who works primarily with the trans community, isn’t just concerned about adolescents who may not be able to access hormones. He also worries about the messages this legislation is sending them. “These young people know that they’re being talked about, and know that people are misunderstanding them, that there are even really hateful factions talking about them,” Barr says. “What a burden for a young person to carry.”
Young people, he says, have a strong need to belong. When peers don’t correctly perceive their gender identity, something that hormones could ameliorate, belonging becomes difficult. And day-to-day experiences like getting misgendered (which can happen with or without hormones), as well as the large-scale social rejection implied by this legislation, can feel devastating. “All of that is just reinforcing that message that there’s not a place for them in our society,” he says. “And that’s painful beyond words.”
There are political forces working to send the opposite message. On June 15, the Biden White House issued an executive order directing the administration to safeguard LGBTQ health care access—and, specifically, to work to prevent suicide. But the order doesn’t just focus on medical care: It also aims to support queer student well-being in schools, broaden access to family counseling, and reduce LGBTQ homelessness, among a slew of other goals.
To experts like Turban and Ducar, an expansive approach is exactly what is needed—not simply to prevent deaths, but also to encourage trans youth to lead happy, fulfilling lives. Achieving that goal means offering them access to appropriate mental health care, ensuring that they know they are supported, and publicly and emphatically speaking out against anti-trans hate. “We should not be striving, as a health care community, just to reduce suicidality,” Ducar says. “Keeping someone safe is the bare minimum.”
