Family Policy Brief

Understanding Transgender Issues: Suicide Risk

This policy brief is part of a series examining transgender issues posted in
FWI’s Family Policy Resource Center at familywatch.org.

Executive Summary
Transgender activists often assert that affirming the preferred “gender identity” of transgender
persons and providing them with access to cross-sex hormones and surgeries is essential to
preventing them from committing suicide. Activists claim suicidality and other mental health
problems result from transphobia, stigma and discrimination, as well as a lack of support or
affirmation by others of a person’s self-perceived gender identity. Moreover, parents of gender-
confused children are often pressured to collude with their child’s self-declared “gender identity”
fantasy and are accused of contributing to their child’s suicidality if they do not.
However, if societal factors such as discrimination or lack of collusion and affirmation were the
major contributors to transgender suicidality, we would expect suicide rates to be lower in
communities where transgender identities are supported and affirmed and higher where they are
not—but that is not what research shows.
There is no research showing that either cross-sex social affirmation or medical procedures have
reduced suicides among those who identify as transgender. In fact, key studies have provided
some evidence that social, medical and surgical affirmation of cross-sex identities might actually
increase suicidality instead. Further, underlying mental health conditions that may contribute to
the dysphoria of transgender people have largely been left untreated, and they often have been
denied the help they really need as it has become politically incorrect to imply there could be any
kind of link between mental illness and gender dysphoria.
Although all suicide threats should be taken seriously, such threats have sometimes been used by
youth and health care providers, as a form of manipulation to coerce parents into allowing their
children to receive life-altering transgender medical procedures. The threat of transgender
individuals committing suicide is often used as a reason to enact policies that impose forced
affirmation of transgender identities.

Data on Transgender Suicidality

The following studies suggest a strong association between transgender identification and
suicidality in general:
 • Over a dozen separate surveys of transgender adults from Canada, Ireland, Belgium,
Germany, the United States and the United Kingdom found lifetime suicide attempts
reported by 25-43 percent of transgender respondents—compared to 4.6 percent of the
general U.S. population and 10-20 percent of lesbian, gay and bisexual adults.1

• The 2015 U.S. Transgender Survey (published by the National Center for Transgender
Equality) reported that among the transgender population,
• Forty percent (40%) have attempted suicide in their lifetime, almost nine times the
rate in the U.S. population (4.6%);
• Seven percent (7%) attempted suicide in the past year—almost twelve times the
rate in the U.S. population (0.6%).2

• The National Transgender Discrimination Survey (NTDS) of 6,450 persons who self-
identify as transgender published in 2011 found that 41 percent said they had attempted
suicide, versus 1.6 percent of the general public.3 Five years later, one of its authors
acknowledged that “the statistic about suicide attempts has, in essence, developed a life
of its own. It has had several key audiences—academics and researchers, public
policymakers, and members of the community, particularly transgender people and our
families.”4
Valid criticism has been made of estimates of transgender suicidality. For example, data like that
from the U.S. National Transgender Survey are based on a “convenience sample” of online
volunteers, a method which does not produce a representative sample of the population.
The 2015-2016 California Health Interview Survey, which was a representative survey, found,
“Transgender adults were nearly six times more likely to report having ever attempted suicide …
(22 percent versus 4 percent)”5—a rate still much higher than the general population, but well
below the often-cited 41 percent in the NTDS.
Hacsi Horváth, an expert in clinical epidemiology, a lecturer at the University of California, San
Francisco, and a former transgender person who “detransitioned” (that is, returned to identifying
with his biological sex) points to a similar survey of adolescents. The survey did not explicitly
ask respondents whether they identified as transgender, but it did identify a population who were
“highly gender non-conforming,” which could be used as a proxy for transgender status. Among
this group, only 3% of girls and 2% of boys reported having attempted suicide.6

“Suicidality” vs. Suicide

There is one factor about data like those above that in one sense is obvious but is nevertheless
often overlooked. None of those statistics look at actual suicides. All of the data come from
surveys of living transgender people, but people who have committed suicide are incapable of
answering surveys.
Instead of looking at “suicide,” surveys only measure “suicidality”—thoughts or behaviors
which may lead to suicide, but usually do not. These measures may include:
• “Suicidal ideation” (that is, thinking about the possibility of committing suicide);

• Suicide “planning” (considering how, when and where one might commit suicide);

• Suicide “attempts” (which may be spontaneous or planned, may not result in serious
injury, and in some cases, may be an effort to gain attention rather than actually to end
one’s life);

• Serious suicide attempts (resulting in life-threatening injury or injury serious enough to

require hospitalization).
The frequency of each of these distinct measures of “suicidality” generally declines as one goes
down the list. While every expression of suicidal thoughts or behaviors should be taken
seriously, it is most important to remember that general statistics on suicidality show that only a
small percentage of people who think or talk about committing suicide ever do so. For example,
CDC data for 2020 indicates that only one in every 265 people who considered suicide actually
committed suicide.7

“Stigma” or Social Support

While the data indicate that transgender-identified individuals may have higher levels of
suicidality (or even of completed suicides), any steps to prevent suicidal feelings, thoughts, plans
or attempts must hinge on a determination of their cause.
Rather than scientifically exploring multiple possibilities, however, activists tend to offer a
single, simplistic answer for the high rates of both mental illness and suicidality among those
who identify as lesbian, gay, bisexual or transgender. Using what is sometimes called “minority
stress theory,” they claim that societal discrimination, or “stigma,” is the cause. This claim,
however, has never been empirically verified.
If mental health problems among those who identify as LGBT were caused by “discrimination,”
one would expect that they would be much more severe in places with higher levels of
discrimination, and much less severe in places where LGBT identities are widely accepted.
However, this is not what the research shows.
With respect to homosexuality, for example, one study has identified what it called the “Dutch
paradox”:
“Despite the Netherlands’ reputation as a world leader with respect to gay rights,
homosexual Dutch men have much higher rates of mood disorders, anxiety disorders and
suicide attempts than heterosexual Dutch men.”8
The NTDS study, which produced the “41%” number cited above, was clearly designed to
suggest that discrimination leads to negative mental health outcomes such as suicide attempts.
However, a different study of 392 male-to-female and 123 female-to-male transgender persons in
San Francisco found similar mental health problems among transgender people, even though
such identities are highly accepted there. In both the male-to-female and the female-to-male
groups in the San Francisco study, 32% reported that they had attempted suicide.9

Parental Support
Pressure is particularly placed upon parents to be fully affirming of a transgender child’s desire
to be recognized as another gender identity. Parents are often explicitly threatened that if they do
not unquestioningly accept and fully affirm their child’s gender confusion, the child will commit
suicide. For example, a therapist will ask parents of a biological male, “Would you rather have a
dead son or a live daughter?”10 Although some studies have purported to show mental health
benefits to children supported in a “gender transition”11 by their parents, the methodology of
these studies has also been widely criticized, calling the validity of their conclusions into
question. Michael Bailey and Ray Blanchard, both Ph.D.s, concluded, “It serves … parents
poorly to exaggerate the likelihood of their children’s suicide, or to assert that suicide or
suicidality would be the parents’ fault.”12
Co-founder of Advocates Protecting Children Maria Keffler puts her critique more strongly:
Nothing about that guidance is supported by research, data, or long-understood principles
of child development, but this emotional manipulation coerces parents like the
thumbscrews of a torture device, terrorizing them with the idea that unless they capitulate
to the transgender industry’s demands, they will inevitably lose their child.13

Gender Transition Medical Treatments Do Not Improve Mental Health

Before examining the specific evidence regarding suicide, it makes sense to examine the broader
question of mental health in general. An obvious but often unspoken reality about gender
transition medical interventions is that their only purpose is to improve a patient’s mental health.
There is no benefit to one’s physical health from blocking normal puberty, administering cross-
sex hormones, or amputating healthy body parts.
Evidence suggests that these procedures do little to improve a patient’s overall mental health,
and certainly do not bring it to the level of the general population. Johns Hopkins University was
the first American medical center to venture into “sex-reassignment” surgery. But under the
leadership of Dr. Paul McHugh, they undertook a study in the 1970s to examine the outcomes for
transgender people who had surgery. Dr. McHugh explained why Johns Hopkins subsequently
stopped doing “sex-reassignment” surgery:
I concluded that Hopkins was fundamentally cooperating with a mental illness. We
psychiatrists, I thought, would do better to concentrate on trying to fix their minds and
not their genitalia.
 … We have wasted scientific and technical resources and damaged our professional
credibility by collaborating with madness rather than trying to study, cure, and ultimately
prevent it.14
In 2016, the Centers for Medicare & Medicaid Services (CMS) declined to issue a “National
Coverage Determination” that would mandate coverage for such surgery under Medicare,
declaring that “there is not enough high quality evidence to determine whether gender
reassignment surgery improves health outcomes.” CMS examined 33 studies but found that all
had “potential methodological flaws,” and that “[o]verall, the quality and strength of evidence
were low.” Patients in the best studies “did not demonstrate clinically significant changes” after
surgery.15
In a 2020 article, Dr. McHugh described results from another review of the literature:
After reviewing 21 studies, the Hayes Directory concluded that the studies “were
inconsistent with respect to a relationship between hormone therapy and general
psychological health, substance abuse, suicide attempts, and sexual function and
satisfaction.” For quality of life, “[d]ifferences between treated and untreated study
participants were very small or of unknown magnitude,” suggesting little evidence of
effectiveness.
Alarmingly, and contrary to the popular narrative, the Hayes Directory reports that the
studies show the prevalence of suicide attempts was not affected by hormone therapy.16
Dr. Miroslav Djordjevic is one of the world's premiere genital reconstruction surgeons, and he
has performed gender “reassignment” surgery. However, even Djordjevic has begun
encountering more and more transgender patients who regret their surgery and seek to
“detransition.”17 Dr. Djordjevic confirms “crippling levels of depression” in his patients and
some who have contemplated suicide.

Do Gender Transition Procedures Prevent Suicide?

Transgender activists often argue that “social support” or “affirmation” of a person’s gender
identity is not enough to prevent suicidality. They insist transgender individuals, including
minors, must be afforded the opportunity to undergo cross-sex gender transition medical
procedures—again, because they allegedly will be at higher risk of suicide if these procedures
are not provided.
Such interventions may include puberty-blocking drugs for pre-pubescent children. These
usually lead to the administration of cross-sex hormones and then to surgical procedures such as
removal of the male genitals as well as mastectomies and hysterectomies for girls. These surgical
procedures cause permanent, irreversible infertility,18 and often a loss of sexual function for the
individual as well.19
In a journal article, Sahar Sadjadi, a professor at Canada’s McGill University, summarizes the
arguments used to support the use of puberty blockers in transgender-identifying children:
 [A] core argument for puberty suppression is frequently repeated by numerous clinicians
and advocates of the treatment: preventing the body from developing unwanted
secondary sex characteristics saves children from violence, suicide, self-harm, and mental
illness at the onset of puberty … and from violence and discrimination (and in some
accounts, unemployment, drug use, prostitution, suicide) which besets … transgender
adulthood.20
In support of this theory, a 2020 study by Jack Turban, et al. in the journal Pediatrics claimed to
have found evidence that suicide risk could be lowered by giving puberty suppression treatments
to youth who want them.21 Though widely touted in the news media, the claim does not really
seem to be supported by the study itself.
Using only subjective, self-reported outcome measures, the authors singled out one of these,
suicidal ideation, and said that “those who received treatment with pubertal suppression, when
compared with those who wanted pubertal suppression but did not receive it, had lower odds of
lifetime suicidal ideation.”
However, statistics regarding rates of “lifetime suicidal ideation” or “lifetime suicide attempts”
for trans-identifying individuals do not necessarily prove anything about the causal effect of
particular interventions. Critical to any meaningful interpretation is understanding whether
suicidal feelings, thoughts, plans or attempts occurred before, during or after medical
interventions. The transgender-affirming GLMA (formerly the Gay and Lesbian Medical
Association) has acknowledged, “Suicide is a risk, both prior to transition and afterward”
(emphasis added).22
The authors of the Pediatrics article admitted that “it is plausible that those without suicidal
ideation had better mental health when seeking care and thus were more likely to be considered
eligible for pubertal suppression.”23 A pediatrician who critiqued the study noted that even those
youth who received puberty suppression had significantly higher than average rates of suicidal
thoughts (75%) and attempts (42%). He concluded, “The prevailing narrative that these
interventions are necessary to prevent suicide is without reasonable evidence.”24
Other studies focusing on transgender adults have also shown that alarming rates of suicide
persist even in those who have undergone medical gender transition procedures. A prominent
2011 study in Sweden followed more than 300 transgender surgery patients for up to 30 years
and concluded: “Persons with transsexualism, after sex reassignment, have considerably higher
risks for mortality, suicidal behavior, and psychiatric morbidity than the general population.”
The study found that 10 years after cross-sex surgery, suicide rates were nearly 20 times that of
the general population.25
Another study using data from Sweden, published online in October 2019, found that utilization
of mental health services (including “hospitalization after suicide attempt”) declines with time
after so-called “gender-affirming” surgery. The authors concluded that this was evidence that
such surgery is beneficial.26 However, criticism of the study led to a re-analysis of the data,
directly comparing those who had received surgery with those who had not. This analysis
showed no benefit from surgery, leading the authors to publish a correction and admit that their
original positive conclusion “was too strong.”27
After a U.K. review of more than 100 international medical studies of post-operative transgender
persons, Christopher Hyde, director of the University of Birmingham's Aggressive Research
Intelligence Facility, warned, “There’s still a large number of people who have the surgery but
remain traumatized—often to the point of committing suicide.”28

Could Gender Transition Procedures Actually Increase Suicide?

There is at least some evidence that gender transition medical procedures may increase rates of
suicide, not decrease them.
Anecdotal evidence of this point can be found in a 2018 op-ed by Andrea Long Chu in The New
York Times. Chu was preparing for gender “reassignment” surgery—but bluntly debunked much
of what is often claimed for such cross-sex hormones, including the assertion that they reduce
suicidality, declaring, “I was not suicidal before hormones. Now I often am.”29
In the 2020 Pediatrics article by Turban, et al., on four of the nine mental health outcome
measures—nearly half—the outcomes for those who received puberty blockers were worse than
for those who did not. Most of these differences were small, but one was dramatic. Those who
received puberty blockers were twice as likely to have had a suicide attempt resulting in
inpatient care (i.e., hospitalization) in the last 12 months as those who did not (45.5 percent vs
22.8 percent).30
It is also important to compare the outcomes in the study with the probable outcomes in the long
term among gender dysphoric children who would not go on to a gender transition. A Norwegian
neuroscience professor examined the Pediatrics study on puberty blockers and suicidality and
explained:
Of 1000 children with GD [gender dysphoria], if all receive puberty suppression then we
expect all 1000 to go on to full transition whereas without the pubertal inhibition only
150 (15% of 1000) will transition. As the authors correctly state in the paper, 40% of
transpersons attempt suicide in a lifetime, which means that with PB [puberty blocker]
administration to all, we expect 40% of 1000 = 400 persons to attempt suicide. The
authors show, however, that because of the benefits of PB, this may perhaps be adjusted
downward by a factor of 0.6; the expected outcome is then 240 attempted suicides. In
contrast, if none of the 1000 subjects receive puberty suppression then only 60 persons
(40% of 150) are expected to attempt suicide.”31
Thus, widespread use of puberty suppression could increase rather than decrease suicide risk.
A 2022 study by Jay Greene of the Heritage Foundation takes a unique approach to studying the
question of whether “gender-related medical interventions” might reduce suicides among young
people. Greene acknowledges, “The research presented here does not directly examine whether
the individuals who receive gender-related medical interventions are at a higher risk of suicide.”
Using various proxy measures, however, Greene found that as interest in gender transition
procedures has grown in recent years, youth suicide rates have increased in states that make it
easier for minors to access medical care without parental consent, relative to the rates in states
without such provisions.32
Regarding the 2011 Swedish study of post-surgical patients, the U.S. Centers for Medicare &
Medicaid Services asserted that “we cannot exclude therapeutic interventions as a cause of the
observed excess morbidity and mortality” [emphasis added].33
Meanwhile, the re-analysis of the 2019 Swedish study found that hospitalizations after suicide
attempts in the one year examined (2015) were nearly twice as high in the surgery group as in the
non-surgery group.34
In other words, so-called “affirming” medical interventions, including hormone therapy and
surgery, have not been shown to reduce the risk of suicide for those who identify as transgender.
Moreover, cross-sex medical interventions may cause harm and increase suicide risk instead.

Underlying Mental Illness

Experts on suicide in general note, “Untreated mental illness (including depression, bipolar
disorder, schizophrenia, and others) is the cause for the vast majority of suicides,” noting, “Over
90 percent of people who die by suicide have a mental illness at the time of their death.”35
This suggests that looking outward (at family and society) for the causes of transgender
suicidality may be misguided, and a look inward (at the individual’s underlying mental health)
might be more important.
It is well established that there is a strong correlation between gender dysphoria and other forms
of mental illness or psychological distress. But transgender activists vigorously resist any effort
to examine whether there might be causal relationships. It is possible that mental illness could
cause gender dysphoria, that gender dysphoria could cause other mental illnesses, or that the two
could be inherently (not just coincidentally) linked.
Yet any such theory is simply ruled out in advance by proponents of transgender-“affirming”
interventions. It is inconsistent with their ideological paradigm, which says that transgender
people are “born that way” and that being transgender is perfectly normal and harmless (except
for having the “wrong” body and facing a hostile social environment, that is).
This paradigm may serve the transgender political agenda, but ironically it may not serve
transgender individuals well. It prevents them from getting treatment for the actual problems
which may underlie their feelings of gender incongruence and/or suicidality.
Authorities in Europe are beginning to recognize this and take action to ensure that a proper
focus is placed on treating underlying psychiatric conditions. A preliminary report from
Sweden’s National Board of Health and Welfare (as translated and quoted with emphasis by the
Canadian Gender Report) said:
 People with gender dysphoria, especially young people, have a high incidence of co-
occurring psychiatric diagnoses, self-harm behaviors, and suicide attempts compared to
the general population. Co-occurring psychiatric diagnoses among people with gender
dysphoria are therefore a factor that needs to be considered more closely during
investigation. Suicide mortality rates are higher among people with gender dysphoria
compared to the general population. At the same time, people with gender dysphoria who
commit suicide have a very high rate of co-occurring serious psychiatric diagnoses,
which in themselves sharply increase risks of suicide. Therefore, it is not possible to
ascertain to what extent gender dysphoria alone contributes to suicide, since these
psychiatric diagnoses often precede suicide.”36

Suicide Threats as Manipulation

We must stress that every suicide threat or expression of suicidal feelings should be taken
seriously, and counseling or other mental health interventions should be always pursued when
they occur.
However, it would be irresponsible not to recognize, especially in the current environment of
socio-political polarization over transgender issues, that threats or warnings of suicide—from
transgender individuals, or from professionals and politicians—may also be used as a form of
manipulation to achieve a desired personal or political outcome.
There is certainly anecdotal evidence of this. The well-known (and openly gay) writer Andrew
Sullivan wrote about meeting with detransitioners who had formerly identified as transgender.
One confessed to him, “I threatened my parents and friends with suicide. It became part of my
identity to be suicidal. I screamed at my parents about this, even though I knew I wasn’t going to
kill myself.”37
One doctor in the field has even recommended this as a strategy. According to a report about a
forum in Vancouver, Canadian psychologist Wallace Wong was recorded on video
recommending to youth that they threaten suicide if necessary: “So what you need is, you know
what? Pull a stunt. Suicide, every time, [then] they will give you what you need,” Wong said,
adding that gender-dysphoric kids “learn that. They learn it very fast.”38
Experts Michael Bailey and Ray Blanchard give a more detailed explanation of “false” reports of
suicidality:
Why would anyone falsely report being suicidal? One reason is to influence the behavior
of others. Saying that one is suicidal usually gets attention—sympathy, for example. It
can be a way of impressing others with the seriousness of one’s feelings or needs.
Although this possibility has not been directly studied, reporting suicidality may
sometimes be a strategy for advancing a social cause.39
Detransitioner Hacsi Horvath notes how the “suicide threat” is used by activists and clinicians—
not just transgender youth and adults themselves:
 In contrast, every type of medical or social intervention for the supposed benefit of
people with GD, especially youth, is described as “life-saving.” The refrain of “life-
saving” echoes everywhere in the discourse around this topic. This has been a key
strategy in convincing people that major surgeries are a “medical necessity” – “the basic
healthcare they need to survive.” According to the trans industry and its friends, spikes in
GD due to transphobia seem to lead almost automatically to AYA-GD wanting to end
their lives. It is as if they are always on a ledge, ready to jump. This incessant repetition
of purported suicide risk is like a strange new variation of Munchausen syndrome by
proxy, wherewith trans activist adults and some clinicians effectively threaten suicide on
behalf of the young people. They do this to socially-engineer, manipulate and intimidate
non-industry doctors, politicians, community leaders and families of AYA-GD. They are
well aware of the emotional responses they will get with this rhetoric.
Horvath notes that this may not be in the best interest of transgender people themselves since
“experts in suicide prevention have always recommended against strongly emphasizing suicide
risk in a given population.”40

Conclusion
Every suicide threat—particularly from a child or adolescent—should be taken seriously.
However, the claim that affirmation of a transgender identity—both socially and with invasive
medical procedures—is the only way to prevent suicides is not supported by the evidence. Rates
of reported suicidality among transgender-identified individuals remain high even among those
who live in affirming communities and who have received gender transition medical
interventions. There is no compelling evidence showing that social affirmation or cross-sex
medical interventions for trans-identifying persons will improve their mental health or reduce
this risk of suicide, and there is some evidence that such affirmation or interventions may
increase that risk.
These findings have significant policy implications. Increasingly, legislatures and policymaking
bodies across the world are being required to grapple with what could appropriately be called
“forced-affirmation” legislation or policies. These well-meaning but ill-advised forced-
affirmation mandates seek to force all persons to collude with and “affirm” the confused mental
state of trans-identifying persons and can include:
• Mandates forcing the use of cross-sex or newly created pronouns when referring to trans-
identifying persons. (The New York City Commission on Human Rights recognizes 31
different genders,41 and a person can be fined up to $250,000 for knowingly
“misgendering” a person by referring to them according to their biological sex instead of
using their preferred pronoun.42)

• Mandates requiring the placement of trans-identifying persons in prison cells or shelters

that do not correspond with their biological sex. (A number of such placements have
 resulted in rapes of female inmates and even pregnancy.43)

• Mandates requiring parents to “affirm” their child’s wrong-sex identity and to facilitate
the administration of puberty blockers or cross-sex hormonal interventions or surgeries to
their trans-identifying child or potentially lose custody. (A tragic example of this was the
2019 suicide of a 16-year-old girl who was affirmed by her school in the wrong sex and
was placed in foster care to facilitate her gender transition, despite the strong protests of
her mother.44)

• Mandates requiring female sports teams to allow males who identify as women to
compete on their teams.45

• Mandates allowing trans-identifying biological males unfettered access to and use of

girls’ showers, locker rooms and bathroom facilities.46

And while opposition to “forced affirmation” policies has largely been based on the harm such
policies can do to the persons who are forced to affirm transgender identities, the evidence
presented in this brief shows that sadly, such forced affirmation policies may harm the very
people they are designed to help. Such policies may lead to more suicidality, not less.
No one—whether a parent, politician, or citizen—should be manipulated by the misleading
claims that colluding with a fantasized alternative gender identity that is alien to a person’s
biological sex will protect them from committing suicide. Indeed, the very opposite may be true.

1
Haas, A. P., Rodgers, P. L., Herman, J. L. (2014). Suicide attempts among transgender and gender non-conforming
adults. American Foundation for Suicide Prevention and The Williams Institute. http://stopsuicide.ch/wp-
content/uploads/2017/07/AFSP-Williams-Suicide-Report-Final.pdf
2
James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016, December). The Report of the
2015 U.S. Transgender Survey. National Center for Transgender Equality. https://transequality.org/sites/default/
files/docs/usts/USTS-Full-Report-Dec17.pdf
3
Grant, J. M., Mottet, L. A., Tanis, J., Harrison, J., Herman J. L., & Keisling, M. (2011). Injustice at every turn: A
Report of the National Transgender Discrimination Survey. National Center for Transgender Equality and National
Gay and Lesbian Task Force. https://transequality.org/sites/default/files/docs/resources/NTDS_Report.pdf
4
Tanis, J. (2016). The power of 41%: A glimpse into the life of a statistic. American Journal of Orthopsychiatry,
86(4), 373–377. https://doi.org/10.1037/ort0000200
5
Herman, J. L., Wilson, B. D. M., & Becker, T. (2017, October). Demographic and health characteristics of
transgender adults in California: Findings from the 2015-2016 California Health Interview Survey. Health Policy
Brief, UCLA Center for Health Policy Research and The Williams Institute. https://healthpolicy.ucla.edu/
publications/Documents/PDF/2017/transgender-policybrief-oct2017.pdf
6
Wilson, B. D. M., et al. (2017, December). Characteristics and mental health of gender nonconforming
adolescents in California. Health Policy Fact Sheet. UCLA Center for Health Policy Research and The Williams
Institute. https://williamsinstitute.law.ucla.edu/publications/gnc-youth-ca/
7
The Centers for Disease Control and Prevention (CDC) reports, “In 2020, an estimated 12.2 million American
adults seriously thought about suicide, 3.2 million planned a suicide attempt, and 1.2 million attempted suicide.”
The number of Americans who died by suicide that year was 45,979. See: Centers for Disease Control and
Prevention. (2022, May 24). Facts about suicide. https://www.cdc.gov/suicide/facts/index.html
8
Aggarwal, S., & Gerrets, R. (2014). Exploring a Dutch paradox: an ethnographic investigation of gay men's mental
health. Culture, Health & Sexuality, 16(2), 105-119. http://www.tandfonline.com/doi/abs/10.1080/
13691058.2013.841290
9
Clements-Nolle, K., Marx, R., Guzman, R., & Katz, M. (2001, June). HIV prevalence risk behaviors, health care use
and mental health status of transgendered persons. American Journal of Public Health, 91(6), 915-921. https://
doi.org/10.2105/AJPH.91.6.915
10
Patria, M., & Lovett, E. (2011, August 29). Transgender kids pioneer early changes to identity, body:
Controversial practice rests on research positing boy brains and girl brains. ABC News. https://abcnews.go.com/
Health/transgender-kids-pioneer-early-identity-body/story?id=14404963
11
“Gender transition” is the process whereby a person goes from publicly identifying with his or her biological sex
to publicly identifying with a psychological “gender identity” different from that (often, but not always, identifying
with the opposite sex). Gender transition can be limited to a “social transition” (changing name, pronouns,
clothing, and hair style, without any physical change to the body), or it can encompass a “medical transition”
(which may involve the use of puberty-blocking drugs, cross-sex hormones, or “gender reassignment surgery” to
alter the appearance and sex-related physical characteristics of the body).
12
Bailey, J. M., & Blanchard, R. (2017, September 8). Suicide or transition: The only options for gender dysphoric
kids? 4thWaveNow. https://4thwavenow.com/2017/09/08/suicide-or-transition-the-only-options-for-gender-
dysphoric-kids/
13
Keffler, M. (2020, May 22). Scaring parents of trans kids with suicide shuts down their ability to consider options
for their kids. The Federalist. https://thefederalist.com/2020/05/22/scaring-parents-of-trans-kids-with-suicide-
shuts-down-their-ability-to-consider-options-for-their-kids/
14
McHugh, P. (2004, November). Surgical Sex. First Things, (147), 35, 38.
15
Jensen, T. S., Chin, J., Rollins, J., Koller, E., Gousis, L., & Szarama, K. (2016, August 30). Gender dysphoria and
gender reassignment surgery (National Coverage Analysis Decision Memo CAG-00446N). Centers for Medicare &
Medicaid Services, 62. https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?
proposed=N&NCAId=282
16
McHugh, P. (2020, June 1). Interrogating the transgender agenda: A psychiatrist questions the scientific and
medical basis for current treatments of gender dysphoria. MercatorNet. https://mercatornet.com/interrogating-
the-transgender-agenda/63387/
17
Shute, J. (2018, October 22). The new taboo: More people regret sex change and want to ‘detransition’, surgeon
says. The Telegraph. https://nationalpost.com/news/world/the-new-taboo-more-people-regret-sex-change-and-
want-to-detransition-surgeon-says
18
The Endocrine Society, in their pro-transgender Guidelines, concedes, “Surgery that affects fertility is
irreversible.” See: Hembree, W. C., Cohen-Kettenis, P. T., Gooren, L., Hannema, S. E., Meyer, W. J., Murad, M. H.,
Rosenthal, S. M., Safer, J. D., Tangpricha, V., & T’Sjoen, G. G. (2017, November). Endocrine treatment of gender-
dysphoric/gender-incongruent persons: An Endocrine Society clinical practice guideline. Journal of Clinical
Endocrinology & Metabolism, 102(11), 3893. https://doi.org/10.1210/jc.2017-01658
19
Even Marci (formerly Mark) Bowers, a surgeon who is transgender, has expressed concern about this. See:
Emmons, L. (2022, May 1). 'Gender affirming' surgeon admits children who undergo transition before puberty
NEVER attain sexual satisfaction. The Post Millennial. https://thepostmillennial.com/gender-affirming-surgeon-
admits-children-who-undergo-transition-before-puberty-never-attain-sexual-satisfaction
20
Sadjadi, S. (2013, March 14). The endocrinologist’s office—Puberty suppression: Saving children from a natural
disaster? Journal of Medical Humanities 34, 255–260. https://doi.org/10.1007/s10912-013-9228-6
21
Turban, J. L., King, D., Carswell, J. M., & Keuroghlian, A. S. (2020, February). Pubertal suppression for transgender
youth and risk of suicidal ideation. Pediatrics 145(2), e20191725. https://doi.org/10.1542%2Fpeds.2019-1725
22
Sprigg, P. (2017, February 16). Don’t be misled by National Geographic and Katie Couric: Three things to know
about ‘gender identity.’ FRC Blog. http://frcblog.com/2017/02/dont-be-misled-national-geographic-and-katie-
couric-three-things-know-about-gender-identity/
23
Turban, et al. (2020).
24
Field, S. S. (2020, February). RE: Pubertal suppression for transgender youth and risk of suicidal ideation.
Pediatrics 145(2), e20191725. https://pediatrics.aappublications.org/content/145/2/e20191725/tab-e-letters#re-
pubertal-suppression-for-transgender-youth-and-risk-of-suicidal-ideation
25
Dhejne, C., Lichtenstein, P., Boman, M., Johansson, A. L. V., Långström, N., & Landén, M. (2011). Long-term
follow-up of transsexual persons undergoing sex reassignment surgery: Cohort study in Sweden. PLOS One, 6(2),
e16885. http://dx.doi.org/10.1371/journal.pone.0016885
26
Bränström, R., & Pachankis, J. E. (2019, October 4). Reduction in mental health treatment utilization among
transgender individuals after gender-affirming surgeries: a total population study. American Journal of Psychiatry
177(8), 727-734. https://doi.org/10.1176/appi.ajp.2019.19010080
27
In 2015, there were 13 hospitalizations after suicide attempts in the 1,018 subjects that had surgery; there were
seven hospitalizations among the 1,018 subjects who did not have surgery. See: Bränström, R., & Pachankis, J. E.
(2020, August 1). Toward rigorous methodologies for strengthening causal inference in the association between
gender-affirming care and transgender individuals’ mental health: response to letters. American Journal of
Psychiatry, 177(8), Table 1, 72. https://doi.org/10.1176/appi.ajp.2020.20050599
28
Batty, D. (2004, July 30). Sex changes are not effective, say researchers. The Guardian. http://www.theguardian.
com/society/2004/jul/30/health.mentalhealth
29
Chu, A. L. (2018, November 24). My new vagina won’t make me happy: And it shouldn’t have to. The New York
Times. https://www.nytimes.com/2018/11/24/opinion/sunday/vaginoplasty-transgender-medicine.html
30
Turban, et al. (2020).
31
Ring, A. (2020, February). RE: Pubertal suppression for transgender youth and risk of suicidal ideation. Pediatrics
145(2), e20191725. https://pediatrics.aappublications.org/content/145/2/e20191725/tab-e-letters#re-pubertal-
suppression-for-transgender-youth-and-risk-of-suicidal-ideation
32
Greene, J. P. (2022, June 13). Puberty blockers, cross-sex hormones, and youth suicide (Backgrounder No. 3712).
Heritage Foundation, Center for Education Policy. https://www.heritage.org/sites/default/files/2022-
06/BG3712_0.pdf
33
Jensen, T. S., Chin, J., Rollins, J., Koller, E., Gousis, L., & Szarama, K. (2016, August 30). Gender dysphoria and
gender reassignment surgery (National Coverage Analysis Decision Memo CAG-00446N). Centers for Medicare &
Medicaid Services, 62. https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?
proposed=N&NCAId=282
34
Bränström & Pachankis. (2020).
35
Caruso, K. (n.d.). Suicide causes. http://www.suicide.org/suicide-causes.html
36
Canadian Gender Report. (2020, November 12). The Swedish U-turn on gender transitioning for children.
https://genderreport.ca/the-swedish-u-turn-on-gender-transitioning/
37
Sullivan, A. (2019, November 1). The hard questions about young people and gender transitions. New York
Magazine. https://nymag.com/intelligencer/2019/11/andrew-sullivan-hard-questions-gender-transitions-for-
young.html
38
Keenan, J. (2019, April 1). ‘Doctor’ advises threatening suicide to get transgender treatments for kids. The
Federalist. https://thefederalist.com/2019/04/01/doctor-advises-threatening-suicide-get-transgender-treatments-
kids/
39
Bailey & Blanchard (2017).
40
Horváth, H. (2018, December 19). The theatre of the body: A detransitioned epidemiologist examines suicidality,
affirmation, and transgender identity,” 4thWaveNow. https://4thwavenow.com/2018/12/19/the-theatre-of-the-
body-a-detransitioned-epidemiologist-examines-suicidality-affirmation-and-transgender-identity/
41
Hasson, P. (2016, May 24). New York City lets you choose from 31 different gender identities. Daily Caller.
https://dailycaller.com/2016/05/24/new-york-city-lets-you-choose-from-31-different-gender-identities/
42
New York City Commission on Human Rights. (2019, February 15). Gender identity/gender expression: Legal
enforcement guidance. https://www1.nyc.gov/site/cchr/law/legal-guidances-gender-identity-expression.page
43
Masterson, M. (2020, February 19). Lawsuit: Female prisoner says she was raped by transgender inmate. WTTW.
https://news.wttw.com/2020/02/19/lawsuit-female-prisoner-says-she-was-raped-transgender-inmate; Ferrechio,
S. (2022, April 14). Two inmates impregnated by transgender inmate at all-women’s prison in New Jersey: Report.
The Washington Times. https://www.washingtontimes.com/news/2022/apr/14/two-inmates-impregnated-
transgender-inmate-all-wom/
44
Boswell, J. (2022, March 22). Exclusive: 'I knew the hormones wouldn't work. Why did they play with her life?'
DailyMail.com. https://www.dailymail.co.uk/news/article-10612285/California-mom-claims-LA-school-
encouraged-daughter-transition-blame-suicide.html; see also video of panel discussion including mother’s
testimony at: Heritage Foundation. (2022, March 7). How radical gender ideology is taking over public schools &
harming kids. YouTube. https://www.youtube.com/watch?v=k33KeLh8aOk
45
Barnes, K. (2022, May 6). Alabama to Wyoming: State policies on transgender athlete participation. espnW.com.
https://www.espn.com/espn/story/_/id/32117426/state-policies-transgender-athlete-participation
46
See, e.g.: Family Research Council. (2016, May). Title IX and transgendered students. Issue Brief IF16E01.
https://downloads.frc.org/EF/EF16E32.pdf; Haynie, R., & Richey, K. M. (2022, April 19). Oklahoma’s confusing
bathroom policy: Context and legal background. Oklahoma Council of Public Affairs (OCPA). https://www.
ocpathink.org/post/oklahomas-confusing-bathroom-policy-context-and-legal-background; Gavin Grimm v.
Gloucester County School Board, 972 F.3d 586 (4th Cir. 2020). https://www.ca4.uscourts.gov/Opinions/
191952.P.pdf