Identifying Intersecting Factors Associated With Suicidal Thoughts and Behaviors Among Transgender and Gender Diverse Adults: Preliminary Conditional Inference Tree Analysis.

backgroundTransgender and gender diverse (TGD) individuals are disproportionately impacted by suicidal thoughts and behaviors (STBs), and intersecting demographic and psychosocial factors may contribute to STB disparities.

objectiveWe aimed to identify intersecting factors associated with increased risk for suicidal ideation, intent, plan, and attempts in the US transgender population health survey (N=274), and determine age of onset for each outcome using conditional inference trees (CITs), which iteratively partitions subgroups of greater homogeneity with respect to a specific outcome.

methodsIn separate analyses, we restricted variables to those typically available within electronic medical records (EMRs) and then included variables not typically within EMRs. We also compared the results of the CIT analyses with logistic regressions and Cox proportional hazards models.

resultsIn restricted analyses, younger adults endorsed more frequent ideation and planning. Adults aged ≤26 years who identified as Black or with another race not listed had the highest risk for ideation, followed by White, Latine, or multiracial adults aged ≤39 years who identified as sexual minority individuals. Adults aged ≤39 years who identified as sexual minority individuals had the highest risk for suicide planning. Increased risk for suicidal intent was observed among those who identified as multiracial, whereas no variables were associated with previous suicide attempts. In EMR-specific analyses, age of onset for ideation and attempts were associated with gender identity, such that transgender women were older compared to transgender men and nonbinary adults when they first experienced ideation; for attempts, transgender women and nonbinary adults were older than transgender men. In expanded analyses, including additional psychosocial variables, psychiatric distress was associated with increased risk for ideation, intent, and planning. High distress combined with high health care stereotype threat was linked to increased risk for intent and for suicide planning. Only high everyday discrimination was associated with increased risk for lifetime attempts. Ages of onset were associated with gender identity for ideation, the intersection of psychiatric distress and drug use for suicide planning, and gender identity alone for suicide attempts. No factors were associated with age of onset for suicide intent in the expanded variable set. The results of the CIT analysis and the traditional regressions were comparable for ordinal outcomes, but CITs substantially outperformed the regressions for the age of onset outcomes.

conclusionsIn this preliminary test of the CIT approach to identify subgroups of TGD adults with increased STB risk, the risk was primarily influenced by age, racial identity, and sexual minority identity, as well as psychiatric distress, health care stereotype threat, and discrimination. Identifying intersecting factors linked to STBs is vital for early risk detection among TGD individuals. This approach should be tested on a larger scale using EMR data to facilitate service provision to TGD individuals at increased risk for STBs.