Access to Pubertal Suppression Linked to Lower Suicidal Ideation Risk in Transgender Young Adults

The Endocrine Society, World Professional Association for Transgender Health, the American Academy of Child & Adolescent Psychiatry and the American Academy of Pediatrics recommend that gonadotropin-releasing hormone analogs ("puberty blockers") may be considered for transgender adolescents once they reach the Tanner 2 stage of puberty.

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Unlike the hormone treatment given to transgender adults, pubertal suppression is fully reversible. It allows transgender adolescents time to decide whether they wish to induce exogenous gender-congruent puberty or allow endogenous puberty to progress.

Jack Turban, MD, MHS, a resident in the Child and Adolescent Psychiatry Residency at Massachusetts General Hospital, Alex S. Keuroghlian, MD, MPH, director of the Massachusetts General Hospital Psychiatry Gender Identity Program in the Department of Psychiatry, and colleagues recently conducted the first investigation into associations between pubertal suppression and suicidality. In Pediatrics, they report that transgender young adults who wanted and received pubertal suppression treatment have 70% lower odds of lifetime suicidal ideation than those who wanted but did not receive the treatment.

Study Details

The researchers examined the 2015 U.S. Transgender Survey, the largest-ever data set on transgender adults (n=27,715). Because pubertal suppression for transgender youth was not available in the U.S. until 1998, the analysis was restricted to 20,619 participants who were 18 to 36 years old when they completed the survey.

Some transgender adolescents have minimal body dysphoria and do not desire pubertal suppression. The sample was, therefore, further restricted to 3,494 individuals (17%) who said they had wanted pubertal suppression as part of their gender-affirming medical care.

Receipt of Treatment

Only 89 (2.5%) of the participants who had wanted pubertal suppression during adolescence reported receiving it. Among the youngest survey respondents, who were 18 years old at the time of data collection in 2015, only 4.7% of those who wanted the treatment said they received it.

Besides younger age, factors predictive of pubertal suppression treatment were:

• Younger age of social transition
• Feminine gender identity and male sex assigned at birth
• Heterosexual sexual orientation
• Higher total household income
• Greater family support of gender identity

Pubertal Suppression and Suicidality

In univariate analyses, when participants who received pubertal suppression were compared with those who did not, pubertal suppression was associated with decreased odds of:

• Past-year suicidal ideation (OR, 0.6)
• Lifetime suicidal ideation (OR, 0.3)
• Past-month severe psychological distress (score ≥13 on the Kessler Psychological Distress Scale) (OR, 0.8)

90% of transgender adults who wanted pubertal suppression but did not receive it reported suicidal ideation at some point in their lifetime. After adjustment for demographic variables, including family support of gender identity, pubertal suppression was associated with 70% lower odds of lifetime suicidal ideation (OR, 0.3; 95% CI, 0.2–0.6; P = 0.001).

What Primary Care Physicians Should Know

These results warrant attention because suicidal ideation is a known predictor of future suicide attempts and deaths from suicide. Suicidality is of particular concern for transgender people, whose estimated lifetime prevalence of suicide attempts is as high as 40%.

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