Youth With Gender Dysphoria Hospitalized for Suicidal Ideation Far More Often

Hospitalizations due to suicidality and self-harm were four or fives times more common in young people with gender dysphoria-related diagnoses compared with those without such diagnoses, a serial cross-sectional study showed.

Among transgender and non-binary young people ages 6 to 20 included in the Kids' Inpatient Database for 2016 and 2019, 36% of those with gender dysphoria-related codes also had suicidality codes compared with 5% of those without gender dysphoria-related codes in 2016 (adjusted prevalence ratio [PR] 5.02, 95% CI 4.67-5.41), and these rates were 55% versus 4% in 2019 (adjusted PR 4.14, 95% CI 4.02-4.28), reported Nadir Yehya, MD, of Children's Hospital of Philadelphia, and co-authors.

Furthermore, 13% of those with gender dysphoria-related diagnoses also had codes for self-harm compared with 1% of those without such diagnoses in 2016 (adjusted PR 3.64), and these rates were 15% versus 1% for 2019 (adjusted PR 3.75), according to the findings in Lancet Child and Adolescent Health.

When combining suicidality and self-harm, the adjusted PR was 4.77 (95% CI 4.46-5.09) in 2016, and 4.04 (95% CI 3.94-4.17) in 2019.

"Transgender and non-binary youth with gender dysphoria are commonly admitted for suicide or self-harm," Yehya told MedPage Today. "This happens more frequently than pediatric providers may be aware of. Further, gender dysphoria should be considered as a possible etiology for any patient who is admitted [for] suicidal behavior or self-harm."

"We are amidst a mental health crisis in children and adolescents, so unfortunately the rates are not totally surprising in general. It is particularly concerning that the prevalence is quite high even in the 6- to 12-year-olds," he added. "The inpatient setting offers a unique opportunity to provide care that is gender affirming to this population placed at risk for poor health outcomes."

"Admission for suicide or self-harm represents a uniquely vulnerable and critical time for these kids," Yehya continued. "We as providers are in a position to provide care that is gender-affirming in the inpatient setting, by using their correct names, pronouns, and linking them to evidence-based, gender-affirming medical and mental health care in the outpatient setting. Their lives depend on it."

Co-author Nadia Dowshen, MD, MSHP, of the Gender and Sexuality Development Program at Children's Hospital of Philadelphia, noted that this patient population has unique disadvantages that clinicians should be prepared to confront.

"The association between gender dysphoria and suicidality should not be seen as a reflection of an intrinsic problem with transgender and non-binary youth with gender dysphoria, but rather as a consequence of stress, discrimination, and stigma they face in our society, in addition to often lacking access to care that affirms their identity," Dowshen told MedPage Today. "We know from many other studies that when trans and non-binary children have their identity affirmed, they have similar physical and mental health outcomes to their cisgender peers."

The total number of young people diagnosed with gender dysphoria in this study suggests that, more and more, reality is being acknowledged, said Jack Drescher, MD, of Columbia University and New York University. The notable increase in diagnoses of gender dysphoria from 2016 to 2019 in this analysis fits with the trend of greater awareness by clinicians and their patients.

"What we're seeing is there's more people presenting and clinicians are using the diagnostic code more often," Drescher told MedPage Today, though he noted that it is unclear why this is happening.

"On one side, people are saying that the numbers are increasing because it's safer for people to talk about it," he noted, but "people on the other side are saying this is something else. These numbers can't possibly be representative of true presentations of gender dysphoria, and therefore, it must be something else going on."

Drescher pointed out that people are interpreting the available data according to their pre-existing beliefs, and much more research will be needed to better explain the observed rise in gender dysphoria diagnoses.

For this study, the researchers used the Kids' Inpatient Database from 2016 (N=1,090,544) and 2019 (N=1,026,752) to identify transgender and non-binary young people ages 6 to 20 years with International Classification of Diseases (ICD)-10 codes related to gender dysphoria. Gender dysphoria-related diagnoses were prevalent in 161 per 100,000 hospital admissions in 2016 and 475 per 100,000 hospital admissions in 2019.

In both years, patients were more likely to have their sex documented as female (63% in 2016 and 51% in 2019), and were more likely to be between the ages of 13 and 20 (73% and 74%, respectively). The majority of patients had public health insurance (53% in 2016 and 51% in 2019), but they were somewhat evenly distributed across four groups of median annual income by Zip code, ranging from less than $43,000 to greater than $71,000.

Final models were adjusted for sex, age, household income, race or ethnicity, type of insurance, along with admission confounders and health system factors.

Yehya and team noted that one limitation to their study was that it relied on official diagnoses of gender dysphoria to identify whether a patient was transgender or non-binary. They pointed out that not every transgender and non-binary young person experiences gender dysphoria, so they may have underestimated the true size of that group.

Still, they said that they believed that the sample was likely an accurate overview, and was consistent with previously reported rates of suicidality in this population.

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