title: Intervenable factors associated with suicide risk in transgender persons: a respondent driven sampling study in Ontario, Canada.
abstract: BACKGROUND
  Across Europe, Canada, and the United States, 22-43 % of transgender (trans) people report a history of suicide attempts. We aimed to identify intervenable factors (related to social inclusion, transphobia, or sex/gender transition) associated with reduced risk of past-year suicide ideation or attempt, and to quantify the potential population health impact.
  
  
  METHODS
  The Trans PULSE respondent-driven sampling (RDS) survey collected data from trans people age 16+ in Ontario, Canada, including 380 who reported on suicide outcomes. Descriptive statistics and multivariable logistic regression models were weighted using RDS II methods. Counterfactual risk ratios and population attributable risks were estimated using model-standardized risks.
  
  
  RESULTS
  Among trans Ontarians, 35.1 % (95 % CI: 27.6, 42.5) seriously considered, and 11.2 % (95 % CI: 6.0, 16.4) attempted, suicide in the past year. Social support, reduced transphobia, and having any personal identification documents changed to an appropriate sex designation were associated with large relative and absolute reductions in suicide risk, as was completing a medical transition through hormones and/or surgeries (when needed). Parental support for gender identity was associated with reduced ideation. Lower self-reported transphobia (10(th) versus 90(th) percentile) was associated with a 66 % reduction in ideation (RR = 0.34, 95 % CI: 0.17, 0.67), and an additional 76 % reduction in attempts among those with ideation (RR = 0.24; 95 % CI: 0.07, 0.82). This corresponds to potential prevention of 160 ideations per 1000 trans persons, and 200 attempts per 1,000 with ideation, based on a hypothetical reduction of transphobia from current levels to the 10(th) percentile.
  
  
  CONCLUSIONS
  Large effect sizes were observed for this controlled analysis of intervenable factors, suggesting that interventions to increase social inclusion and access to medical transition, and to reduce transphobia, have the potential to contribute to substantial reductions in the extremely high prevalences of suicide ideation and attempts within trans populations. Such interventions at the population level may require policy change.
authors.affiliation: Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Canada. greta.bauer@schulich.uwo.ca.
authors.forename: Greta R
authors.initials: GR
authors.lastname: Bauer
authors.affiliation: Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Canada. ayden.scheim@schulich.uwo.ca.
authors.forename: Ayden I
authors.initials: AI
authors.lastname: Scheim
authors.affiliation: School of Social Work & Gender Studies and Feminist Research Program, McMaster University, Hamilton, Canada. pynejm@mcmaster.ca.
authors.forename: Jake
authors.initials: J
authors.lastname: Pyne
authors.affiliation: Health Sciences Program & Department of Psychology, Wilfrid Laurier University, Waterloo, Canada. rtravers@wlu.ca.
authors.forename: Robb
authors.initials: R
authors.lastname: Travers
authors.affiliation: Sherbourne Health Centre, Toronto, Canada. re.becca@ymail.com.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Hammond
mesh_terms: D000328:Adult; D005260:Female; D005783:Gender Identity; D006801:Humans; D016015:Logistic Models; D008297:Male; D009864:Ontario / Q000453:epidemiology; D010290:Parents; D011287:Prejudice / Q000523:psychology; D015995:Prevalence; D012494:Sampling Studies; D057566:Self Report; D012934:Social Isolation / Q000523:psychology; D012944:Social Support; D059020:Suicidal Ideation; D013405:Suicide / Q000523:psychology* / Q000706:statistics & numerical data*; D013406:Suicide, Attempted / Q000523:psychology / Q000706:statistics & numerical data; D063106:Transgender Persons / Q000523:psychology* / Q000706:statistics & numerical data*; D014189:Transsexualism / Q000523:psychology; D014481:United States