Through the use of elastic net regression, the present analyses revealed several variables that were most relevant in determining whether a TGD participant had suicidal thoughts, plans, and attempts. Worries about being negatively evaluated by one’s healthcare provider or having diagnoses impacted due to gender identity or sexual orientation emerged as highly important variables across STB outcomes. Results further highlighted that individuals who have received counseling have elevated odds of STB outcomes; it appears that the individuals who most need counseling to address STB risk are being correctly identified and treated. Additional findings provided further valuable directions to improve suicide prevention approaches among TGD individuals, with an emphasis on targeting healthcare experiences.

An important and consistent finding was the impact of worries about being negatively evaluated by one’s healthcare provider or having diagnoses impacted due to gender identity or sexual orientation on STB outcomes in this population. This underscores the need for clear demonstration of acceptance and support from healthcare providers, including through the use of correct pronouns, avoiding gendered language when describing health conditions and treatments, as well as educating oneself and transgender health topics to remove the burden from patients on needing to educate their providers [37]. Numerous existing studies have highlighted specific approaches that healthcare providers can take to demonstrate their support and improve their care of TGD patients [37, 38]. This is further supported by the finding that individuals with a provider they could go to for transgender-related healthcare had lower odds of suicidal ideation with intent and suicide attempts. Additionally, worries about negative evaluation and experiences of transphobia and discrimination may be a result of negative experiences in participants’ daily lives with non-providers, which extend to fears in the healthcare system. This information may be relevant to other countries, beyond the United States, where gender-affirming treatments may be covered more consistently by insurance. High-quality gender-affirming care, goes beyond insurance, prescriptions, and diagnoses. It necessitates active work to maintain a positive patient-provider relationship, where the patient feels supported.

Despite results underscoring the importance of supportive and accepting providers, some additional results appeared to be somewhat in contrast. Individuals who reported having been to an LGBT clinic in the past year as well as individuals who had gender-affirming care had higher STB risk, specifically suicidal ideation with intent and suicidal ideation, respectively. Importantly, the items pertaining to worries about negative evaluations and diagnoses being impacted as well as having a transgender-related healthcare provider were asked about the present, whereas going to an LGBT clinic was specific to the last five years and having gender-affirming healthcare was about lifetime experiences. Accordingly, findings of STB risk among those who reported having been to an LGBT clinic in the past 5 years and having ever had gender-affirming care may be reflective of current distress and gender dysphoria, which is linked to increased suicide risk [39], or it could be reflective of previous experiences of gender dysphoria. Thus, these findings could reflect an artifact of participants who previously had experience greater levels of risk at an earlier timepoint. Given the variation in the timescales used, future research would benefit from examining the relationship between these risk factors and STB outcomes using a more intensive study design that allows for improved understanding of the temporal nature of these relationships.

Receiving mental health counseling was the only variable that was consistently associated with increased odds of STBs, across each outcome. It is to be expected that those receiving counseling, or those have previously, would be the individuals with greatest STB risk. While the aim of therapy is to reduce suicide risk, these findings suggest that the individuals who are most in need of counseling are receiving that support. Counseling for gender identity-related concerns also emerged as an important variable. Given the impact of gender dysphoria on STB risk [39]. this is also to be expected. These findings suggest the need for continued identification and treatment of TGD adults who are likely to be at increased risk of mental health challenges [2], given the considerable discrimination and stressors experienced by this population [3].

Ability to access healthcare was also associated with STB risk in this population. Inability to access healthcare due to the cost of seeing a doctor was associated with higher suicide plans. Moreover, having insurance was associated with lower odds of suicidal ideation with intent. These findings support the notion that inability to obtain healthcare due to financial challenges impacts suicide risk among TGD individuals. Accordingly, legislation is needed to support the ability of TGD individuals to access affordable healthcare. Notably, self-reported excellent health was associated with lower odds of suicidal ideation, which is consistent with previous research showing medical problems to be a suicide risk factor [40]. Ensuring that TGD individuals have access to healthcare, in order to promote excellent health, is a valuable form of suicide prevention in this population.

Notably, average health was found to be associated with higher odds of suicide attempts, whereas poorer health was associated with higher odds of suicidal ideation and suicide plans, highlighting the unique relationships between healthcare variables and the STB outcomes. One potential mechanistic explanation for this finding related to specific health rating and associated STBs relates to the idea of acquired capability [41]. While individuals with poorer health may have suicidal ideation and plans, it is possible that in a poor health state they lack the functional capacity to act on suicidal urges. Thus, while poor health is a known suicide risk factor [42], it may not translate into attempts due to barriers to enact plans. Comparatively, individuals with average health have underestimated distress from appearing functionally capable but perhaps still have unmet health needs and/or chronic conditions, leading to a nuanced position wherein distress is present, and they have the physical capability to act on suicidal urges, leading to higher attempt rates. The current findings underscore the importance of considering each STB outcome as distinct to understand the factors associated with each outcome. Such delineation of STB variables may allow for improved understanding, prediction, and prevention of such outcomes.

It is important to consider the current findings within in the context of the following limitations. Most notably, this study was cross sectional in design, preventing analyses that parse apart temporal associations. Future studies should employ longitudinal designs to better identify healthcare risk and protective factors for STBs in this high-risk population. For instance, research studies will be needed to understand the long-term impact of medications taken as part of gender-affirming care [43]. Additionally, on a smaller timescale, leveraging ecological momentary assessment would allow for identification of proximal risk and protective factors, allowing for clear intervention targets to reduce suicide risk for TGD individuals. While this study was cross sectional, numerous time scales were used across the items, including lifetime, past five years, as well as the present moment. The use of different time scales further complicates some of the findings, again suggesting the value of an intensive longitudinal design that allows for improved understanding of temporality. Finally, to optimally leverage elastic net regression, many variables were recategorized or dummy coded, which may impact power.

This study extended upon previous research using the TransPop database and revealed several healthcare-related variables that were most impactful on STB risk. The current findings support the need for healthcare providers to be supportive and accepting as well as to ensure that TGD individuals are able to access high-quality mental and physical healthcare. Access to such care is essential for preventing suicide among this population.