Suicide is Not Reducible to Simple Explanations

It is unlikely that any one theory can explain phenomena as varied and complicated as human self-destructive acts. At the least, suicide involves an individual’s tortured and tunneled logic in a state of intolerable, inner-felt, idiosyncratically-defined anguish. 

-Edwin Shneidman, founder of contemporary suicidology

When criticizing aspects of society, some people amplify their arguments by saying that those aspects cause suicide. Typically, the claim goes something like this, “____ is so bad that it leads people to kill themselves. Therefore, it’s urgent that we stop ____.” You should be skeptical when you hear these kinds of claims, because suicide is not reducible to simple explanations. It hurts to think about people grieving a suicide loss and then hearing that there was a simple fix all along. This is especially painful when there is little or no evidence that ____ substantially increases suicide risk. Additionally, if an empirically-weak claim receives enough public attention, limited suicide prevention resources can be squandered in the wrong places.

How to Evaluate Causal Claims about Suicide

Suicide is complex, and it’s extremely challenging to conduct research that yields results with causal implications. The closest we have to experiments may be randomized controlled trials designed to reduce suicidality. Keeping in mind that the majority of suicide research is correlational, here’s one set of criteria that you can use to evaluate whether ____ causes suicide.

1) temporal precedence: If ____ causes suicide, ____ must occur before the suicide (or a societal change must precede changes in suicide rates). Non-experimental research can speak to this criterion through longitudinal studies or other examinations of suicide rate data over time. However, it’s important to look at long-term trends rather than capitalizing on specific time points with fluctuations that are consistent with the claim.

2) covariation: If ____ causes suicide, then changes in ____ must accompany changes in suicide rates. I often see partial demonstrations where someone will say, “Here are higher suicide rates coinciding with more of ____,” but then leave out the necessary counterpart of establishing correlation: less of ____ should also be associated with lower suicide rates. Both are required to meet this criterion, and you don’t need experimental studies if you examine it through naturally-occurring differences. For example:

-Looking at World Health Organization suicide data, do countries with more of ____ have higher suicide rates than countries with less of ____?

-Do demographic groups who experience more of ____ have higher suicide rates than groups with less of ____ over the same time period?

If the answer is “no,” then the covariation criterion has not been met.

3) nonspuriousness: If ____ causes suicide, then the relationship must persist even after ruling out alternative explanations. This criterion is arguably the most difficult to prove without experimental studies, but there are some correlational data that you’d expect to see if the claim is true. Questions to ask of such claims include:

-What else increased aside from ____ during the time period of increased suicide rates? Is there research linking those other factors to suicide, and could that better explain the observed pattern?

-Do people experiencing more of ____ also experience more of something else empirically-linked to suicide that could better explain the observed pattern?

Here‘s a strong example of someone evaluating an alternative explanation for an observed pattern using correlational data on a completely different topic (specifically, the part on self-censorship).

I wrote this post to share a framework for evaluating causal claims that I learned in grad school, and I hope that you find it useful. Even if it’s completely unintentional, when people use unsubstantiated claims about suicide to magnify societal concerns, it can feel exploitative of a group of people I care deeply about. Fortunately, this is outweighed by incredible, compassionate work reflecting the complexities and multiple pathways to suicide. I’ll link to some of my favorites below:

American Association of Suicidology

The Best Way to Save People from Suicide

The Interpersonal Theory of Suicide

Live Through This

Suicide Prevention Social Media Chat

The Three-Step Theory

We Tell Suicidal People to ‘Get Help.’ But What Happens When They Do?

Thank you for reading! Here’s a post with more information and resources about preventing suicide.

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In Defense of Diagnosis

In “Why I Do Not Attend Case Conferences,” Paul Meehl (1973) described reasoning errors that emerge during case conceptualization conversations among mental health professionals. One of the issues Meehl discussed at length (pp. 272-281) was an antinosological bias, defined as “an animus against diagnosis.” Here’s his response to a common objection to diagnostic labels:

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Meehl described his style there as “highly critical and aggressively polemic,” which he justified by saying, “If you want to shake people up, you have to raise a little hell.” The second section has a much more constructive tone. Both sections are valuable, and I agree with his overall thesis that compassionate, effective mental health care requires clearheaded case conceptualization. Meehl is also correct that 1) meaningful diagnostic systems are crucial for advancing the field and 2) some critiques of the Diagnostic and Statistical Manual of Mental Disorders (DSM) reflect misunderstandings of the diagnostic process. I’ll discuss some of the major criticisms and benefits below.

Criticisms

1. The DSM pathologizes nonpathological behavior.

Barbara_Gittings,_Frank_Kameny,_and_John_Fryer_in_disguise_as__Dr._H._Anonymous_

Barbara Gittings, Frank Kameny, & Dr. H. Anonymous, gay rights activists at a 1972 APA convention

This is true in specific cases. One of the most well-known examples is homosexuality being labeled as a mental disorder in older versions of the DSM. As a result of persistent, organized activism bolstered by research, homosexuality was removed from the DSM. You can learn more about it in excellent podcast episodes by This American Life and Radiolab. Currently, the DSM developers attribute elevated mental health problems among lesbian, gay, and bisexual people to discrimination, actively oppose conversion therapy, and push for policies and law that reduce disparities. In order to prevent future harm, this history must be considered in diagnostic decisions. As Martin Luther King, Jr. said, psychology shouldn’t label people as maladjusted for not adjusting to bigotry.

However, we should also consider that appropriate diagnoses have helped people access beneficial services (e.g., children with intellectual disabilities or autism receiving accommodations in school and other public places). Additionally, the DSM specifically instructs clinicians to only assign diagnoses when a cluster of multiple symptoms: 1) causes clinically significant distress and/or impairment, 2) is persistent and severe for a length of time, 3) deviates significantly from developmental expectations, and 4) cannot be attributed to other factors (e.g., medical, cultural). These types of safeguards reduce the likelihood of pathologizing nonpathological behavior.

2. People are over/misdiagnosed.

Misdiagnosis occurs for many reasons ranging from improper assessment procedures, failure to consider pertinent contextual factors, and biases. For example, attention-deficit/hyperactivity disorder is a meaningful diagnostic category with real-world implications. Nonetheless, there’s evidence that it may be overdiagnosed, which can lead to inappropriate treatment plans.

Issues that exacerbate the problem include 1) lack of funds/insurance coverage for comprehensive assessment procedures and 2) diagnosers who rely too much on their intuition instead of established diagnostic tools. The Ethical Principles of Psychologists and Code of Conduct lays out stringent rules for assessment. A system that ensures adherence to these rules would reduce misdiagnosis while permitting proper diagnosis for people who need treatment and/or services.

use of assessments

3. Classification decisions are made by people with conflicts of interest.

There have been some egregious examples of psychiatry researchers receiving large sums of money from pharmaceutical companies and not properly disclosing them. One instance is covered in a PBS Documentary and in this New York Times article:

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In an effort to address this problem, DSM-5 panel members were required to disclose conflicts of interests. Cosgrove and Krimsky (2012) made a compelling case that further action was needed:

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To be clear, psychiatric medications have helped numerous people and are warranted in particular circumstances. However, steps must be taken to reduce potential biases driven by the pharmaceutical industry.

4. Labeling someone with a mental disorder is stigmatizing.

Despite signs of improvement, prejudice and stigma continue, especially for certain mental health conditions. The solution is to eradicate the stigma rather than the nosology (but it’s worth listening to Szasz’s arguments opposing that idea). When properly applied and understood, diagnoses can alleviate suffering by pointing to effective treatments, connecting people with support and advocacy groups, and evoking compassion. This was nicely demonstrated in Crazy Ex-Girlfriend:

I’m aware mental illness is stigmatized/But the stigma is worth it if I’ve realized/Who I’m meant to be/Armed with my diagnosis

5. Diagnostic categories do not accurately reflect nature.

There are different versions of this, but I’ll focus on the most common: 1) most mental health problems are dimensional (occurring on a continuum) rather than categorical (e.g., there are gophers and chipmunks, but no “gophmunks“), 2) there’s too much variability within diagnostic categories for them to be meaningful, and 3) DSM symptoms are not necessarily the core symptoms of disorders (e.g., for depression).

In response, 1) people have proposed replacing the categorical model with empirically-informed dimensional models (e.g., even if psychopathy occurs on a continuum, it’s quite meaningful to diagnose those in the highest range), 2) diagnostic presentation variability depends on the diagnosis (e.g., people with bulimia nervosa have more in common, on average, than people with borderline personality disorder) and fewer diagnoses with more specifiers could help (e.g., see Pincus, 2011), 3) network analyses are useful for identifying the central symptoms of mental disorders. A concern about major DSM changes is that they will disrupt the work of clinicians and researchers (see Pilkonis et al., 2012). Despite these issues, we need to create a DSM that’s better at carving nature at its joints rather than resisting change or giving up the enterprise altogether.

Benefits

1. Agreed upon definitions facilitate clinically-relevant research.

I agree with McFall’s Manifesto (1991), which states that “the future of clinical psychology hinges on our ability to integrate science and practice” (to hear this debated, check out this Talk of the Nation episode). For example, treatment research for bipolar disorder has more generalizability to real-world clinical settings when therapists and scientists use the same operational definition of bipolar disorder. Moreover, consistent mental disorder definitions across studies makes cumulative knowledge possible. Classification systems enhance communication and research, which contribute to the big picture goal: alleviating suffering.

2. Diagnoses convey useful information when derived from appropriate assessment procedures.

Accurate diagnoses point to literature on the causes, correlates, and effective treatments for specific mental health problems. If an adolescent girl is accurately diagnosed with anorexia nervosa, we learn that she has an increased risk for bone fractures, arrythmias, depression, and suicide and should be monitored for each of these dangers. Importantly, we also know that family-based treatment is likely to be a good treatment option for her and that her parents can connect with parents experiencing similar struggles. To learn more about the process for evaluating levels of empirical support for therapies, look here for youth treatments and here for adult treatments.

3. Diagnostic feedback (when done well) can lead to positive effects.

People tend to experience positive feelings (e.g., optimism, relief) after receiving diagnostic information derived from appropriate assessment procedures and delivered in a collaborative, constructive manner. Similarly, there’s evidence that taking personality inventories and being told about the results from a therapist leads to increased self-esteem, more perceived self-competence, and lowered distress. Why would people feel better after learning about their mental health problems and potentially maladaptive personality characteristics? My guess is that people already know that they’re experiencing certain kinds of issues. When a therapist demonstrates an understanding of the problems by placing them in a meaningful context, they feel validated and hopeful that they can be helped.

4. Diagnostic labels enhance communication between treatment team members and aid continuity in care.

Diagnostic labels ease the transition for clients from one therapist to another (e.g., by saving them from having to repeat assessment procedures) and by communicating efficiently to other members of their treatment team (e.g., social workers, psychiatrists, physicians, clergy).

5. The DSM-5 has improved since the original version and has built-in mechanisms for change.

Despite the hindrances mentioned above, the DSM has formal, built-in processes for evolving with new scientific discovery. New versions are created with the explicit goal of making the classification system better reflect nature. Hyman (2010) argued that we should not reify existing diagnostic constructs. Instead, we must remember that diagnoses are constructed for clinical and scientific purposes. Therefore, improving the DSM requires openness to change and flexibility.

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In conclusion, despite the concerns highlighted above, I agree with Meehl that antinosological biases impede progress and that mental health classification systems should be improved rather than abandoned altogether. I’m grateful for the dedicated clinicians and scientists working to deepen our understanding of mental health and feel encouraged by efforts to use that information to improve people’s lives.

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In an effort to keep this post relatively brief, I highlighted some main points and examples. Some of the more technical, in-depth things I’ve co-written about classification are linked below:

The Classification of Eating Disorders – The Oxford Handbook of Eating Disorders

Empirical Approaches to the Classification of Eating Disorders – Developing an Evidence-Based Classification of Eating Disorders

Nonsuicidal Self-Injury Disorder: A Preliminary Study – Personality Disorders: Theory, Research, and Treatment

Patients’ Affective Reactions to Receiving Diagnostic Feedback – Journal of Social & Clinical Psychology

Suicidal Behavior on Axis VI – Crisis

Taxometric Analysis: Introduction and Overview – International Journal of Eating Disorders

The Validity and Clinical Utility of Binge Eating Disorder – International Journal of Eating Disorders

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A major inspiration for creating the Jedi Counsel blog and podcast was to demystify issues surrounding diagnosis through analyses of fictional characters.

3000x3000_JediCounsel

Brother Ali’s Song about Losing His Dad to Suicide

I’ve seen Minneapolis-based rapper Brother Ali in concert several times, and he strikes me as someone who’s as kind as he is talented. When I told him at a Chicago show that I had previously chatted with him in Orlando, he tried to remember me. He told me that he doesn’t recall faces due to albinism-related vision issues, but he recognizes people through reminders of previous conversations. He rapped about his experiences in “Us”: And I go with the feeling from the start/Blind in the eye, so I see you with my heart/And to me all y’all look exactly the same/Fear, faith, compassion and pain.

All of this is to say that I’m a Brother Ali fan and my expectations were high for his 2017 album, All The Beauty In This Whole Life. I think it’s a musical masterpiece, and “Out of Here” is a standout song. The lyrics are a detailed expression of his feelings and thoughts after losing his dad to suicide. In this post, I included all of his lyrics (in bold) and my comments (in italics) with some links to relevant research.

I recommend watching his performance of the song before reading the rest of the post:

Okay so it might appear
To an outsider that you found your way up out of here
They’re saying you died of suicide
People who are suffering may view suicide as an escape from a painful life. I like how Ali phrases the third line, because it removes the stigma associated with other phrasing (e.g., commits suicide).
That’s the last thing I want to hear
They tell me that it’s hardly fair to blame myself
What a hell of a cross to bare
You didn’t say it in your letter
But the fact that I failed you is loud and clear
Suicide can be a particularly painful kind of death to grieve because 1) it means someone you love was deeply hurting and 2) there may be more of a sense that you could have prevented it, if only you had acted differently in some way. It’s a common response for people to tell you that someone’s suicide is not your fault, and yet, it can be hard to refrain from blaming yourself for not stopping the person.
Found out the amount of fear
You would drown when you found yourself naked staring down a mirror
And partners are supposed to lay the cards bare
I left you playing solitaire, and I promise you that I’m sincere
When someone dies by suicide, it might feel like there was a misunderstanding or even a kind of dishonesty between you if you didn’t know the person was contemplating suicide. I think Ali is saying that his dad might have been trying to tell him how he felt (‘lay the cards bare’), but that Ali felt like he failed him by leaving him ‘playing solitaire.’ Powerful imagery.
If you’re looking for some judgment, you won’t find it here
Let’s be honest here
I can’t say I’ve never known that kind of despair
When the clouds appear, how’s life fair
Some people erroneously perceive people who die by suicide as selfish or weak. However, Ali feels compassion and humbly links it to his own experiences. He may also be fearful about his own future (e.g., will his suicidal desire increase to the levels that his dad’s ultimately did?).
I just want to draw you near
As he sorts through the different feelings, there’s a basic desire just to be close to his dad again.
Not to make it about me, but how could you check out
Before you really allowed me a chance to sit down and hear?
I think I would’ve listened
Or were you saying it all along and I just missed it?
You sang your swan song, we all dismissed it
Ali acknowledges that the suicide isn’t about him, but feels a frustration about his father leaving without trying to ask Ali for help first. He then changes course and tries to look for signs that his dad *tried* to reach out, but that Ali missed or ignored it.
Because you filled the room with laughter
I watched when you thought no one was looking at you
In hindsight, I wonder where your smile went
When the party ended and you swallowed it
I saw you swallow it
Sometimes, people who have lost someone to suicide say they saw it coming, but others feel completely shocked. It can also switch back-and-forth in the mind of a person as they try to make sense of it.
Okay so it might appear
That you took yourself up out of here
How many cries soak through your disguise
Before you drown in your silent tears?
Okay so it might appear
That you took yourself up out of here
How many times can you fight for your life
Before you throw that white flag up and volunteer? (x2)
Here, Ali seems to be trying to figure out the threshold that was crossed before his dad killed himself. I don’t know if this is Ali trying to understand if his own life obstacles and past suicidal ideation might ever exceed that threshold or if he is trying to understand his dad’s experience better (or both).
I’ve had car accidents
Where everything is slow motion no matter how fast it’s happening
Every second that pass stretches so that you can watch it unraveling
But can’t always react to it
Your whole life might flash before your eyes
The minute when you transition to the other side
But what can actually happen in that time?
In-between the leaping and the moment you collide
In-between the trigger and the blast
In-between you let go of the wheel and you crash
In-between the moment when you swallow the last pill in the bottle
Turn out the lights, roll the dice on tomorrow
Is there a moment to reflect, can there be regret?
Is there a wait, not yet, let me reset?
Or is it just too painful to accept?
That maybe death just seemed best
I think Ali is trying to imagine what his dad was going through at the time he died by suicide since he cannot ask him about it. He’s wondering if he crossed his dad’s mind or any reluctance emerged that could have prevented his death. Or was it more like an uncontrollable-type of experience where he felt like he was watching himself but could not change the outcome?
Suicide prevention researchers, such as Thomas Joiner (1,2), have argued that an innate drive for survival and fear of death saves the lives of many people who desire suicide. I have heard Joiner describe this as a ‘flinch’ that people might experience right before or during a suicide attempt. He has presented compelling anecdotal evidence of this through stories of people who survived suicide attempts. Kevin Hines, a suicide attempt survivor from the Golden Gate Bridge, said he felt instant regret after he jumped. Along with others, suicide prevention researcher Mike Anestis, has proposed that this window maybe an opportunity to prevent some suicides through means restriction during high risk periods
I heard this as Ali arguing for not taking one’s life, even in the face of repeated, seemingly unjust hardships…’you can go down swinging.’
Okay so it might appear
That you took yourself up out of here
I’m trying not to resent you
But you left me defenseless in the life we share
Every man before me in my fam died by his own hands
How am I supposed to understand my own role in the plan
When nobody who grows old stands a chance?
Ali lost both his dad and his grandfather to suicide. He’s wrestling with sympathy for his dad and his own feelings about being left behind.
What about this mysterious dance
Made you cut the cord to the curtain in advance?
But these are questions I can only ask
The person looking back in the looking glass
Ali recognizes that he is full of questions that now must go unanswered.
I’ll close by saying that I am truly sorry if you’ve lost someone to suicide – this post is dedicated to you. I’m especially thinking of a friend who is going through this now. Research by Julie Cerel and colleagues suggests that each suicide affects a large number of people (even larger than previously thought). It’s imperative that we increase the effectiveness of suicide prevention efforts. If you need support, please consider some of the resources below.
Resources
You can find a therapist through the Association of Behavioral and Cognitive Therapy, and you can find a support group for survivors of suicide loss through the American Foundation for Suicide Prevention website.
The National Suicide Prevention Lifeline has an online chat option, and their phone number is 1-800-273-TALK.

Fact-Checking 5 Suicide-Related Statements from a Viral Ben Shapiro Video

In a YouTube video titled, “Ben Shapiro DESTROYS Transgenderism and Pro-Abortion Arguments,” Shapiro made several claims about suicide. His video currently has 3,126,889 views, which is probably 3,126,885 more views than this blog post will get. Because I feel strongly about making accurate mental health information available to the public, I decided to put a good faith effort into fact-checking the video despite my limited reach. I focused on the suicide-related claims in the video, because I am cautious about commenting on topics outside of my areas of expertise. His statements appear below in bold and my evaluations of their veracity, using empirical data, are beneath them.

1. “The idea behind the transgender movement, as a civil rights movement, is the idea that all of their problems would go away if I would pretend that they were the sex to which they claim membership. That’s nonsense. The transgender suicide rate is 40%. It is 40%.”

False. The American Foundation for Suicide Prevention-Williams Institute study that he appeared to be referencing found that 41% of a sample of transgender and gender-nonconforming (TGNC) adults reported having a lifetime suicide attempt, not a suicide death. The distinction between suicide attempts and suicide deaths is important for reasons directly noted in page 4 of the report:

deaths

It’s possible Shapiro misspoke here and genuinely could not recall the information accurately, but I have not seen a correction released from The Daily Wire despite the highly-viewed video being out for over a year. If you see that a correction has been made, please let me know, and I will update this post.

2. “According to the Anderson School of UCLA, it makes no difference – there’s a study that came out last year – it makes no difference, virtually no difference statistically speaking, as to whether people recognize you as a transgender person or not, which suggests there’s a very high comorbidity between transgenderism  — whatever that mental state may be — and suicidality that has nothing to do with how society treats you.”

False. As mentioned above, I believe that Shapiro meant the Williams Institute of UCLA study instead of the “Anderson School of UCLA,” and that was simply a mistake. But Shapiro gets two things wrong here. First, I am not certain, but based on the context from the full video, I think he misconstrued or misused how “recognition” was defined in the study. The study measured whether people tend to recognize (in the sense that they can tell) that a person is TGNC rather than recognition in the sense I think Shapiro meant (accepting a transgender person’s gender identity as valid — e.g., personally and/or legally). Secondly, there was a statistically significant difference found in the study’s recognition analysis, as seen in pages 8 and 9 of the report:

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Regarding the next part of his claim, how society treats you does appear to be correlated with suicidal ideation and suicide attempts among TGNC individuals, including in the study he referenced (from the Executive Summary, more details on pp. 11-13):

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In a separate study, TGNC youth reported whether or not people called them by their preferred name in 4 domains (home, school, work, friends). They found that chosen name use in more contexts (which the researchers used as a proxy of gender affirmation — i.e., recognizing the validity of their gender identity) was correlated with lower depression symptom levels, less suicidal ideation, and less suicidal behavior. This study was published after his video was made, but I am adding it here for informational purposes.

3. “The idea that the normal suicide rate across the United States is 4% — the suicide rate in the transgender community is 40% — the idea that 36% more transgender people are committing suicide because people are mean to them is ridiculous. It’s not true, and it’s not backed by any science that anyone can cite. It is pure conjecture. In fact, it’s not even true that bullying causes suicide…according to a lot of studies.”

False/Oversimplified. His larger point of comparing TGNC suicide attempt rates to general population rates is informative for characterizing disparities, but the 4% statistic reflects the lifetime suicide attempt rate featured in the report rather than the suicide death rate. Regardless, I don’t think that people typically claim that the entire explanation for the TGNC/general population suicide attempt rate disparity is due to meanness/bullying. Rather, the argument is that certain stressful factors (including some typically considered mean/bullying) may contribute to a higher risk for suicide attempts among transgender people. For example, from page 13 of the report:

stressors.png

Suicidologists do not talk about suicide as being caused by one factor, because there are a multitude of interacting factors at work. That is why I consider the bullying claim to be oversimplified. Moreover, there is scientific evidence that being bullied is associated with higher levels of suicidal ideation and suicide attempts (e.g., 1, 2,3) and that bias-based harassment (e.g., due to sexual orientation or race) is associated with particularly negative effects.

4. “For example, in the Black community where the idea is supposedly that America’s a racist society….Blacks are bullied a lot. Okay, in the Black community, there’s significantly lower suicide rates than in the White community.”

Half True. It is true that, in the United States, Black people generally have lower suicide rates than White people (over most age ranges, with the exception of the higher suicide rates found among Black children than White children) as you can see from this table of CDC data posted on the American Association of Suicidology website (where rate is defined as number of suicides by group/by the population of the group X 100,000):

Untitled

But this does not, as Shapiro suggested, prove that bullying is unrelated to suicide rates. As mentioned above, suicide is an outcome influenced by the interplay of risk and resilience factors. If, hypothetically, one group was bullied in equal amounts as another group, and there were disparate suicide rates, that does not necessarily mean that the group with the higher rate has a particular mental state with comorbidities (as Shapiro characterized being transgender) that accounts for all of the difference. It could be due to a number of possible factors (e.g., being a member of a group that, on average, has less social support to buffer against risk factors like bullying).

Further, racism is evident in various domains (e.g., discrimination in housing, education, healthcare, voting, and the criminal justice system), but bullying may not be one of them. At least one study using a nationally representative sample found that Black youth (19%) reported being bullied at comparable rates to White youth (21%).

5. “In fact, in third world countries, the suicide rate is significantly lower than in first world countries. Suicide actually seems to be a privilege of the upper classes if you actually look at it from a financial perspective. So, the idea that suicidality is directly a result of people like me saying, ‘No, men are not women and women are not men.’ It’s not true.”

Mostly false. I’m not sure that I fully understand the thread through this argument. My best guess, based on the full video context, is that Shapiro proposed that suicide occurs more among people with societal privilege and therefore high suicide attempt rates among transgender people would not be improved if they had more societal privilege? Or that denying the validity of transgender people’s gender identity and bullying do not increase risk for suicide, but having a lot of money does?

There are two claims to fact-check here. First, I’ll focus on the statement about suicide rates in “third world” (developing) vs. “first world” (developed) countries. To evaluate this, I examined the World Health Organization‘s 2016 suicide data by country (units are # of suicide deaths/100,000 people) paired with the World Bank’s 2017 country classification data (high income, upper middle income, lower middle income, low income). There was a lot of variability within the categories (especially in the high income group). For example, the high income group (n = 50) ranged from 0.5/100,000 (Antigua and Barbuda) to 31.90/100,000 (Lithuania). Meanwhile, the low income group (n = 31) ranged from 3.7/100,000 (Malawi) to 11.7/100,000 (Haiti). I conducted an ANOVA on the 174 countries I had data for and found statistically significant differences in the direction that Shapiro asserted. Stats people may have noticed that the assumption of homogeneity of variance was violated and that the groups are unequal sizes. Parallel analyses using a robust (Welch’s) ANOVA and nonparametric (Kruskal-Wallis) testing suggested comparable results.

Chart 1.png

Because Shapiro mostly meant suicide attempts when talking about suicide deaths, I’ll also include results from a study which found, “twelve-month prevalence estimates of suicide ideation, plans, and attempts were 2.0%, 0.6% and 0.3% respectively for developed countries and 2.1%, 0.7% and 0.4% for developing countries.” There were no meaningful differences for suicide attempt rates related to developed/developing status in that study, and contrary to Shapiro’s second claim, they found that lower income was associated with higher levels of suicidal ideation, plans, and attempts in both developing and developed countries. Similarly, a meta-analysis revealed that low (not high) income level was associated with increased risk for death by suicide:

risk in females

suicidemales

In summary, at a broad level (developing vs. developed countries), Shapiro accurately described the pattern of suicide rates. However, when examining the variables with more precision (e.g., at the individual financial status and suicide risk level), the data are inconsistent with his claim that suicide is a “privilege of the upper class.” It is possible that specific societal structures and cultural elements better account for the observed disparities in national suicide rates.

In conclusion, Ben Shapiro argued that he and others should not be pressured into personally or legally recognizing transgender people’s gender identity as valid rather than their assigned sex at birth. One way that he tried to justify those feelings was to make several statements purportedly proving that societal treatment of transgender people has no impact on their suicide risk. Shapiro has every right to have and express his feelings on this issue. However, his feelings don’t change the fact that societal treatment is, according to a lot of studies, related to suicide risk among transgender people.

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Note 1: The widely-watched Shapiro video is from February 19, 2017, and as of May 14, 2018, I see no notation that corrects any of the misinformation in the video or on his website. If you are aware of such corrections, please contact me, and I’ll update the post. 

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Note 2: For more information and resources about suicidal behavior among TGNC people, please see my post about gender dysphoria and suicidality in Laura Jane Grace’s memoir and the links below:

For Accurate Information on this Topic: American Psychological Association

Learn More about the Lived Experiences of TGNC People in Their Own Words: Aydian DowlingChaz Bono, ContraPoints, Janet MockJazz Jennings, Laverne CoxLeelah AlcornLive Through This ProjectTrans documentaryTrue Trans documentary series with Laura Jane Grace

Suicide Prevention Resources: American Association of SuicidologyAmerican Foundation for Suicide PreventionDarcy Jeda Corbitt FoundationNational Suicide Prevention Lifeline, Trans Lifeline, The Trevor Project

Information for Mental Health Professionals about Affirming Psychological Practice With TGNC People: APA GuidelinesA Model for Children & Adolescents

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Thank you to Linda & Keith for helping me figure out how to best fact-check #5.

Gender Dysphoria & Suicidality in Laura Jane Grace’s Memoir

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Laura Jane Grace playing with Against Me! in Fargo, ND in 2017

I’m a big Against Me! fan, and I recently re-read Laura Jane Grace‘s captivating memoir. I loved learning the stories behind the lyrics and catching Grace’s clever references, like when she said that NoFX never had to wait at the end of the longest line at Warped Tour. I grew up in the Florida punk scene during the late 90s/early 00s and enjoyed the nostalgic recollections throughout the book (e.g., making free copies at Kinko’s, reading zines, and going to concert venues like The Edge). I could write a super-long post about the many poignant parts of the book (see below for a picture of all the pages that I marked to revisit later), but there are people who do that professionally, so I’ll leave it to them.
book

Instead, I’ll focus on the angle that I’m more familiar with: discussing mental health research in the context of people’s stories (e.g., 1, 2, 3). Grace identifies as a transgender woman and has described her gender dysphoria as a deeply distressing experience resulting from a misalignment between her self-perception and physical body. Her book opened with her earliest memory of gender dysphoria, which occurred at age 5 while watching Madonna on TV:

Her dirty blond hair was moussed and frizzed to perfection. Her neon and black clothes were ripped and torn to accentuate her curves. Her chunky bracelets and necklaces sparkled and jangled against her arms and neck as she moved to the beat. I reached out my hand and touched her on the screen. That’s me, I thought, clear as day. I wanted to do that. I wanted to be that. 

This sense of wonderment was cut short by confusion. Suddenly I realized that I would never be her, that I could never be her. Madonna was a girl; a confident symbol of femininity, singing and dancing onstage in a short skirt and high heels. I was just a small boy, living in a ranch house on an Army base in Fort Hood, Texas.

My father’s name was Thomas. My uncle’s name was Thomas. My cousin’s name was Thomas. And I was born Thomas James Gabel, the son of a soldier, a West Point graduate who never went to war. That was the name written on my birth certificate, but I never felt that it suited me.

Beginning in childhood and continuing through adulthood, Grace secretly wore women’s clothes (at first, her mother’s and later, clothes she purchased). She felt overwhelming shame about this behavior and tried to stop it many times, but always found herself drawn back to it and the relief it brought her (she referred to these episodes as “binges and purges”). In her youth, she thought she might be gay (though she was mostly attracted to girls), a “pervert,” or that she maybe had schizophrenia. She pled with God, and even the devil, to change her body to match her gender identity.

Grace endured several stressful events throughout her youth, including her parents’ divorce, disapproval from a church she attended, being bullied at school, legal troubles, and an incident where she was assaulted by police officers. Meanwhile, Grace struggled with depression and substance abuse and ultimately dropped out of high school. She started focusing on making her band successful and moved from Naples to Gainesville, Florida, which had a thriving punk scene at the time (shout-out to my friend’s band from that era, FIYA).

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Le Tigre show that I went to in Gainesville, 2000

While the success of Against Me! brought adventures, fans, and recognition of Grace’s skills and talents, there were also conflicts among band members, record label issues, difficulties in her first marriage, and a backlash from some punk rock purists who thought Against Me! had sold out. She tried to distract herself from the gender dysphoria by channeling her attention into music, drugs, drinking, and working out. She tried repeatedly to accept living as a man and tried to push ideas of living as a woman out of her mind. Grace recalled a particular time on tour when she and her band saw a group of transgender women walking together. She joined in with her bandmates to make fun of them, while secretly wishing she was as brave as them. No one in her life was aware that she was going through these struggles, even though she wrote lyrics about her gender dysphoria in Against Me! songs. In 2007, Grace got married for the second time. The gender dysphoria decreased during certain periods of her marriage, but always returned (including during her wife’s pregnancy with their child, who was born in 2009).

Grace decided that she would come out as a transgender woman in a 2012 Rolling Stone article at the age of 31. After beginning her transition, she felt more authentic and experienced relief from her gender dysphoria. Still, she continued to face challenges. She got divorced and her father stopped talking to her after she disclosed that she was transgender. Through the hardships, Grace continued to speak out about the rights of transgender people, talk openly about mental health issues, make really good music, and inspire many people. That’s my brief summary of her book — but seriously, you should read her entire memoir, which concludes with this lovely moment between Grace and her daughter:

It’s the new issue of Rolling Stone. On the cover is a close-up shot of Madonna. She looks exactly the way I remember when I first saw her at five years old, the same age Evelyn is now. Red lipstick, piercing blue eyes, not a single hair out of place. Her skin is delicate and gorgeous.

“Daddy, who is this?” she asks me.

“That’s Madonna, Evelyn,” I tell her. She’s a musician.”

“Just like you?”

“Just like me.”

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Against Me! playing in Lansing, Michigan in 2018

While I’ve been wanting to write this post since I first read the book, my motivation was renewed after the release of the “trans military ban” memo, which states that “transgender persons with a diagnosis or history of gender dysphoria…are disqualified from military service except under certain limited circumstances.”  The link between gender dysphoria and suicidality was cited as one of the reasons for this decision. Estimates vary across studies, and there are methodological components that should be carefully considered, but the existing research consistently finds an elevated risk for suicidal ideation, suicide attemptssuicide-related events, self-harm, and suicide among transgender and gender-nonconforming (TGNC) people. I will unpack some of what we know about this empirical relationship, but I want make it clear that I agree with the American Psychological Association and the American Medical Association that the memo is discriminatory. It’s worth reading both organizations’ statements in full here and here.

Back to Laura Jane Grace…in a 2017 interview, she referred to herself as “part of” the 41% lifetime suicide attempt rate among TGNC people. That statistic should be interpreted within the context of the methodology (the report acknowledged that the rate might be inflated due to measurement and sample recruitment methods). Data were not collected on the timing of the suicide attempts in relation to transitioning, which was another limitation of the study. Grace attempted suicide ~1.5 years after she began transitioning, and she partially attributed it to a serious, adverse reaction to the hormones she was taking. In a 2016 interview, she described having suicidal thoughts at various points throughout her life, “…while I’ve struggled with gender dysphoria for my whole life, I’ve also struggled with depression. Those aren’t necessarily linked.” In her memoir, she points to a family history of mental health problems that may have contributed to her mood struggles as well.

The American Foundation for Suicide Prevention and the Williams Institute identified the following risk factors for suicide attempts among TGNC people (from the Executive Summary, p.2):

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Another study found that twice as many transgender youth (34%) reported suicidal desire in the previous year as compared to non-transgender youth (19%) and that depression and school-based peer victimization explained part of the empirical relationship between gender identity and suicidal ideation. Here again, it’s important to interpret the findings within the context of the methods (in this case, self-report questionnaires with some limitations were used).

A 2017 study sought to build on existing research by testing a general theory of suicide (the interpersonal-psychological theory of suicidality, IPTS) and the gender minority stress and resilience model (GMSR) among TGNC adults (again, it’s important to look at the study details for full context when interpreting the results). They reported two main findings: 1) GMSR variables (e.g., discrimination, victimization, internalized transphobia, non-affirmation) explained 20% of the variance in suicidal ideation in the sample and 2) IPTS variables (i.e., social disconnection and perceiving oneself as a burden on others) mediated the relationship between GMSR variables (internalized transphobia, negative expectations for the future, and nondisclosure of one’s gender identity) and suicidal ideation, accounting for 54% of the statistical variance in the sample. A study in TGNC youth also found that IPTS variables were correlated to suicidal ideation and suicide attempts, while another found that a GMSR-related variable (being addressed by a chosen name in multiple contexts) was linked to lower depression and suicidality among TGNC youth.

In summary, we need more research to fully understand elevated suicidality risk among TGNC people. The available science suggests that depression, discrimination, victimization, and other structural factors (e.g., difficulty accessing medical care and affirmative mental health practice) disproportionately impact the TGNC community and contribute to suffering, as Grace wrote about in her memoir. For an equitable and just society, we must join with those working to break down these societal barriers. It’s the compassionate and right thing to do.

I’ll conclude with this wisdom from Laura Jane Grace:

Interviewer: Do you ever get tired of being part of people’s learning curve and constantly explaining to people?

Laura Jane Grace: I don’t get tired of it in a way…talking about trans issues, trying to educate people about trans issues — translates to a real world thing that does actually save lives and helps make other people’s lives easier, including my own. That’s what it’s about…humanizing things.

I wanted to keep this post relatively brief, but if you are interested in learning more about any of the ideas presented in it, you can check out some of these links:

Learn More about the Diverse Lived Experiences of TGNC People in Their Own Words: Aydian DowlingChaz Bono, ContraPoints, Jazz JenningsJanet MockLaverne Cox, Leelah Alcorn, Live Through This ProjectTrue Trans documentary series with Laura Jane Grace, Trans documentary

Information for Mental Health Professionals about Affirming Psychological Practice With TGNC People: APA Guidelines, A Model for Children & Adolescents

Suicide Prevention Resources: American Association of Suicidology, American Foundation for Suicide PreventionNational Suicide Prevention Lifeline, Trans Lifeline, The Trevor Project, Darcy Jeda Corbitt Foundation