Written by Jesse White
Over the past year, Equip has partnered with Jesse White, a seminary-trained Christian leader who has been faithfully stewarding his own gender incongruence, to develop Equip’s Gender Incongruence Course. Learn more about Jesse’s education and story at equipyourcommunity.org/about and learn with Jesse about how Christians can offer God’s love and wisdom to trans* people at equipyourcommunity.org/gendercourse.
Trans* people have become the focus of culture war church sermons, cable sports network debates, political posturing, and legislative stunts. Politicians, neighbors, and social media strangers have argued about bathrooms, participation in women’s sports, and medical decisions between parents, their children, and their doctors. Dangerously, the voice of and care for trans* people has been lost among competing agendas.
Those navigating gender incongruence suffer.
Disturbingly, 41% of trans people attempt suicide, as compared to 1.6% of the general population. Trans* suicide rates rose even higher for those who lost a job due to bias (55%), were harassed/bullied in school (51%), had low household income (61%), were the victim of physical assault (61%), or were the victim of sexual assault (65%).1
Trans* people are generally at greater risk of mental illness, experiencing higher rates of borderline personality disorder, schizophrenia, obsessive compulsive disorder (OCD), attention deficit hyperactivity disorder (ADHD), and autism spectrum disorder compared to the general population.2
Within the broader LGBTQ+ community, trans* people are at a higher risk for self-harm and external victimization than any other subgroup.3
According to CBS News, “Everytown’s Transgender Homicide Tracker found a 93% increase in tracked homicides of trans and gender-nonconforming people in the United States and Puerto Rico over the last four years.”4 In 2021, 56 people were killed, compared to 29 reported deaths in 2017. Notably, while only 13% of the transgender community is estimated to be Black, according to UCLA School of Law’s Williams Institute, Black trans women accounted for nearly three-quarters of the known victims.5
Loved ones of trans* people are rightly alarmed by these statistics. Those navigating gender incongruence are at greater risk of mental illness and suicide than nearly any other subpopulation.
Unhelpful advice from the extremes
Different extremes in the debate about gender incongruence offer trans* people equally unhelpful advice:
One side yells, “Just be normal!” They ignore the reality that trans* people did not choose to experience gender incongruence and that there is no proven combination of counseling or spiritual practices to eliminate gender incongruence. Those on this extreme minimize the daily, painful reality of navigating enduring gender incongruence. They seem to forget that trans* people are also made in the image of God, are greatly valued by Him, and that Christians should greatly value trans* people as well.
Then the other side yells, “Transition or suicide!” They suggest that transition is an effective intervention to address mental illness (including suicidality) and that those who hesitate to bless hormonal and surgical transition are increasing suicidality.
However, available research is inconclusive about the effectiveness of hormonal and surgical transition to reduce suicide risk. A person cannot claim that transition has been proven to effectively reduce suicidality.
Some scientists, clinicians, and trans advocates argue that hormonal transition is safe and effective, even for minors.6 7 8 9 But other studies found meaningful health safety concerns related to hormonal transition, particularly if the individual does not display robust gender dysphoria.10
Some studies demonstrated that side effects of hormonal transition could include increased risk of blood clots, risk of diabetes, increased risk of cancer, chronic low energy, increased risk of heart attack/stroke, and detrimental changes in blood pressure and cholesterol.11 12 13 14 15 16 17 Furthermore, prolonged use of cross-sex hormones is known to have irreversible effects such as a deeper voice in females and infertility in both biological sexes.18 19 20 Even greater risks are known for minors who undergo hormonal transition.21 22 23 24 25 26
While research about the safety of hormonal transition is mixed, have studies found that hormonal transition reduces suicidality? Some analyses demonstrated that use gender-affirming hormones or puberty blockers was associated with a lower risk of suicidal ideation.27 28 29 Yet different analysis of the same data found that “[m]ales who took estrogen are more likely to plan suicide, to attempt suicide, and to require hospitalization for a suicide attempt.”30 Similar analysis found that 16- and 17-year-olds who received hormones were more than twice as likely to report a “past-year suicide attempt requiring inpatient hospitalization.” That same research found that suicide rates among trans* adolescents was significantly higher in states that “have a provision that allows minors to receive routine health care without parental consent than in states without such a provision.”31
Considering the limited studies available and contradicting analysis, research is inconclusive about the effectiveness of hormonal transition to reduce suicidality, but more research is needed and may conclusively demonstrate that hormonal transition does lower rates of suicidal ideation.
A similar story emerges for surgical transition. Studies consistently show that sex reassignment surgery effectively reduces gender dysphoria and leads to high patient satisfaction.32 33 34 35 36 Yet other studies offered mixed results, leading Johns Hopkins Hospital to discontinue sex reassignment surgeries for nearly half a century.37 These studies and analyses revealed that while surgical transition effectively reduced gender dysphoria, rates of depression and suicidality often remained relatively elevated, with repeated analyses finding available studies to suffer from significant methodological limitations and to follow-up with patients for only a year or two after surgical transition.38 39 40 41 42 43
One of the largest and methodologically robust longitudinal studies of surgical transition in Sweden found that sex reassignment surgery effectively alleviated gender dysphoria but failed to adequately reduce suicidality, as compared to the general population.44 A different longitudinal study of surgical transition in Denmark found that while 21.2% of participants experienced a reduction in suicidality after transition, 15.4% of participants experienced an increase in suicidality after transition.45
Similar to hormonal transition, available research is inconclusive about the effectiveness of surgical transition to reduce suicidality, particularly because of methodological limitations. While more research is needed, the few robust longitudinal studies available suggest that surgical transition is not correlated with a meaningful reduction in suicide risk and therefore an ineffective treatment for suicidality. It cannot be claimed that transition is a scientifically proven method for reducing suicide risk.
Neither “just be normal” nor “transition or suicide” addresses the real need of trans* people with proven solutions. Instead, those offering care to trans* people struggling with mental health challenges should first focus on addressing the mental illness directly with interventions proven to be effective while helping the trans* person accept that transition is at best ineffective to address mental illness and at worst a contributor to mental illness.
How can you help?
Research shows that the following have been proven to be most effective at reducing depression and suicidality (in no particular order):
- In-person talk therapy with a counselor to address grief/loss46
- Regular exercise/physical activity47
- Use of antidepressants48
- A broader community of social support49
If a trans* person you’re supporting is struggling with suicidality, help them find a therapist or counselor, go with them on walks, and help them maintain and deepen connections with safe friends and family.
Believe trans* people when they share about their experience. Recognize that trans* people have done nothing to bring about their gender incongruence. Honor that faithfully stewarding gender incongruence will be costly and demands the support of trans* people’s siblings in Christ.
Remind trans* Christians that Jesus cares for them and is with them in the pain and mess of life. While it is painfully difficult to live in a world (and a body) burdened by brokenness, brokenness will not be our experience forever; we have a hope and a future in Jesus for resurrected bodies and life when all will be made right.
Science is, however, confident that the social stress and rejection trans* people experience as minorities increases their risk of depression and suicide.50 51 52 Tragically, this minority stress can be multiplied in churches where overt and accidental transphobic attitudes persist. So while evidence-based interventions of therapy, exercise, medication, and social support are most effective on an individual level, Christians can simultaneously work to reduce societal discrimination and harassment of trans* people. To reduce suicide risk for trans* people on a societal level, Christians must imitate Christ by protecting those on the margins from harm.
Get access to Equip’s Gender Incongruence Course today to learn how to care for trans* people navigating mental illness at equipyourcommunity.org/gendercourse.
1 Grant, J. M. M. L., Mottet, L., Tanis, J., Herman, J. L., Harrison, J., & Keisling, M. (2010). National transgender discrimination survey report on health and health care.
2 Rajkumar, R. P. (2014). Gender identity disorder and schizophrenia: neurodevelopmental disorders with common causal mechanisms?. Schizophrenia research and treatment, 2014.
3 Hendricks ML, Testa RJ: A conceptual framework for clinical work with transgender and gender nonconforming clients: An adaptation of the Minority Stress Model. Prof Psychol Res Pract 2012.
6 Butler, G., Wren, B., & Carmichael, P. (2019). Puberty blocking in gender dysphoria: suitable for all?. Archives of Disease in Childhood, 104(6), 509-510.
7 Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., … & Zucker, K. (2012). Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. International journal of transgenderism, 13(4), 165-232.
8 De Vries, A. L., McGuire, J. K., Steensma, T. D., Wagenaar, E. C., Doreleijers, T. A., & Cohen-Kettenis, P. T. (2014). Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics, 134(4), 696-704.
9 Gómez-Gil, E., Zubiaurre-Elorza, L., Esteva, I., Guillamon, A., Godás, T., Almaraz, M. C., … & Salamero, M. (2012). Hormone-treated transsexuals report less social distress, anxiety and depression. Psychoneuroendocrinology, 37(5), 662-670.
10 Hembree, W. C., Cohen-Kettenis, P. T., Gooren, L., Hannema, S. E., Meyer, W. J., Murad, M. H., … & T’Sjoen, G. G. (2017). Endocrine treatment of gender-dysphoric/gender-incongruent persons: an endocrine society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 102(11), 3869-3903.
11 Boehmer, U., Gereige, J., Winter, M., Ozonoff, A., & Scout, N. (2020). Transgender individuals’ cancer survivorship: Results of a cross-sectional study. Cancer, 126(12), 2829-2836.
12 Streed Jr, C. G., Harfouch, O., Marvel, F., Blumenthal, R. S., Martin, S. S., & Mukherjee, M. (2017). Cardiovascular disease among transgender adults receiving hormone therapy: a narrative review. Annals of internal medicine, 167(4), 256-267.
13 Moore, E., Wisniewski, A., & Dobs, A. (2003). Endocrine treatment of transsexual people: a review of treatment regimens, outcomes, and adverse effects. The Journal of Clinical Endocrinology & Metabolism, 88(8), 3467-3473.
14 Alzahrani, T., Nguyen, T., Ryan, A., Dwairy, A., McCaffrey, J., Yunus, R., … & Reiner, J. (2019). Cardiovascular disease risk factors and myocardial infarction in the transgender population. Circulation: Cardiovascular Quality and Outcomes, 12(4), e005597.
15 Getahun, D., Nash, R., Flanders, W. D., Baird, T. C., Becerra-Culqui, T. A., Cromwell, L., … & Goodman, M. (2018). Cross-sex hormones and acute cardiovascular events in transgender persons: a cohort study. Annals of internal medicine, 169(4), 205-213.
16 Feldman, J. L. (2002). New onset of type 2 diabetes mellitus with feminizing hormone therapy: Case series. International Journal of Transgenderism, 6(2).
17 Defreyne, J., De Bacquer, D., Shadid, S., Lapauw, B., & T’Sjoen, G. (2017). Is type 1 diabetes mellitus more prevalent than expected in transgender persons? A local observation. Sexual Medicine, 5(3), e215-e218.
18 Bewley, S., Griffin, L., & Byng, R. (2019). Safeguarding adolescents from premature, permanent medicalisation. Retrieved from BMJ Rapid Responses website: https://www. bmj. com/content/364/bmj. l245/rr-1.
19 Cler, G. J., McKenna, V. S., Dahl, K. L., & Stepp, C. E. (2020). Longitudinal case study of transgender voice changes under testosterone hormone therapy. Journal of Voice, 34(5), 748-762.
20 Irwig, M. S., Childs, K., & Hancock, A. B. (2017). Effects of testosterone on the transgender male voice. Andrology, 5(1), 107-112.
21 Biggs, M. (2019). Britain’s experiment with puberty blockers. Inventing transgender children and young people, 40-55.
22 Richards, C., Maxwell, J., & McCune, N. (2019). Use of puberty blockers for gender dysphoria: a momentous step in the dark. Archives of disease in childhood, archdischild-2018.
23 Brik, T., Vrouenraets, L. J., de Vries, M. C., & Hannema, S. E. (2020). Trajectories of adolescents treated with gonadotropin-releasing hormone analogues for gender dysphoria. Archives of Sexual Behavior, 49(7), 2611-2618.
24 Hruz, P. W., Mayer, L. S., & McHugh, P. R. (2017). Growing pains: problems with puberty suppression in treating gender dysphoria. The New Atlantis, 3-36.
25 Giovanardi, G. (2017). Buying time or arresting development? The dilemma of administering hormone blockers in trans children and adolescents. Porto Biomedical Journal, 2(5), 153-156.
26 Sadjadi, S. (2013). The endocrinologist’s office—puberty suppression: Saving children from a natural disaster?. Journal of Medical Humanities, 34, 255-260.
27 Turban, J. L., King, D., Kobe, J., Reisner, S. L., & Keuroghlian, A. S. (2022). Access to gender-affirming hormones during adolescence and mental health outcomes among transgender adults. PLos one, 17(1), e0261039.
28 Turban, J. L., King, D., Carswell, J. M., & Keuroghlian, A. S. (2020). Pubertal suppression for transgender youth and risk of suicidal ideation. Pediatrics, 145(2).
29 Green, A. E., DeChants, J. P., Price, M. N., & Davis, C. K. (2022). Association of gender-affirming hormone therapy with depression, thoughts of suicide, and attempted suicide among transgender and nonbinary youth. Journal of adolescent health, 70(4), 643-649.
30 Biggs, M. (2022). Comment on Turban et al. 2022: Estrogen Is Associated with Greater Suicidality Among Transgender Males, and Puberty Suppression Is Not Associated with Better Mental Health Outcomes for Either Sex. figshare, journal contribution.
31 Greene, J. P. (2022). Puberty Blockers, Cross-Sex Hormones, and Youth Suicide. Heritage Foundation Backgrounder, (3712), 2022-06.
32 Cohen-Kettenis, P. T., & Van Goozen, S. H. (1997). Sex reassignment of adolescent transsexuals: a follow-up study. Journal of the American Academy of Child & Adolescent Psychiatry, 36(2), 263-271.
33 Johansson, A., Sundbom, E., Höjerback, T., & Bodlund, O. (2010). A five-year follow-up study of Swedish adults with gender identity disorder. Archives of Sexual Behavior, 39, 1429-1437.
34 Karpel, L., Gardel, B., Revol, M., Bremont-Weil, C., Ayoubi, J. M., & Cordier, B. (2015, July). Psychological and sexual well being of 207 transsexuals after sex reassignment in France. In ANNALES MEDICO-PSYCHOLOGIQUES (Vol. 173, No. 6, pp. 511-519). 21 STREET CAMILLE DESMOULINS, ISSY, 92789 MOULINEAUX CEDEX 9, FRANCE: MASSON EDITEUR.
35 Lawrence, A. A. (2003). Factors associated with satisfaction or regret following male-to-female sex reassignment surgery. Archives of sexual behavior, 32, 299-315.
36 van de Grift, T. C., Elaut, E., Cerwenka, S. C., Cohen-Kettenis, P. T., & Kreukels, B. P. (2018). Surgical satisfaction, quality of life, and their association after gender-affirming surgery: a follow-up study. Journal of sex & marital therapy, 44(2), 138-148.
37 Meyer, J. K., & Reter, D. J. (1979). Sex reassignment: Follow-up. Archives of General Psychiatry, 36(9), 1010-1015.
38 Udeze, B., Abdelmawla, N., Khoosal, D., & Terry, T. (2008). Psychological functions in male-to-female transsexual people before and after surgery. Sexual and Relationship Therapy, 23(2), 141-145.
39 Ross, M. W., & Need, J. A. (1989). Effects of adequacy of gender reassignment surgery on psychological adjustment: A follow-up of fourteen male-to-female patients. Archives of Sexual Behavior, 18, 145-153.
40 White Hughto, J. M., & Reisner, S. L. (2016). A systematic review of the effects of hormone therapy on psychological functioning and quality of life in transgender individuals. Transgender health, 1(1), 21-31.
41 Murad, M. H., Elamin, M. B., Garcia, M. Z., Mullan, R. J., Murad, A., Erwin, P. J., & Montori, V. M. (2010). Hormonal therapy and sex reassignment: A systematic review and meta‐analysis of quality of life and psychosocial outcomes. Clinical endocrinology, 72(2), 214-231.
42 Kuhlman, K. R., Urizar Jr, G. G., Robles, T. F., Yim, I. S., & Schetter, C. D. (2019). Testing plausible biopsychosocial models in diverse community samples: Common pitfalls and strategies. Psychoneuroendocrinology, 107, 191-200.
43 Yarhouse, M. A., & Sadusky, J. (2019). The complexities of gender identity: Toward a more nuanced response to the transgender experience. Understanding transgender identities, 101-130.
44 Dhejne, C., Lichtenstein, P., Boman, M., Johansson, A. L., Långström, N., & Landén, M. (2011). Long-term follow-up of transsexual persons undergoing sex reassignment surgery: cohort study in Sweden. PloS one, 6(2), e16885.
45 Simonsen, R. K., Giraldi, A., Kristensen, E., & Hald, G. M. (2016). Long-term follow-up of individuals undergoing sex reassignment surgery: Psychiatric morbidity and mortality. Nordic Journal of Psychiatry, 70(4), 241-247.
46 Zalsman, G., Hawton, K., Wasserman, D., Van Heeringen, C., Arensman, E., Sarchiapone, M., … Zohar, J. (2016). Suicide prevention strategies revisited : 10-year systematic review. LANCET PSYCHIATRY, 3(7), 646–659. https://doi.org/10.1016/S2215-0366(16)30030-X
47 Davidson, C. L., Babson, K. A., Bonn‐Miller, M. O., Souter, T., & Vannoy, S. (2013). The impact of exercise on suicide risk: examining pathways through depression, PTSD, and sleep in an inpatient sample of veterans. Suicide and Life‐Threatening Behavior, 43(3), 279-289.
48 Zalsman, G., Hawton, K., Wasserman, D., Van Heeringen, C., Arensman, E., Sarchiapone, M., … Zohar, J. (2016). Suicide prevention strategies revisited : 10-year systematic review. LANCET PSYCHIATRY, 3(7), 646–659. https://doi.org/10.1016/S2215-0366(16)30030-X
49 Wright, K. B., Rosenberg, J., Egbert, N., Ploeger, N. A., Bernard, D. R., & King, S. (2013). Communication Competence, Social Support, and Depression Among College Students: A Model of Facebook and Face-to-Face Support Network Influence. Journal of Health Communication, 18(1), 41-57.
50Tebbe, E. A., & Moradi, B. (2016). Suicide risk in trans populations: An application of minority stress theory. Journal of counseling psychology, 63(5), 520.
51 Hendricks, M. L., & Testa, R. J. (2012). A conceptual framework for clinical work with transgender and gender nonconforming clients: An adaptation of the Minority Stress Model. Professional Psychology: Research and Practice, 43(5), 460.
52 Sevlever, M., & Meyer-Bahlburg, H. F. (2019). Late-onset transgender identity development of adolescents in psychotherapy for mood and anxiety problems: Approach to assessment and treatment. Archives of sexual behavior, 48, 1993-2001.
Note: Equip is grateful for the work of Preston Sprinkle to curate much of the research presented in this article. If you’re looking for a book on a biblical response to gender incongruence, we highly recommend Embodied: Transgender Identities, the Church, & What the Bible Has to Say.