Real-time Study of Psychotherapy, Suicide Risk, and Resilience in Transgender and Non-binary Adults

Transgender and non-binary (TNB) people show significantly elevated rates of suicidal thoughts and behaviors, and are more likely to die by suicide, than their cisgender peers. This marked disparity is thought to be associated with experiences of gender minority stress. TNB people face greater external minority stressors, such as victimization, harassment, and violence, than cisgender people, and these experiences are positively associated with suicide risk. Internal minority stressors, such as internalized transphobia, have also been associated with suicidal thoughts and behaviors in TNB people.

Prior research in this area has been limited, however, by use of cross-sectional methods and failure to examine the relative importance of different types of minority stressors in predicting changes in suicide risk over time. Further, most research on TNB health disparities has focused on risk, rather than protective, factors, yielding little actionable data for families, clinicians, and policymakers to improve the health and well-being of the TNB community. In particular, the potential benefits of psychotherapy in buffering against gender minority stressors has been woefully understudied. 

This study will recruit 50 TNB adults from across the United States who are currently engaged in outpatient psychotherapy and who have experienced suicidal thoughts or behaviors in the month prior to enrollment. During a virtual baseline session, participants will complete self-report and interview measures related to mental health, suicidal thoughts and behaviors, gender identity, gender minority stress and resilience, and psychotherapy experiences. Participants will then complete a four-week ecological momentary assessment (EMA) protocol, allowing us to examine changes in suicidal thoughts and suicidal behavior risk over time in relation to gender minority stress, resilience factors, and perceptions of psychotherapy. Following the EMA portion of the study, participants will complete a virtual feedback interview to inform further protocol refinement for future research.

First, we hypothesize that internal minority stressors (e.g., internalized transphobia) will contribute to short-term increases in suicidal ideation, and increased odds of suicidal behaviors, in daily life. Further, we expect that external minority stressors (e.g., victimization) will exacerbate suicidal ideation through changes in internal minority stressors. Second, we predict that increases in perceived social support, as well as increases in gender resilience factors (e.g., trans identity pride), will be associated with short-term decreases in suicidal ideation. Third, we predict that participants who report more negative therapist attitudes towards TNB people will exhibit greater suicidal ideation, and higher odds of suicidal behaviors, over follow-up. During the follow-up period, greater perceptions of task-specific change following psychotherapy sessions will predict decreases in suicidal ideation over time. 

Through the use of advanced methodological strategies, such as EMA and dynamic structural equation modeling, the proposed project will permit fine-grained assessment of different types of minority stressors and resilience factors as they relate to subsequent, within-person changes in suicide risk over time, particularly in the context of ongoing psychotherapeutic change. By drawing on an at-risk sample followed with intensive longitudinal methods, this study will yield clinically actionable and theoretically relevant results that inform suicide prevention strategies for TNB people.