Evidence of Syndemic Effects Affecting Suicidal Ideation among Transgender Persons of Color: Results from a Large National Study

Rates of suicidal ideation are much higher among transgender adults than they are among adults in the population-at-large. For the adult population as a whole, estimates suggest that approximately 2.1%-10.0% of adults contemplated suicide during the past year (with the most recent and most reliable estimates typically being in the 4.3%-4.8% range) and anywhere from 5.6%-14.3% had considered suicide at least once during their lifetime [1-3]. In contrast, Wolford-Clevenger [4] research with transgender and gender-nonconforming adults in the American southeast found that 59.5% of these persons had thought about committing suicide during the previous month. Data from the Generations and TransPop studies-two of the largest recent studies of transgender persons in the United States-showed that 81.3% of transgender adults had contemplated suicide at least once during their lives and more than one-half of these persons (42.0% of the total sample) reported a previous actual suicide attempt [5].

Considerable research has been done to understand the factors underlying the high prevalence of suicidal ideation and suicide attempts among transgender persons. Many factors have been linked with suicidal thoughts in this population, including substance use/misuse [6,7], experiencing transgender-related discrimination [8,9], experiencing gender abuse-that is, verbal abuse or harassment due to one’s gender identity presentation [10,11], unmet desire to begin gender-affirming hormone therapy and/or to have genderconforming surgical procedures [12-14], and a host of others. From the standpoint of the present study, it is noteworthy that very few studies have focused specifically on suicide-related issues among transgender persons of color or addressed any particular needs that members of different racial minority groups of transgender adults may experience when it comes to suicide risk or suicide prevention. One notable exception is the work published by Meza Lazaro [15], focusing on Latina transgender women.

The present study focuses on this under-researched area by examining suicidal ideation among transgender persons of color. The principal aim of this research is to determine whether there is evidence of syndemic-type effects underlying suicidal ideation among transgender adults who self-identify as members of racial minority groups. For readers who may be unfamiliar with the construct, “syndemic” is a term coined during the mid-1990s by Merrill Singer [16], who used it to refer to the tendency for multiple epidemics, problems, or behavioural phenomena to co-occur, and when they do co-occur, they do so in such a manner as to worsen or heighten one another’s effects. Expanding upon his original work, Singer [17] subsequently stated.

Beyond disease clustering and interaction, the term syndemic also points to the importance of social conditions in disease concentrations, interactions and consequences. In syndemics, the interaction of diseases or other health problems . . . commonly arises because of adverse social conditions . . . that put socially devalued groups at heightened risk. (p. 2011).

In the three or so decades since the term “syndemic” first appeared in the scholarly literature, the construct “syndemic” has been expanded into a full-fledged theoretical paradigm and, as such, it has been used as a way of trying to understand various social problems and how they affect disadvantaged persons’ lives. Numerous studies have adopted a Syndemics Theory approach to studying phenomena such as substance use/misuse, mental health functioning, childhood maltreatment, HIV risk practices, and a host of other often-interacting variables [18,19]. Of specific relevance to the present study, in recent years, a syndemics approach has been applied to a few-but seemingly just a few-studies of transgender persons and their life challenges [20,21].

Relying upon a large research sample of American transgender persons of color, the present study examines the impact of experiencing multiple types of problems on suicidal ideation. The goal is to determine whether or not there is evidence of syndemic effects operating when it comes to understanding transgender persons of color’s likelihood of thinking about ending their lives. Additionally, the present researchers examine how impactful the co-occurrence of multiple problems is (i.e., just how great the syndemic effect is). Toward this end, five different types of potentially-syndemic factors are examined in the present paper: (1) workplace issues (specific to transgender identity and experiences), (2) interactions with professionals (specific to transgender identity and experiences, (3) using public services (specific to transgender identity and experiences, (4) personal safety (specific to transgender identity and experiences), and (5) socioeconomic disadvantages (irrespective of transgender identity and experiences). The present authors strategically chose to examine five domains of potentiallysyndemic influences so that a broader analysis of the presence/ absence and impact of syndemic factors could be undertaken with regard to understanding minority transgender persons’ contemplation of suicide. This study concludes by examining the characteristics associated with a wider array of potentiallysyndemic effects, because knowing which subgroups of people are most exposed to a larger number of anti-transgender life challenges can shed light on which subgroups of transgender persons, if any, are in need of targeted intervention efforts.

Data and procedures

The data for the present research came from the 2015 U.S. Transgender Survey (USTS2015) [22]. Data were collected during the summer of 2015, from a total sample of 27,715 transgender persons residing anywhere in the United States or one of its territories, or who were living overseas while serving actively in the U.S. military. At the time it was undertaken, it was the largest study of its kind ever having been undertaken to understand transgender persons’ lives. In the present study, the 4,842 persons who self-identified as belonging to any racial group other than white / Caucasian are included in the analyses. Access to the survey was centralized via a single online portal/website, and all persons completed the survey online. It could be completed via any type of web-enabled device (e.g., computer, tablet, smart phone, etc.) and was available both in English and Spanish language versions.

The questionnaire collected information pertaining to a wide variety of types of harassment, discrimination, and violence that transgender persons may have experienced in a wide variety of settings, such as work, school, public restrooms, public places, governmental offices, while serving in the military, among others. The USTS2015 questionnaire contained some information pertaining to substance use and mental health functioning. It also captured information about various aspects of the transitioning process, including social aspects of transitioning (e.g., divulging information about one’s transgender identity to partners, friends, family members, coworkers, etc.), taking hormone treatments, and various surgical procedures that might be undergone to facilitate gender identity integration. Detailed demographic-type data about each respondent were also collected.

Participants were offered the opportunity to win either a $500 participation grand prize (n=1) or a $250 participation prize (n=2), chosen by random at the end of the data collection period. More than one-third (35.2%) of the eligible persons opted not to enter in the prize drawing. If they did not enter the raffle or were not one of the three prize winners chosen at random, then participation entailed receiving no other rewards/incentives/remunerations.

Extremely detailed information about the study, its content, its initial development, and its implementation may be found in James et al. [22]. The original USTS2015 study received institutional review board approval from the University of California-Los Angeles prior to implementation. The present research for the secondary analysis of the USTS2015 data received institutional review board approval from California State University-Long Beach.

Measures used

For the present paper, dependent variable of interest was suicidal ideation. It was assessed via a dichotomous measure indicating if the person had or had not thought about ending his/ her life during the previous year.

Five domains of variables that are hypothesized to interact with one another in a syndemic fashion were included as independent variables in this study:
1. workplace issues,
2. interactions with professionals,
3. using public services,
4. personal safety, and
5. socioeconomic disadvantages.

The workplace issues domain consisted of six items. These were
a) terminated from a job due to being transgender,
b) forced out of a job due to being transgender,
c) not hired for a position or not promoted at work due to being transgender,
d) felt a need to take proactive steps at work in order to minimize the chances of harassment, discrimination, and/or violence,
e) had problems with one’s supervisor due to being transgender, and
f) was physically assaulted or attacked at work.

Interactions with professionals was comprised by four items.
These were a) received unequal or unprofessional treatment from a health insurance company representative over a transgenderrelated issue,
b) experienced problems or unsatisfactory treatment from a physician or other healthcare professional as a result of being transgender,
c) harassed or mistreated by a Transportation Services Administration employee when trying to fly somewhere, and
d) mistreated by a police officer as a result of being transgender.

Using public services consisted of four items. These were
a) feeling a need to leave or being ejected from a religious/ worship community due to being transgender, (b) being threatened or harassed when using a public restroom,
b) experiencing transgender-related harassment or discrimination with regard to one’s housing situation, and
c) feeling a need to avoid using publicly-available services in an effort to minimize potential transgender-related harassment or discrimination.

The personal safety domain was constructed from four items:
a) received verbal harassment or threats as a result of being transgender,
b) was physically assaulted or attacked due to being transgender,
c) experienced transgender-related harassment, threats, or bullying while in elementary, middle, or high school, and
d) experienced transgender-related harassment or threats while attending college.

Three measures made up the socioeconomic disadvantages domain:
a) having no more than a high school education or the equivalent,
b) living near or below the poverty line, and
c) being unemployed.

For the purposes of constructing analytic measures in the present study, items in each domain were collapsed into three categories:
1) experienced none of these,
2) experienced any but not all of these, and
3) experienced all of these.

Subsequently, one additional syndemic measure was constructed, combining the information gleaned from the five individual domains. It, too, was coded so as to indicate whether the person (1) experienced none of the problems from any of the domains, (2) experienced one or some of the problems from any of the domains, or (3) experienced all of the problems in all of the domains.

In the multivariate analyses, several demographic measures were included as control variables: age (continuous), educational attainment (dichotomous, comparing people who had no more than the equivalent of a high school diploma to those with more education), relationship status (married or “involved” versus people who were not in a relationship), and self-assessed level of overall health (ordinal).

In addition, previous research by the present authors [23,24] has shown that level of psychological distress plays a central role in understanding suicidal ideation in this population. Accordingly, level of psychological distress during the previous 30 days was included as another control variable in the multivariate analysis. It was assessed using the Kessler-6 Scale [25]. It consists of six items, summed for the purpose of creating the overall level of psychological distress scale, with ordinal responses including “never” (scored 0), “a little of the time” (scored 1), “some of the time” (scored 2), “most of the time” (scored 3), and “all of the time” (scored 4). Each item inquired how frequently, during the previous 30 days, people felt (1) so sad that nothing could cheer them up, (2) nervous, (3) restless or fidgety, (4) hopeless, (5) that everything was an effort, and (6) worthless. The scale is reliable, with a Cronbach’s alpha of 0.91.

Other research conducted by the present authors [23,24] also demonstrated that reaching specific transition milestones is related to psychological distress and suicidal ideation among transgender adults. Transition milestones refers to specific events or occurrences in transgender persons’ transitioning experiences that demarcate their lives in a “before X happened” versus “after X happened” kind of way. These transition milestones represent different stages of progress in transgender persons’ journey toward fully accepting their gender identity and incorporating that identity more fully into their everyday lives. Each milestone, once reached or achieved, is one additional step toward living authentically and completely as a member of the gender with which the person identifies most closely. In the present study, six transition milestones (each coded as “milestone reached” or “milestone not reached”) were included as independent variables in the multivariate analyses: (1) telling any friends that one is transgender, (2) telling any family members that one is transgender, (3) telling any work colleagues or classmates that one is transgender, (4) changing one’s name and/or gender on any of one’s legal documents, (5) taking gender-affirming hormones, and (6) undergoing gender-conforming surgical procedures.

Statistical analysis

Due to the large sample size, results are reported as being statistically significant whenever p<.01 instead of the usual p<.05. The analysis was undertaken in four parts. In the first part of the analysis, using persons experiencing none of the factors in question as the comparison group, the aim was to examine how experiencing any of the factors comprising each of the five syndemic domains individually was related to the likelihood of contemplating suicide and, subsequently, how experiencing all of those factors affected suicidal ideation. Data for all of the constituent items in each domain were combined, so as to indicate that the person had experienced “none of those problems,” “one or more but not all of those problems,” or “all of those problems.” Then the statistical comparisons of none-versus-any and none-versus-all were undertaken on a domain-by-domain basis by computing odds ratios and their 95% confidence intervals.

In the second part of the analysis, the goal was to look at all potentially-syndemic influences combined instead of studying them on a domain-by-domain basis. All of the items comprising all five of the syndemic domains were combined and recoded to divide respondents into three groups:
1) experienced none of the problems in any of the domains,
2) experienced one or more-but not all-of the problems in any/all of the domains, and
3) experienced all of the problems in all of the domains.

Then the statistical comparisons of suicidal ideation were made for persons experiencing none versus any of the potentiallysyndemic factors and, separately, for persons experiencing none versus all of the potentially-syndemic factors. Both of these analyses entailed the computation of odds ratios and their 95% confidence intervals.

The third part of the analysis entailed performing a multivariate analysis to determine if the impact of the syndemic factors was still statistically significant even when the impact of the other independent variables was taken into account. This was done via multivariate logistic regression.

In the fourth part of the analysis, the goal was to try to identify whether or not there are factors that are associated with experiencing greater versus fewer different types of antitransgender discrimination, harassment, and/or violence. To examine this, all of the items comprising the five syndemic domains were combined into a single scale measure. Higher scores on the scale indicated exposure to a greater number of different types of life challenges that are potentially syndemic in nature. The scale was found to have adequate reliability (Cronbach’s alpha=0.76). Student’s t tests were used to compare scale scores for relationship status (married/“involved” versus not “involved”), gender identity (transgender male versus transgender female), and the various transition milestones (reached versus not reached). Pearson’s correlation coefficients (r) were computed for the analysis involving age because both variables were continuous in nature.

Sample characteristics

LatinX persons comprised 30.4% of the sample, followed by biracial or multiracial persons (29.5%), African Americans (16.4%), Asians and Pacific Islanders (16.2%), Native Americans or Native Alaskans (6.6%), and non-Caucasians who said that they identify with some other racial minority group (0.8%). A majority of the respondents were transgender men (63.9%). Respondents’ mean age was 28.6 (SD=11.0), with nearly-two thirds of the study participants (66.4%) being between the ages of 18 and 29. Most of the participants had either some college education (50.1%) or a bachelor’s or post-graduate degree (31.8%), followed by a high school diploma or the equivalent (13.7%) and less than a completed high school education (4.4%). The large majority (87.0%) of the study participants were not married or involved in a relationship. More than one-third of the respondents (37.7%) were living near or below the poverty line. Slightly more than one participant in four (27.4%) was unemployed at the time of interview.

Syndemic effects: Each domain examined separately

Workplace Issues: Experiencing any of the workplace problems was associated with a 53% increase in the odds of contemplating suicide compared to experiencing none of these problems (OR=1.53, CI₉₅ = 1.38-1.72, p<.0001). Experiencing all of the workplace problems increased those odds even more, by 71% (OR=1.71, CI₉₅=1.33-2.20, p<.0001). These relationships, as well as those for the next four domains of syndemic effects, are depicted in Figure 1.

Figure 1:

Interactions with Professionals: Experiencing any of these types of issues was associated with only a nominal increase in the odds of contemplating suicide (OR=1.14, CI₉5 = 1.02-1.28, p=.03). Experiencing problems in all four of these specific ways was associated with a somewhat larger elevation in the likelihood of contemplating suicide (OR=1.65, CI₉5 = 1.10-2.49, p=.02).

Using Public Services: People who experienced any problems using publicly-available services as a result of their transgender identity were 77% more likely to contemplate suicide than their counterparts who experienced no such problems (OR=1.77, CI₉5=1.57-1.99, p<.0001). Those who experienced problems in all four of the arenas included in the public services domain were at an even greater risk of contemplating suicide-nearly four times the risk-when compared to their peers who experienced no such problems (OR=3.97, CI₉5 = 2.63-6.00, p<.0001).

Personal Safety: Experiencing any of the safety-related problems included in this domain was associated with a greaterthan- doubled risk of contemplating suicide when compared to people who experienced none of them (OR=2.20, CI₉5 = 1.95-2.47, p<.0001). Experiencing all of the safety-related problems elevated that risk even farther, by a factor greater than three (OR=3.26, CI₉5=2.01-5.31, p<.0001).

Sociodemographic Disadvantages: Living near/below the poverty line or having no more than a high school education or being unemployed-any of the three-more than doubled the risk of contemplating suicide compared to people who were better off financially, more highly educated, and who were not unemployed (OR=2.18, CI₉5=1.94-2.44, p<.0001). Experiencing all three of these conditions nearly doubled again the risk of suicidal ideation (OR = 3.82, CI₉5 = 2.83-5.15, p<.0001).

Syndemic effects: All domains combined

Experiencing any of the anti-transgender problems included in this study was associated with a nearly-threefold increased risk of thinking about committing suicide when compared to people who experienced none of these problems (OR=2.79, CI₉₅=2.04- 3.81, p<.0001). Experiencing all of these problems elevated that risk even farther, almost doubling the risk above and beyond that observed for experiencing any-even one-of the problems (OR=5.46, CI₉₅=3.83-7.77, p<.0001). Figure 2 depicts this particular finding and shows the cumulative effect of experiencing none versus some versus more different types of anti-transgender discrimination, harassment, and/or violence.

Figure 2:

Multivariate result

Table 1 shows the results of the multivariate analysis examining whether or not the syndemic effects measures remain influential in understanding suicidal ideation once the impact of other key independent variables is taken into account. The first line of the table shows that, even when the influence of all other measures is taken into account, the syndemic effects measure still contributes significantly (p<.0001) to the likelihood of whether or not people had contemplated suicide. It was the second most important measure in the model, only ranking behind level of psychological distress (p<.0001). A more-detailed analysis of how the various syndemic effects domains operated showed that, if they are entered separately as individual items rather than examined by using the combined measure shown in Table 1, three of the five types of syndemic effects contributed to the likelihood of contemplating suicide. Those were: workplace issues (OR=1.23, CI₉₅=1.09-1.38, p=.0009), personal safety (OR=1.45, CI₉₅=1.25-1.68, p<.0001), and socioeconomic disadvantages (OR=1.21, CI₉₅=1.07-1.37, p=.0029).

Table 1:Multivariate predictors of suicidal ideation.

Factors associated with syndemic effects

Age was found to be related inversely to the number of different types of harassment, discrimination, and violence that people experienced (r=0.07, p<.0001). Closer examination of the data revealed that people in their teens or twenties were at particularly great risk compared to those who were older. Being married or “involved” with a partner was a protective factor against harassment, discrimination, and violence (t=4.91, p<.0001). Reaching some of the specific transition-related milestones was identified as a risk factor for experiencing a wider array of harassment, discrimination, and violence. This was true for telling anyone in one’s family that one is transgender (t= 7.81, p<.0001), telling any of one’s friends about being transgender (t= 4.91, p<.0001), disclosing one’s transgender identity to people at work and/or school (t=7.96, p<.0001), and taking gender-affirming hormones (t= 5.62, p<.0001). Gender identity was not found to be related to the number of types of harassment, discrimination, and/ or violence to which people were subjected (t=1.99, p=.047)

The principal aim of the present study was to determine whether or not there is evidence of syndemic-type effects influencing the likelihood that transgender persons of color will contemplate suicide. Unmistakably, there is. This research examined five categories of potentially-syndemic effects: workplace issues, interactions with professionals, using public services, personal safety, and socioeconomic disadvantages. Individually, four of the five domains (all except interactions with professionals) were associated with significantly elevating the likelihood of thinking about committing suicide. The magnitude of these increases ranged from 71% (workplace issues) to 326% (personal safety) to 382% (socioeconomic disadvantages) to 397% (using public services). Moreover, when overall syndemic effects across all five domains combined were examined, the data showed that there was morethan- fourfold greater risk of contemplating suicide among people who had experienced all of the types of potentially-syndemic influences included in the present research. In concrete terms, this translates to more than 70% of the transgender persons of color who experienced all of the different types of anti-transgender actions included in this study having considered ending their lives at least once during the preceding year. This is an extremely high percentage, particularly when compared to the population-at-large, for whom previous research has shown that 4.7% of all adults and 12.6% of all adults belonging to racial minority groups seriously considered committing suicide during the preceding year [26,27].

Clearly, there is great need for improved mental health services to assist transgender persons of color to stave off thoughts of suicide-something that other authors have noted as well [28- 30]. Moreover, resiliency education and resiliency-building skills techniques specifically designed for transgender persons of color are needed in order to help minority transgender adults to cope with the various types of anti-transgender discrimination, harassment, and violence that so many of them experience on a fairly-regular basis [31]. Previous researchers have noted that strong relationships with one’s family and with one’s friends, in particular, tend to play pivotal roles in developing and maintaining the resiliency skills that many transgender persons need in order to cope with the anti-transgender sentiments and actions that they encounter as they live their daily lives [30,32]. Numerous initiatives have been undertaken to promote resiliency skills-building among transgender youths [33-35], and research has shown that resiliency skills have been very helpful at improving transgender youths’ lives [36,37]. Similar efforts specific to the needs of the adult population are warranted for transgender adults as well, and as the present study has shown, for transgender persons of color in particular.

The present study’s findings indicate that such efforts, if undertaken, will need to be multifaceted endeavors that are capable of addressing myriad challenges facing transgender persons. This is an essential point because it was not “merely” the case that being discriminated against or harassed at the workplace, for example, elevated transgender persons’ odds of contemplating suicide, or “merely” the fact that they felt unsafe in public places that elevated their risk of thinking about terminating their lives. Rather, each and every one of these types of anti-transgender experiences that they had to deal with elevated their odds of suicidal ideation even more. Ostensibly, this means that resiliency-building efforts targeting transgender persons of color will need to be able to address how to try to prevent and recover from the psychological harm(s) done by transgender-related discrimination and harassment at work and separately how to try to prevent and recover from the psychological harm(s) done by transgender-related physical safety concerns and separately how to try to prevent and recover from the psychological harm(s) caused by the inability to feel/be safe when using publiclyavailable services, and so forth. Each of these domains of problems for transgender persons requires a unique set of solutions and strategies, and this is likely to make future prevention and intervention efforts quite challenging.

It is also important to point out that the present study revealed that socioeconomic disadvantages, such as not being well-educated, not having a job, and living near or below the poverty line, factor into the suicidal ideation equation in a meaningful way as well. Any program that endeavors to diminish the likelihood that transgender persons of color will think about ending their lives will have to contend with the impact of these socioeconomic factors. Previous researchers have also commented upon the socioeconomic-related challenges faced by many transgender persons [38-40]. In practical terms, this means that initiatives designed to reduce suicidal ideation among minority transgender adults will not only have to address anti-transgender discrimination, harassment, and violence and be culturally sensitive to their needs as racial minority group members but also their additional needs as people who are less well-educated, out of work, and/or impoverished.

The final part of the present study’s analyses identified a few subpopulations of transgender persons of color who appear to be at particularly great risk for experiencing greater-than-average numbers of the types of problems that interact syndemically with one another. The present authors wish to elaborate upon two of these. The first pertained to reaching certain transition milestonesspecifically, disclosing one’s gender identity to one’s friends, family members, and/or work/school colleagues, and having begun taking gender-affirming hormones. In a previous article [23], the present authors reported on the psychological benefits of attaining various transition milestones. In the context of the present study, however, it may be the case that reaching these specific milestones elevates the odds that people experience multiple types of syndemicallyinteracting problems because, as part of their active transitioning process, some transgender persons of color have become more identifiable as transgender individuals to others in their lives who are not well informed about transgender issues and/or who are not very accepting of transgender persons. That is, while they were still keeping their identity as transgender persons to themselves (i.e., prior to reaching specific transition milestones), they were less visible to others around them as members of a social “out group” and, thus, less likely to experience discriminatory and unaccepting treatment from others. Those others could not mistreat them on the basis of their gender identity until such time as they became aware of that gender identity and then, when they did gain that awareness, it is likely that many of them did not handle their interactions with the transgender person in question particularly well. Brumbaugh- Johnson and Hull [41] noted that the possibility of encountering violent reactions must be taken into account anytime a transgender person discloses his/her gender identity to others. Others in the scientific community have written about “grievable losses” that oftentimes occur when transgender people disclose their gender identity to various people in their lives and, as a result, experience distancing in their relationships or outright loss of friendships [42]. Wall [43] remarked “coming out into a world with pervasive gender identity-based discrimination may drive the well-documented mental health disparities faced by [transgender] individuals.” Similarly, the present study’s findings for persons who reached some of these specific transition milestones suggest that increased “outness” as a transgender person may carry along with it some negative interpersonal encounters, difficulties, and challenges, in addition to the psychological benefits that the present researchers have reported previously [23,24].

Another of the subpopulations of transgender persons of color found to be at particularly great risk of experiencing many of the types of syndemic effects examined in the present study was younger adults, in particular those aged 18 to 29. This begs the question What is it about younger transgender persons of color that makes them particularly vulnerable to experiencing harassment or discrimination at work, being and/or feeling unsafe in public places, fearing and/or experiencing harassment when using publicly-available services, and experiencing problems in the arenas of having a job and having sufficient money? In all likelihood, it is a combination of things. First, as younger people, they may not have been living their lives as transgender persons long enough to have developed good support networks to help them cope with and subsequently bounce back emotionally from the various types of discrimination, harassment, and violence that often confront them. Second, younger transgender adults may not have honed the personal and interpersonal skills that are needed in order to minimize anti-transgender-related confrontations and conflicts, at least not to the same extent as their older counterparts, many of whom have had more years living as transgender persons. Third, regarding the socioeconomic disadvantages aspect of their lives, finding and keeping better-paying jobs comes with more years of work experience and more years of education-something that, in their later teens and twenties, they simply have not had the chance to accumulate yet. Numerous scholars have written about the challenges that younger transgender people face and the myriad ways that their lives are disadvantaged by the frequency with which they are confronted by discrimination, harassment, and violence [44-46]. The present study’s findings are consistent with those studies, and highlight the importance of finding effective ways of helping younger minority transgender adults to avoid antitransgender confrontations and to develop resiliency skills when they are, indeed, victimized or discriminated against.

In conclusion, the present study demonstrated that experiencing any transgender-related discrimination, harassment, or violence significantly elevated the odds that transgender persons of color would contemplate suicide. Furthermore, the greater the number of different types of problems that transgender persons of color experienced, the greater the odds of suicidal ideation became. These effects were not merely cumulative in nature but rather multiplicative in nature, in a “classic” syndemic fashion. This was evidenced by the very large difference in the odds of contemplating suicide among people who had experienced none of the various problems included in the present study when compared to those who had experienced all of them. Given the pervasive and varied nature of the challenges that transgender persons of color face in the United States, these findings are of great concern when it comes to the actual survival of these individuals and to the mental health challenges that they experience on a day-to-day basis.

Future researchers doing work in this area might wish to examine other domains of potentially-syndemic effects, in addition to those included in the present study. For example, oftentimes, syndemic-based research with sexual minority populations has included substance use or abuse as one of the syndemic domains [47-50]. This domain was omitted from the present study because of the generally-weak measures of substance abuse that were included in the USTS2015 questionnaire. As another example, future syndemics-related studies of suicidal ideation in the transgender population of persons of color might wish to examine a domain examining childhood maltreatment experiences-again, another oft-included construct when undertaking syndemics research with LGBTQ populations [51-53]. As a third possibility, other types or categories of transgender-related harassment, threats, discrimination, and violence beyond those examined in the present study could also be included in future researchers’ work in this arena. Future researchers wishing to expand upon the present study’s findings might wish to investigate other mental health and psychosocial outcomes in addition to suicidal ideation. These might include such constructs as self-esteem, anxiety, body image and body satisfaction, and optimism about the future. All of these are understudied and insufficiently-understood subject areas when it comes to transgender persons, and even more so when it comes to transgender persons of color. Finally, future researchers might wish to undertake studies in which outcomes for transgender persons of different racial minority groups and/or transgender persons of different gender identities can be compared. There is a reasonable likelihood that the life experiences of, say, transgender African Americans and transgender LatinX persons differ in systematic ways. There is also a reasonable chance that the life experiences of transgender men and transgender women and people identifying as nonbinary differ from one another. To date, those kinds of differences have been subjected to very little scientific scrutiny. Undertaking efforts to understand the nuances of how life experiences, race, and gender identity intersect when it comes to suicidal ideation and the various syndemic-type effects that influence the likelihood of contemplating suicide would be an excellent way of advancing scientific knowledge about transgender persons’ mental health.

This study has examined suicidal ideation among transgender persons of color, with the aim of determining whether or not there is evidence of syndemic effects operating in such a manner as to heighten the risk of experiencing suicidal ideation among members of this population. Substantial evidence of syndemic effects was revealed in this investigation. Experiencing problems in ANY of the five domains studied (which included workplace issues, interactions with professionals, using public services, personal safety, and sociodemographic disadvantages) increased the risk of suicidal ideation by nearly a factor of three. Experiencing problems in ALL of the domains increased that risk even further, to more than a factor of five. This effect was found to be a robust one, and it held up even when the effects of a wide variety of other variables was taken into account. Three of these domains-workplace issues, personal safety, and sociodemographic disadvantages-were particularly influential in understanding the likelihood that transgender persons of color would experience suicidal ideation. Finally, a number of factors were found to be predictive of the extent to which people would be likely to experience greater syndemic effects. These included age (being younger was a risk factor), relationship status (being married or having a relationship partner was a protective factor), and reaching versus not reaching some of the transition milestones studied (reaching these milestones was a risk factor).

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