Method

This literature scoping review was conducted according to the protocol proposed by Prisma. The search for the analyzed materials happened by online search in an open network. First, the descriptors that best fit the research problem were sought, using the Health Science Descriptors, provided by the Biblioteca Virtual em Saúde (BVS)¹. In the search for descriptors, the library listed the terms transgender people and suicide; the first was about the target population of this research, while the second was the variable analyzed.

To search, the research followed pre-established steps. The steps pointed out by ^{Costa and Zoltowski (2014}) were adopted: the problem to be researched was defined; the data sources to be used were chosen; the search descriptors were chosen; the results were searched and stored; the articles were selected by abstract, from the listed criteria; the data were extracted; the articles were evaluated, and the data were interpreted.

The search, selection, and analysis of the articles were carried out by two judges, independently, in August 2020, using the Medline, Lilacs, and PubMed databases. Initially, the terms in Portuguese (pessoas transgênero and suicídio) did not show significant results in the search, so the search was conducted by descriptors in English: transgender persons and suicide. Therefore, the abstracts of the articles included for analysis were grouped in a single text corpus and analyzed by the Iramuteq software. This software allows several forms of textual data analysis, such as lexicographic analysis and hierarchical descending classification (CHD; ^{Camargo & Justo, 2013}).

The database search resulted in 360 articles, as shown in figure 1: Medline (n = 172), Lilacs (n = 01), and PubMed (n = 187). First, duplicate titles were excluded, and the search was initiated based on titles and abstracts. After that, the inclusion criteria raised in the construction of the research protocol were applied: being empirical scientific articles; having been published in the last five years in the databases searched (2015-2020); having trans people as the target population; and correlating the suicide theme. The exclusion criteria used were being a review article and having been published before 2015. After adopting the inclusion criteria mentioned above, the database listed 22 articles, which were read, translated into Portuguese, and organized in the corpus for analysis. Figure 1

Figure 1: Flow chart with the phases of the systematic review 

Results

Initially, Table 1 presents the detailed characterization of the articles selected for this review. One can see the concentration of studies in the North American part, but with the presence of studies in regions with conflicting histories, such as Pakistan. Brazil did not present any results in the searches performed.

Table 1: Characterization of the articles 

The 22 abstracts of the articles elected in the review were submitted to the analysis of the descending CHD, in this analysis the semantic approximation between the lexicographic elements of the texts seized is evaluated, resulting in classes formed from the analysis of frequencies and chi-square (^{Camargo & Justo, 2013}). The analyzed textual corpus was subdivided into 109 text segments. The CHD analysis categorizes the vocabulary words lexicographically into approximation categories, thus, at the present writing the analysis divided the corpus into five classes of textual elements. Figure 2 presents the resulting dendogram of the CHD.

Figure 2: Descending hierarchical classification dendogram 

The results found allowed the creation of classes, therefore, it is recommended that these classes be named (^{Camargo & Justo, 2013}). Thus, class 1 was formed from 11 STs (Text Segments), representing 16.18 % of the total, and presented fragments that recalled aspects of the trans experience. That is, from the analysis of the listed texts, it was observed in the constituent words that the fact of expressing the real gender identity of the trans person can be seen as a risk factor for a suicide attempt, as well as participating in a “social minority”; besides the fact that most studies show that this population experiences - recurrently - abuses (physical and moral) during life. Considering this, the class had been named “Impact of being trans”. In this class, studies 07, 11, and 16 (see Table 1) presented the most strength for the formation of the class.

Therefore, class 2 was formed by 12 STs, representing 17.65 % of the total. In this class, it was possible to observe aspects such as the discussion about the trans population; as well as the recognition of these people in areas of power and health can be configured as a protective factor against suicide attempts, as well as the existence of a work that involves the mental health of this population. In this way, the class was named “Trans visibility”, having writings 03 and 14 as the most representative for the formation of the class.

Directly related to the previous class, class 5 presents itself as a counterpoint to what was observed in Class 2, showing words and texts that are directly linked to greater risks of suicide attempts among transgender people. Formed by 14 STs, representing 20.59 % of the total, class 5 presents that the health care offered to this population is a crucial factor, which can be protective or risk, depending on how this care is offered; the class also points to the use of illicit substances and depression as risk factors; community support is also pointed out as protective to suicide issues in these individuals. Therefore, the class was listed as “Risks to trans health”, with writings 01, 04, and 13 as the most representative for the class.

Classes 3 and 4 were also formed from a subdivision of the corpus. Class 3 was made up of 14 STs and represented 20.59 % of the total. In this class, there were notes of results from the studies, where most of them lead to the perception that the depressive symptoms perceived in the trans population are directly associated with the high risk of suicide attempts, especially in the models studied. Therefore, the class was named “Tenuity between depression and suicide”, studies 08 and 19 were the most representative in this class.

Class 4, formulated from 17 STs and representing 25 % of the total, shows some findings of the studies present in the review. Presenting a direct connection with the previous class, it was noticed that the analyzed texts pointed out that the life of trans people includes - most of the time - a low quality of life; as well as showing this population to be more vulnerable to the experience of ideation or suicide attempt throughout life in the researched samples. Thus, the present class was named “Challenges of trans life”, with writings 09, 15, 17, and 18 more representatives for the formation of the class.

Discussion

In class 1 named “Impact of being trans”, stressors experienced by trans people for the reason of not socially corresponding to their birth gender are portrayed (^{Thoma et al., 2019}). In this sense, the findings suggest that being trans exposes people to experience life with discrimination, prejudice, invisibility, feelings of rejection, fear of punishment, violence, family conflicts; therefore, these are considered triggers of distress among people who self-identify as trans (^{Testa et al., 2017}; ^{Vitali et al., 2019}).

Some statistical data corroborate the results found. A survey conducted in the United States about discrimination related to transgender people identified that 63 % of respondents reported having experienced discrimination, mistreatment, abandonment, loss of employment, denial of care in health services, physical and sexual violence (^{Edwards et al., 2019}). In Brazil, according to ANTRA data, in 2020 there was a 49 % increase in the number of murders of trans people when compared to 2019. In addition, 22 attempted murders, 11 suicides, and 21 human rights violations were reported in the months of January to April (^{Benevides & Nogueira, 2020}).

The most representative studies within this class discuss the main psychosocial factors linked to low quality of life among transgender people. Family abuse, anxiety, impactful experiences during life regarding gender, lack of support, and internalized transphobia are recurrent elements pointed out by authors regarding the risk of suicide attempts in this population (^{Kota et al., 2020}; ^{Perez-Brumer et al., 2017}; ^{Tebbe & Moradi, 2016}).

The data presented in the class brings up points where a greater focus on the trans experience is needed. ^{Tucker et al. (2018}) in their study shows that the lives of trans people are constantly vulnerable since the risk of attempted suicide in this population is twenty times higher than in cisgender people. The aspects are of fundamental importance, since social support, emotional stability, and the presence of anti-discrimination policies can configure response to the high mortality rate of this population (^{Budhwani et al., 2018}; ^{Edwards et al., 2019}; ^{Tebbe & Moradi, 2016}).

Class 2 and class 5, directly interconnected, named “Trans visibility” and “Trans health risks”, discuss some factors that can provide an equitable life for the trans experience. Thus, there must be interference from social powers in the fight for the life of this population. The presence of public policies for education, health, and assistance can provide more positive paths during the experience of these subjects. On the other hand, the lack of these policies can corroborate the path of prejudice, discrimination, and stigma faced by trans people. The classes point out that the scientific results found in the most diverse research should serve as a basis for greater understanding about the trans experience, as well as be seen as resources to act in the face of the demands experienced by these (^{Chang & Delaney, 2019}; ^{Chen et al., 2019}; ^{Romanelli et al., 2018}; ^{Seelman, 2016}).

The main articles that made up the formation of class 2 point to paths that can be adopted as protective factors in the lives of trans people. Offering greater trans visibility is one of the main ways out of the alarming rates regarding suicide in this population, the authors point out that the simple fact of using the bathroom in conformity with the gender can work as a protective factor in the lives of these people. In addition, the person-environment relationship can also function as a protective factor, pointing out that a better bond with the social space can help in decreasing the risk of suicide attempts (^{Chang & Delaney, 2019}; ^{Seelman, 2016}).

In contrast, the most representative studies of class 5 point to elements that may contribute to the high rates of suicide in the trans population. That is, in addition to the factors that can influence and configure as aids previously exposed, it is necessary to understand the various facets that reassemble the suicide phenomenon in the trans population. Compared to cisgender individuals, trans people have higher rates of suicide risk, attempts, and deaths by such factors (^{Staples et al., 2017}). A survey of trans people in Argentina showed that 33 % of people had attempted suicide at least once in their lifetime (^{Marshall et al., 2016}). Furthermore, it was documented that in the long term, 20.5 % of trans people in one study indicated that suicide is something likely in the future (^{Tebbe & Moradi, 2016}).

Another research showed that 23 % of transgender people reported using alcohol or drugs to cope with the stressors suffered, and in cases where there was family rejection, harmful health behaviors were more frequent (^{Klein & Golub, 2016}). In this scope, substance use is considered a mechanism used to cope with psychic pain, however in cases where there is suicidal ideation the use tends to increase impulsivity and disinhibition and thus intensifies the risk of suicide consummation (Klein & Golub, 2016; ^{Tebbe & Moradi, 2016}). Studies point out that substance use shows strong associations with suicidal ideation and suicide. Further, it is perceived that gender identity conversion therapies are related to adverse effects on the mental health of the trans population, they are considered largely harmful “treatments” (^{Kota et al., 2020}; ^{Turban et al., 2020}).

In dialogue with the above, the research data from ^{Romanelli et al. (2018}) shows itself to be directly related to the present classes. The study evaluated the experience of trans people in health care settings. In the research, results were found that confirm the need for a look at assistance and recognition of this population in these spaces. In the data found, the denial of services to the trans population was related to a decrease in the receipt of treatment; and the non-provision of treatment was positively related to substance use and high suicide rates. However, receiving support was configured as a protective aspect for the effective receipt of treatment, showing how the offer of care can influence the saving of trans lives.

The data from this review discusses in its entirety international aspects, showing that the path of understanding and offers of subsidies and assistance to this population is a path to reduce the suicide rate. However, in Brazil, ^{Oliveira and Romanini (2020}) demonstrate in their study that public and health policies are still paths little traveled by trans people. For the authors, this lack of assistance is not beneficial to the health of this population, pointing out that the various knowledge needs to be in favor of this population for a better quality of life, both quantitatively - offering greater longevity - and qualitatively - providing greater quality of life.

Among the protective factors reported in studies, research with transgender adolescents indicated that hormone suppression therapy was associated with lower rates of lifetime suicidal ideation (^{Turban et al., 2020}). In addition to greater body satisfaction, the use of a social name congruent with gender identity indicates a reduction in symptoms of depression, as well as a reduction in suicidal ideation and risk of suicide consummation (^{Russell et al., 2018}).

It highlights that emotional support mediated by meaningful relationships with family, friends is considered key in suicide prevention (^{Klein & Golub, 2016}; ^{Zeluf et al., 2018}). As such, social support and positive self-concept are considered predictors for having better mental health among transgender people (^{Kuper et al., 2018}). However, data highlights that protective factors related to image, respect for gender identity, and social support can be harmful if insufficient to the physical and mental health of trans people.

Following, classes 3 and 4 also interconnected and named as “Tenuity between suicide and depression” and “Challenges of trans life”, depict grafts that suggest the presence of a positive correlation between suicide and depression in this population, as well as challenging aspects, such as the low quality of life experienced by these social actors (^{Kota et al., 2020}). In this direction, it is evidenced that social stressors predispose trans people to high suicide rates. In the interim, the literature explored in this systematic review addresses that discrimination, depression, family conflicts, substance abuse are considered risk factors for suicide attempts (^{Chen et al., 2019}; ^{Lehavot et al., 2016}; ^{Zeluf et al., 2018}).

In most of the articles analyzed, as well as in those that specifically composed class 3, depression is indicated as a risk factor for suicide attempts in the trans population. The study by ^{Tucker et al. (2018}) demonstrates that discrimination and rejection can act as triggers for suicide attempts and are minority stressors that this population experiences. These stressors that can lead the trans person to suicide have a direct link with depressive symptoms, thus, the study points out that the control and management of these stressors - in an early way - can contribute to reducing suicide attempts, as well as in the decrease of depressive symptoms, acting as a protective factor.

Other factors/stressors are still in a direct conversation between depression and suicide regarding the trans population, examples of these are experiences of prejudice and discrimination, transphobia, stigmas, lack of social support, and use of licit or illicit substances. These factors also need to be managed during the life experience of these people, because they are crucial aspects that dictate how this subject will face the demands imposed in a still transphobic society (^{Tebbe & Moradi, 2016}; ^{Tucker et al., 2018}; ^{Zeluf et al., 2018}).

These factors also contribute to the low quality of life offered to the trans population, being presented in most of the words present in class 4. The early departure from the family, the lack of educational opportunities, and the low level of schooling directly influence the low quality of life of trans people. This data is important because this factor is directly related to a lower monthly income, where the research of ^{Suen et al. (2017}) points out that trans people with lower income have a higher propensity to commit suicide.

In this sense, the studies pointed out the existence of key aspects in the experience of trans life. Both in the direction of negative and risk points, such as just the fact of being trans being a favorable factor for the risk of suicide, as well as the studies reviewed aspects of possible directions and of what may work as protective factors, such as the creation of welfare policies and the promotion of debate about issues directly linked to suicide in this population. In summary, the findings of this review indicate as the main risk factors for attempted suicide in trans people: transphobia; psychological disorders (such as anxiety, depression, among others); lack of social support; physical, moral, and sexual abuse; and low quality of life of this population. In counterpoint, trans visibility, social support, the use of social spaces, and the person-environment relationship are protective factors to this reality.

The compulsory cisgenderism imposed by the current society crosses the trans experience in its entirety. As pointed out by the studies, the experience of trans life is rooted in negative and difficult elements, which often show themselves as obstacles to the existence of a good quality of life. There must be a broader understanding of the various edges that make up the non-cisgender experiences, especially when it comes to lives lost early, as in cases of suicide.

Conclusions

The present study aimed to identify risk and protection factors related to the high suicide rate among the transgender population. The literature investigated pointed out that prejudice, discrimination, family abandonment, scarce opportunities during life, violence, and lack of policies aimed at the transgender population reflect in the high suicide rates evidenced. Furthermore, studies show that depression and substance abuse are correlated with suicidal ideation and suicide. On the other hand, factors linked to healthy peer relationships, hormone therapy, and other mechanisms linked to gender identity are considered protective to the lives of trans people.

In this sense, it is believed that the initial objectives were achieved regarding the understanding of factors related to suicide in trans people. As positive aspects considered in this review, it is believed that the studies found are essential in the literature, given the conditions experienced by the trans population and need scientific and social visibility, since the focus on the particularities of this population is scarce in many government plans and societies in general. However, among the limitations, it is inferred that the articles were selected based on pre-established criteria, such as the choice of data source and the election of keywords for the search, besides not having included the OR operator in the search, which could make it more comprehensive. In addition to these factors, the studies hardly address issues related to interventions that enable a better quality of life for the studied population.

In this sense, it is suggested the promotion and subsidies for the realization of studies with trans people worldwide since the high rate of violence and suicide of the population in question in the world plausibly justifies this approach. In addition, the development of intervention proposals and their application are essential to ensure better living conditions for trans people.