Gender identity and suicidal ideation
BACP Children, Young People and Families, September 2019

Adolescence is a time for identity exploration and discovery. A complex task for many, especially considering the psychosocial, historical, biological and cultural elements that make up identity. Erikson describes the experience of optimal identity as a ‘psychosocial sense of wellbeing’.¹ When there is a crisis of identity or a lack of this sense of wellbeing, an individual is likely to suffer. This could manifest as poor self-esteem and low confidence, or compulsive addictive behaviours and self-harm.

We know from several studies, that adolescents whose gender identity does not match the sex they were assigned at birth are much more likely to struggle with suicidal thoughts and ideation than the general population.² The Stonewall Report,³ which explores the experiences of LGBTQ+ young people in schools across the UK, reported 92 per cent of trans 
young people thought about taking their own life, compared with 25 per cent of the general population. Some of the reasons for this include feeling isolated, being at a high risk of bullying from peers resulting in further social exclusion⁴ and lack of acceptance within the family.

These findings align with the trends we have noticed at Kooth. Kooth is a self-referral digital counselling and self-help platform, currently available to just under half of all young people aged 11–19 across England. Our online counsellors support young people across a huge spectrum of presenting issues. Typically, the general population of young people who use our services come seeking emotional or psychological support. As such, they are not experiencing Erikson’s definition of optimal identity,¹ and are often seeking help to improve their psychosocial sense of wellbeing.

In the period 2014–2018, we have seen a 552 per cent increase in the recorded presenting issue of gender identity, accounting proportionately for the increase of users over that time. What this means is that across the population of young people we work with, six times as many are exploring their gender identity in some form, whether through a counselling session, asynchronous messaging to the counselling team, or some form of expression within the content-focused domains of the platform.

Case study

A young person I will call Charlie represents a composite of young people who present to Kooth with gender identity issues and suicidal thought. Charlie is a 17-yearold college student who identifies as transgender. They first heard about Kooth in school when they were 15 and recently decided to register as they felt they were in need of support. Charlie’s first engagement with the service was through the Kooth online magazine where they came across an article titled ‘Being accepted is hard’ (article title invented for the purpose of the case study, but is representative of the types of articles published on Kooth). Charlie left a comment about the article on the platform, identifying with the author and sharing that they similarly found it hard to feel accepted. They wrote that they were experiencing feelings of isolation, which sometimes led to thoughts of wanting to end their life.

A moderator messaged Charlie after reading the comment, suggesting that they might find it useful to speak to a counsellor about the thoughts they’d been having, and also informed Charlie about the live peer support forum coming up the following week, focusing on gender dysphoria. Charlie was grateful for the suggestions and took action on both of them, joining the chat queue to engage with a counsellor and attending the live forum the following week.

Charlie shared with the counsellor that they felt unsupported and misunderstood by their family, and that they didn’t know where to find help. They also shared that they sometimes felt overwhelmed by how alone they felt as a result of not being able to be honest about who they were. This led to occasional thoughts of suicide. Charlie was offered a named counsellor with whom they could have weekly sessions online. The goals Charlie wanted to work towards were to find a supportive community, either online or locally, and also to build the confidence to speak openly with their family about gender transition.

As with all young people who speak to a counsellor on Kooth, Charlie’s risk was assessed through a number of questions about themselves and their environment, and recorded using the red, amber, green (RAG) traffic light system for denoting risk. Risk accounts for any potential harm facing the individual, whether from themself, another person or their environment. Charlie was marked as amber risk by the clinical team after disclosing suicidal thought, as they were deemed to be at potential risk to themself, which required monitoring, but they did not disclose any plans to act on their thoughts. This meant their risk would be monitored and checked regularly. By their fifth session, Charlie’s risk was reduced to green as they were no longer having regular thoughts about ending their life. Charlie felt safer having found an online community within Kooth, which was giving them the confidence to confide in their brother about their feelings around gender identity. Risk assessment is always ongoing, occurring during each individual interaction between a young person and their counsellor.

Charlie continues to engage with the peer-support forums on Kooth, finding young people going through the same experiences, and gaining courage, validation and acceptance from their experiences. Charlie has discussed with the community and their named counsellor how they might find a supportive group of people in their local area so that they may be supported in the longer term after their 19th birthday. In many areas, including Charlie’s, Kooth is commissioned for young people aged 11 to 19 years old.

Gender identity

When young people register on Kooth they can select a gender they most identify with from four options: male, female, agender and gender fluid. Those who access Kooth identifying as agender, a term to denote those who feel genderless, have the lowest rate of drop-off post registration of all users. This means that young people who register with this identity are least likely to log off without using some aspect of the platform. In 2018, most young people identifying as agender on the platform fell into the 16 to 18-year-old age category and 67 per cent of this group who registered became active users of the site, compared with only 61 per cent of females, 58 per cent of males and 59 per cent of those identifying as genderfluid in the same age category. Gender fluid refers to individuals who do not commit to a specific gender, may express several genders at the same time or switch between genders flexibly.

Agender-identifying children and young people across all age groups are proportionately the most active on the peer support and self-help forums on Kooth. Forty-one per cent of agender 16 to 18 year olds access the online articles, compared with 35 per cent of females, 29 per cent of males and 27 per cent of those who identify as gender fluid in their age group. These community-focused online spaces are known for offering a safe place to be curious and ask questions, which might be too challenging in an offline setting. The forums promote peer identification where young people are able to put questions to their peers and generate discussion, which promotes a sense of belonging. All discussion boards and comments are reviewed by a moderator prior to being published, to safeguard service users and ensure that any safeguarding concerns that come from young people’s comments are acted upon.

Trends

The forum boards and online magazine articles provide insight into how these young people are feeling. Agender users share a ‘fear of rejection’, ‘not being [preferred gender] enough’, feeling ‘stuck’ or like a ‘fraud’, and ‘invalidated’ by people close to them. A ‘poor sense of belonging’, which many of these young people refer to, is commonly cited as an association to suicidal ideation.⁵ There has been a 61 per cent increase in ‘suicidal thought’ as a recorded presenting issue on Kooth from 2014–2018. While this figure does not directly reflect the large increase we have seen in gender identity as a presenting issue, the increase in crude numbers of individuals is much greater. The table below illustrates those young people who identified presenting issues of gender identity and suicidal thought in 2014 compared with 2018, and the figures are striking. When accounting for the increase of users on the platform, there has been a 552 per cent increase in the presenting issue of gender identity across the four-year period, and a 61 per cent increase in the presenting issue of suicidal thought in the same period. The figures also appear to demonstrate a statistical association between the two presenting issues, in that young people who identify with gender identity issues are almost three times as likely to present with suicidal thought as the general Kooth user.

Presenting issues

The increase in young people exploring their gender identity within Kooth reflects an increasing awareness, and crucially acceptance, of the LGBTQ+ community within the UK over recent years. By looking at our own trend data and comparing them with the national picture, we are able to continuously improve our processes – both for the young people accessing our service as well as our staff. Supporting young people presenting with high levels of distress requires a healthy balance of compassion and resilience, so clinical support and supervision is of paramount importance. 

The future

In addition to our robust assessment processes and ongoing clinical governance, we have recently commissioned an external training expert in the field of LGBTQ+ and gender to ensure all our staff members have up-to-date knowledge and skills. These sessions encourage practitioners to become aware of their own gender and sexual identities, to promote curiosity, and essentially empathy for young people. Counsellors are able to bring their own experiences, whether personal or professional, to the subject to generate discussion and provide the counselling team with the tools and knowledge required to meet young people in an emotional and semantic space that is familiar for them. Using language that is familiar and relatable to service users prevents barriers emerging that would require the young person to educate the counsellor, and thus supports them in exploring the issue that is important to them within the constraints of the counselling hour. Training encourages the counsellor to consider the individual as a whole, accounting for all the other influences in their life rather than focusing solely on gender identity as an isolated challenge for a young person.

Much more research is needed to better understand the links between gender identity and suicidal ideation so that services can work in a proactive manner, rather than reacting to crises when young people hit rock bottom. One area where we have recognised potential for improving preventing crisis escalation is machine learning and natural language processing. This is a process whereby vast amounts of data are used to teach a machine to recognise language and patterns in language to identify an outcome. For example, a machine may well have the ability to detect when a young person who is struggling with identity or suicidal thoughts is digressing, through a change in the language they use. A machine-led intervention such as this would work to aid the counsellor, rather than replace them, by working as an alert system which can pick up on nuances a human might miss. This is where we see room for taking early intervention and prevention beyond what we are able to offer presently.

Our anonymous approach at Kooth is designed to remove traditional barriers to accessing help and we continue to advocate this as a crucial factor in enabling early intervention and preventing escalation of need. Understanding trends is really important to help us develop services that are fit for purpose in supporting young people. However, understanding individuals is at the heart of what we do – and we truly believe that this approach can save lives, regardless of gender, culture, or ethnicity.

Charlotte Mindel is a project manager within the research and evaluation team at XenZone. She has a background in social sciences research, with a particular interest in children and young people’s mental health and marginalised groups.

Lynne Green contributed to the final paragraph, ‘The future’. She is clinical director at XenZone and a consultant clinical psychologist with 20 years’ NHS experience.

XenZone developed the online counselling platform Kooth in 2004 and continues to run it. It delivers a range of clinical services focusing on early intervention and prevention of poor mental health for children, young people and adults.

References

1 Erikson E. Identity: youth and crisis. New York: Norton; 1968.
2 Plöderl M, Fartacek R. Childhood gender nonconformity and harassment as predictors of suicidality among gay, lesbian, bisexual, and heterosexual Austrians. Archives of Sexual Behavior 2009; 38(3): 400–410.
3 Bradlow J, Bartram F, Guasp A, Jadva V. School report: the experiences of lesbian, gay, bi and trans people in Britain’s schools in 2017. Year of Stonewall. https://www. stonewall.org.uk/ system/files/the_ school_report_2017.pdf (accessed 5 April 2019).
4 Skagerberg E, Parkinson R, Carmichael P. Self-harming thoughts and behaviors in a group of children and adolescents with gender dysphoria, International Journal of Transgenderism 2013; 14(2): 86–92. DOI:
10.1080/15532739. 2013.817321
5 Hatcher S, Stubbersfield O. Sense of belonging and suicide: a systematic review. The Canadian Journal of Psychiatry 2013; 58(7): 432–436. DOI: https:// doi.org/10.1177/0 70674371305 800709

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