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Gender Expansive Students at Higher Risk for Suicidal Behavior

Also available in [PDF] format.

Suicide is the second leading cause of death among youth aged 13-19. According to national data from 2015, 18% of high school students have seriously considered suicide, 15% made plans about how they would attempt suicide, and 9% attempted to take their own life one or more times in the 12 months prior to being surveyed.

Who are Gender Expansive Youth?

Youth whose gender expression does not fit traditional roles based on their sex assigned at birth are often referred to as gender nonconforming, gender expansive, genderqueer, or nonbinary youth. While some gender expansive youth may be transgender, this brief focuses on a broader category of youth, many of whom do not use any particular label to describe the way they express their gender. Research shows that the majority of gender expansive youth identify as heterosexual.

We know from prior research that some young people are more at risk for suicide than others. Young people who report using alcohol or other substances, those who have experienced bullying and harassment, those who are facing a crisis (such as sexual assault or death of a loved one), those who have attempted suicide in the past, and those who have access to a lethal method such as a gun, among others, are at increased risk.

We also know that young people who identify as lesbian, gay, or bisexual are 4 times more likely to attempt suicide and young people who are questioning their sexual orientation are 2 times more likely to attempt suicide than their heterosexual peers. There is very little research on transgender youth but a national study of transgender adults revealed that 40% had attempted to suicide at some point. Among those who had, 92% attempted suicide before they turned 25.

Until recently, however, we had limited research about gender expansive young people showing that they are at increased risk for bullying, abuse, sexual harassment, depression, and drug use. New population-based research has confirmed that they are also at increased risk of suicidal behavior and various risk factors for suicide. This issue brief presents data from two sources which provide insight into the experiences of gender expansive youth and their unique risk for suicide.

The YRBSS data and analysis in this issue brief comes from, Health Risk Behaviors among Gender Expansive Students: Making the Case for Including A Measure of Gender Expression Population–Based Surveys, a report published by Advocates for Youth. You can download the full report on our website: https://www.advocatesforyouth.org/wp-content/uploads/2018/03/Final_Trevor_AFY_GE_and_Suicide.pdf


The Centers for Disease Control and Prevention’s (CDC) Youth Risk Behavior Surveillance System (YRBSS) has surveyed high school students across the country every two years since 1991. The YRBSS asks questions about a variety of risk behaviors including drug and alcohol use, nutrition, access to fire arms, sexual behavior, experiences with violence, sadness and suicidality, and safety precautions like seatbelts and bike helmets.

In 2013 and 2015, the CDC approved an optional question that helped state and municipalities to examine gender expression and gender nonconformity among students. It asked:

A person’s appearance, style, dress, or the way they walk or talk may affect how people describe them. How do you think other people at school would describe you?”

Students could choose:

Very feminine; Mostly feminine; Somewhat feminine; Equally feminine and masculine; Somewhat masculine; Mostly masculine; Very masculine.”

Four sites Broward County, FL; Chicago, IL; Los Angeles, CA and San Diego, CA asked the optional question and about 9,000 students answered the question. While the majority of students expressed their gender in traditionally masculine or feminine ways, 14.7% of males described their gender expression as feminine and 3.7% of females described their gender expression as masculine. There were similar percentages of androgynous males (10.0%) and females (11.2%), whose gender expression was equally masculine and feminine.


The new report compares the risk behaviors that gender expansive students reported to those of their peers. The results found that gender expansive students are more likely than their peers to have experiences such as bullying or substance use that put them at higher risk for suicide. Moreover, gender expansive students are more likely to think about and actually attempt suicide. Figures 2 – 6 display the percentage of students who had engaged in each risk behavior related to sadness and suicidality, analyzed by sex and by response to the gender expression question.

Gender expansive students are more likely to have ever felt sad or hopeless almost every day for two or more weeks in a row so much so that they stopped doing some of their regular activities. Figure 2 – Felt Sad or Hopeless among Males and Females by Gender Expression


Gender expansive students are more likely than their peers to have seriously considered suicide, made a plan to commit suicide, or attempted suicide in the last 12 months. Figure 3 – Seriously Considered Attempting Suicide among Males and Females by Gender Expression


Figure 4 – Made a Plan about Attempting Suicide among Males and Females by Gender Expression


Figure 5 – Attempted Suicide among Males and Females by Gender Expression


Gender expansive students are more likely than their peers to have engaged in nonsuicide self-harm in the last 12 months. Figure 6 – Nonsuicide Self-Harm among Males and Females by Gender Expression



The Trevor Project provides a number of life-saving and life-affirming services to young people who are in crisis, with a focus on LGBTQ young people age 24 or younger. Two key services are TrevorChat, which is a free, confidential and secure instant messaging service, and TrevorText, a confidential and secure service that provides live help for LGBTQ youth with a trained specialist over text messages. For more information about these services, please visit http://www.thetrevorproject.org

Data from over 4,000 individual contacts to TrevorChat and TrevorText during a 6-month period in 2017 found that 6.3% of callers identified as genderqueer. While this data cannot be generalized to all gender expansive youth or compared directly with the YRBSS data because the gender categories that The Trevor Project uses are different, it is helpful to give us insight into the subset of gender expansive youth who may identify as genderqueer and their interactions with The Trevor Project’s crisis services.

Genderqueer young people who contacted The Trevor Projects’ services were more likely than their peers to have had recent thoughts of suicide or to refuse to answer a question on this topic.

  • 41.8% of genderqueer young people said they had thoughts of suicide in the past 24-hours compared to an average of 31.5% of young people with other gender identities.
  • 23.7% of genderqueer young people refused to say whether they’d had thoughts of suicide compared to an average 16.9% of young people with other gender identities.

Genderqueer young people who contacted The Trevor Projects’s services were more likely than their peers to be at medium or higher risk for suicide.

  • 38.0% of genderqueer young people were assessed by Trevor counselors to be at medium or higher risk compared to each of the other gender identity categories (average of 25.4%).

Genderqueer young people who contacted The Trevor Projects’s services were more likely than their peers to have previously attempted suicide.

  • 51.5% of genderqueer young people reported having previously attempted suicide compared to an average of 40.9% of young people with other gender identities. Genderqueer young people were the group most likely to have attempted suicide in the past.  

This data show that gender expansive students are more likely to experience sadness and suicidal behaviors as well other risk factors such as bullying and harassment. This research is unable to draw any direct connections between these experiences and the heightened risk for suicide for gender expansive youth. Nonetheless, it sheds light on the additional challenges that gender expansive youth face both in and out of school.

Additional research is necessary to fully understand the complex relationship between gender expression and suicide. In the meantime, there are steps that advocates, researchers, policymakers, educators, and public health practitioners can take to reduce the risk of suicide among gender expansive young people.

Improve Data Collection regarding Gender Expansive Youth.
The available data on gender expansive youth shows that gender expression can predict health risk behaviors related to suicide, yet there is still so much more we should know in order to help these young people navigate adolescence and avoid risk behaviors, including suicide. We recommend that states, municipalities, schools, and organizations begin to collect data regarding gender expression to help all practitioners further their understanding of gender expansive youth and how gender expression affects adolescent risk behaviors.

Pass safe schools policies with specific protection on the basis of gender expression.
Schools can impact several of the risk factors for suicide that disproportionately affect gender expansive students, especially those relating to bullying and harassment. Research has shown that in schools with comprehensive anti-bullying policies, students experience less victimization related to their gender expression, school staff are more likely to intervene when bullying takes place, and students are more likely to report incidents of bullying. Moreover, school district can develop policies and procedures to help schools ensure that students in crisis are referred to supportive resources and that suicide attempts and deaths within the school community are addressed appropriately. We recommend that schools districts pass 1) comprehensive anti-bullying policies that specifically enumerate gender expression and 2) comprehensive policies that deal with suicide prevention, intervention, and postvention.

Train educators and health professionals regarding the health disparities and risk behaviors experienced by gender expansive students.
Many education and health professionals already receive suicide prevention training. In fact, such training is mandatory for school personnel in 27 states and health professionals in 6 states. Such trainings can help school personnel and others who work with youth identify risk, refer students in crisis to supportive resources, and handle suicide attempts and deaths within a community appropriately so as to reduce suicide risk and prevent suicide contagion. We recommend that school and health professionals be trained to identify risk and prevent suicide among young people, and information about gender expansive youth should be integrated into these training programs.  

Integrate gender expansive students and gender expression into programming aimed at reducing risk factors for suicide.
The vast majority of school districts have prevention programs relating to one or more risk factors for suicide, such as bullying, substance use, or violence prevention. New data relating to gender expansive students can be used to develop a greater understanding of how gender expression and nonconformity relate to heightened risk for suicide and the relevant risk factors among students. We recommend that educators, policymakers, advocates, and public health practitioners integrate data about gender expansive youth into prevention programs focusing on bullying, substance use, violence, and other risk factors for suicide.


Web-based Injury Statistics Query and Reporting System (WISQARS) [database online]. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2014.

Centers for Disease Control and Prevention. Youth risk behavior surveillance—United States, 2015. Morbidity and Mortality Weekly Report 2016;65(No. SS-6):1–174.

U.S. Department of Health and Human Services (HHS) Office of the Surgeon General and National Action Alliance for Suicide Prevention. 2012 National Strategy for Suicide Prevention: Goals and Objectives for Action. Washington, DC: HHS, September 2012.

CDC. 2016. Sexual Identity, Sex of Sexual Contacts, and Health-Risk Behaviors Among Students in Grades 9-12: Youth Risk Behavior Surveillance. Atlanta, GA: U.S. Department of Health and Human Services

James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M. 2016. The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality. See also Haas AP, Rodgers PL, Herman JL. 2014. Suicide Attempts among Transgender and Gender Non-Conforming Adults. Los Angeles, CA: American Foundation for Suicide Prevention and The William Institute.

See, e.g., Ioerger M, Henry KL, Chen PY, Cigularov KP, Tomazic RG. 2015. Beyond Same-Sex Attraction: Gender Variant-Based Victimization Is Associated with Suicidal Behavior and Substance Use for Other-Sex Attracted Adolescents. PLoS ONE 10 (6): 1–16. doi:10.1371/journal.pone.0129976; Reisner SL, Greytak EA, Parsons JT, Ybarra ML. 2015. Gender Minority Social Stress in Adolescence: Disparities in Adolescent Bullying and Substance Use by Gender Identity. Journal of Sex Research 52 (3): 243–56. doi:10.1080/00224499.2014.886321; Roberts AL, Rosario M, Corliss HL, Koenen KC, Austin SB. 2012. Childhood gender nonconformity: A risk indicator for childhood abuse and posttraumatic stress in youth. Pediatrics, 129(3), 410–417; Toomey RB, Ryan C, Diaz RM, Russell ST, Card NA. 2009. Gender non-conforming lesbian, gay, bisexual, and transgender youth: School victimization and young adult psychosocial adjustment. Dev. Psychol., 46(6):1580–1589

The new data available in this brief comes from a report on the YRBSS data commissioned by Advocates for Youth: Gill AM and Frazer MS. 2016. Health Risk Behaviors among Gender Expansive Students: Making the Case for Including a Measure of Gender Expression in Population-Based Surveys. Washington, DC: Advocates for Youth. Available at https://www.advocatesforyouth.org/storage/advfy/documents/YRBSS.pdf.

Centers for Disease Control and Prevention. Youth risk behavior surveillance—United States, 2015. Morbidity and Mortality Weekly Report 2016;65(No. SS-6):1–174

Due to the nature of these services, the project tracks contacts rather than individuals because individuals may initiate contact more than once or drop contact. For the purpose of this analysis, the cutoff for statistical significance is a p-value less than or equal to .05.

Kosciw JG, Greytak EA, Giga NM, Villenas C, Danischewski DJ. (2016). The 2015 National School Climate Survey: The experiences of lesbian, gay, bisexual, transgender, and queer youth in our nation’s schools. New York: GLSEN.

AFSP. 2016. State Laws: Training for Health Professionals in Suicide Assessment, Treatment, and Management. Washington DC: American Foundation for Suicide Prevention.


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