Please Write About Suicide In A Responsible Way

Everyone seems to be violating some fairly basic, well-established guidelines

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As you are likely aware, there is an escalating culture war — I wish it weren’t a culture war, but it is — over puberty blockers. Things are extremely heated right now because of the collision of two events: the passage of an Arkansas law outright banning youth medical transition in that state (I’m ardently against such bans) and the release of an important new report from the UK’s National Institute of Health and Care Excellence (NICE), finding that the level of evidence for the efficacy of puberty blockers in this context is very low. Many other conservative states are weighing such laws, too, meaning things are only going to heat up further.

On the next free episode of Blocked and Reported, out Monday (or already out if you’re a patron), I talk a bit more about why I’m against these laws but frustrated by the expectation that I’m supposed to (effectively) lie to my readers and listeners and say we have super-solid evidence for the efficacy and long-term safety of early medical transition, when we don’t. My view is simply that for kids who are deeply, durably dysphoric, I think the best option, unless and until we have better data suggesting otherwise, is medical transition. It’s a serious decision but some medical uncertainty is acceptable. Of course that view rests on the assumption that the kids in question are going through comprehensive, competent assessments beforehand, and have good care every step of the way. Given the state of the American healthcare system, I am doubtful this is the case in many places, unfortunately. But I’m still extremely uncomfortable with the idea of state legislators making this decision for kids and their parents and doctors.

But here I want to focus more on a small but important slice of this debate on which there should be absolutely no disagreement whatsoever: responsible versus irresponsible media and activism coverage of youth suicide among transgender and gender nonconforming (TGNC) youth. There’s an almost complete absence of it, because it has become more or less a tic, at this point, to draw a straight line between a kid not being able to get access to blockers or hormones exactly when they want them, and that kid killing themself.

This is a terrible, harmful, generally inaccurate narrative. I say ‘generally’ because yes, I do think there are cases in which a lack of access to blockers or hormones could contribute to suicidal ideation or completed suicide. But there’s also a risk of misunderstanding just how complicated suicide is, and of allowing it to cast a shadow over important medical decisions.

To repeat myself:

[T]he existence of a high suicide rate among trans people—a population facing high instances of homelessness, sexual assault, and discrimination—does not imply that it is common for young people to become suicidal if they aren’t granted immediate access to puberty blockers or hormones. Parents and clinicians do need to make fraught decisions fairly quickly in certain situations. When severely dysphoric kids are approaching puberty, for instance, blockers can be a crucial tool to buy time, and sometimes there’s a genuine rush to gain access to them, particularly in light of the waiting lists at many gender clinics. But the clinicians I interviewed said they rarely encounter situations in which immediate access to hormones is the difference between suicide and survival. [Dr. Scott] Leibowitz noted that a relationship with a caring therapist may itself be an important prophylactic against suicidal ideation for TGNC youth: “Often for the first time having a medical or mental-health professional tell them that they are going to take them seriously and really listen to them and hear their story often helps them feel better than they’ve ever felt.”

The conversations parents are having about gender-dysphoric children online aren’t always so nuanced, however. In many of these conversations, parents who say they have questions about the pace of their child’s transition, or whether gender dysphoria is permanent, are told they are playing games with their child’s life. “Would you rather have a live daughter or a dead son?” is a common response to such questions. “This type of narrative takes an already fearful parent and makes them even more afraid, which is hardly the type of mind-set one would want a parent to be in when making a complex lifelong decision for their adolescent,” Leibowitz said.

Unfortunately this has become a cultural script: Kids are told online to say they’re suicidal to access blockers and hormones, and are informed, over and over, including by otherwise responsible adults, that they will kill themselves if they experience any significant delay in obtaining them. It’s just repeated endlessly.

This is very bad. There’s little ambiguity here about the wrong ways to talk about youth suicide, as far as the experts are concerned. Take, for example, Talking About Suicide & LGBT Populations (PDF), a report authored by the American Foundation for Suicide Prevention and two other mental-health organizations, with the listed ‘partners’ including GLAAD, HRC, and a handful of other high-profile LGBT groups.

Here are two of its points (emphasis in the original):

DON’T attribute a suicide death to a single factor (such as bullying or discrimination) or say that a specific anti-LGBT law or policy will “cause” suicide. Suicide deaths are almost always the result of multiple overlapping causes, including mental health issues that might not have been recognized or treated. Linking suicide directly to external factors like bullying, discrimination or anti-LGBT laws can normalize suicide by suggesting that it is a natural reaction to such experiences or laws. It can also increase suicide risk by leading at-risk individuals to identify with the experiences of those who have died by suicide

[...]

DON’T talk about suicide “epidemics” or suicide rates for LGBT people. Remember that sexual orientation and gender identity are not recorded at the time of death, so we do not have data on suicide rates or deaths among LGBT people. In addition, presenting suicide as a trend or a widespread occurrence (for example, tallying suicide deaths that occur in proximity to an external event) can encourage vulnerable individuals to see themselves as part of a larger story, which may elevate their suicide risk.

So many people are violating these guidelines. So many people! It’s really bad. This is just one of a million examples, but here’s Melissa Gira Grant in The New Republic, writing about the Arkansas law before it passed:

“We need to correct the record,” said Dr. Michele Hutchinson in one recent hearing, “because the folks that spoke before got an awful lot of time to tell you a lot of inaccuracies.” She went on to cite the standards of care for trans youth, which are recognized by the American Academy of Pediatrics, the American Psychiatric Association, and the Pediatric Endocrine Society, among others. But underneath her appeals to the evidence, Dr. Hutchinson was upset, and she said so. “I’m doing everything I can to maintain my sanity here … just after this bill passed the house, these kids heard about it. I’ve had multiple kids in our emergency room because of an attempted suicide. Just in the last week.” If this bill passes, she said, children will die. “And I will call you guys every single time one does.”

It isn’t TNR’s fault that this doctor is communicating so irresponsibly about this issue. But the magazine shouldn’t be helping her do so! A lot of people are making this mistake at the moment, because it is a scary time and the stakes feel high and people understandably want to do whatever they can to help. But sometimes when you try to help, you end up hurting.

Now, there’s a bit of a paradox here. If I were to run in screaming TALKING ABOUT VARIOUS EVENTS MAKING KIDS KILL THEMSELVES WILL CAUSE KIDS TO KILL THEMSELVES, of course I’d be committing the same error. We should always be cautious and measured when discussing youth suicide. But suicide is a more impulsive act than many realize, and these sorts of storylines do seem to make it more likely that some people will harm themselves. So I think there’s a way to calmly communicate that by propagating these stories, outlets are generally creating a more dangerous environment for those who are most at-risk.

Of course everything I’m saying here also applies to the separate but overlapping issue of bullying: In much the same way I don’t want outlets relaying the oversimplified storyline that if kids are cut off from access to puberty blockers, they will kill themselves, I don’t want outlets relaying the oversimplified storyline that if kids are bullied, they will kill themselves. People are quite resilient. Suicide is a terrible tragedy but every day, a billion people endure a billion hardships without harming themselves.

There’s a way to talk about this reasonably and responsibly. Unfortunately many writers and activists don’t seem to be very interested in that.


Questions? Comments? Urgent requests for a lighter subject? I’m at singalminded@gmail.com or on Twitter at @jessesingal. The image of a green “Talk to us if things are getting to you” sign for Samaritans, a suicide hotline, is from here.