Science Corner: Responding in Kind

“What a piece of work is a man” declares Hamlet, and indeed human beings are quite extraordinary. What other organism can organize 334 million individuals (or even 158 million) over 3.8 million square miles in a shared activity in service of an abstraction like democracy? In terms of sheer numbers, the closest would probably be an ant colony or a bacterial film, both of which can coordinate the activities of that many individuals, but via genetics and biochemistry. Only humans are socially engaged at such a scale largely through words and ideas.

This uniquely human trait can have powerful benefits. For example, we can mobilize efforts to support people displaced and disrupted by the recent hurricanes in the southeastern United States. There may be many animals and plants that would share food with others nearby who are without, especially if there is some expectation that sharing could be reciprocated later on. But we humans can organize food, shelter, medicine and all manner of goods across vast distances for people we will never meet and can never expect anything directly from in return. We even pool resources in advance just in case via taxes and other means, and as far as I can tell we are generally glad to do so (at least in general, even if we might have different priorities for how those resources are distributed when disasters do occur). I imagine for those receiving such aid it probably feels uplifting in some way to have the support of so many from so far.

I also imagine the opposite must feel fairly deflating as well. And that’s what the research I want to talk about today seems to show. The study by Lee et al. looked at the impact of recently passed state laws on suicide attempts among transgender and nonbinary young people. (alternate option for full text) The laws considered restrict those folks in various ways, from barring their participation in sports to removing gender-affirming healthcare options. In the second and third years following the enacting of these laws, there were statistically significant increases in the number of past-year suicide attempts and in the likelihood of any past-year suicide attempt among transgender and nonbinary young people ages 13-24 who lived in the states where those laws were passed, compared to the same group in states without those laws. In addition, there was a smaller but still statistically significant increase in the first year following the laws among transgender and nonbinary teens ages 13-17. The size of the increases ranged from 7-72%.

Of course, suicide and mental health are complex matters that can be impacted by a variety of factors. For example, we might wonder whether the increase in suicides was driven by negative media coverage of the laws rather than the impacts of the laws themselves. Did these young people buy into negative hype rather than the reality? The data from this study would suggest that is not as good an explanation. First, there were no differences observed in the period prior to the laws being enacted. So media coverage about the possibility of such laws did not seem to have an effect, nor is there evidence that people were anticipating something bad and reacting to that before anything happened. Second, the researchers repeated the analysis based on the timing and location of when laws were introduced for consideration rather than when they were passed and did not find any comparable effects. These observations are more consistent with the study participants responding to the reality of the laws rather than the perception of them. The study also controlled for possible impacts of the COVID-19 pandemic which had its own mental health consequences, differences associated with age and race & ethnicity, and fixed differences between states (e.g. whether a given state has an overall higher or lower rate of suicide attempts among transgender and nonbinary young people).

Given the difference-in-differences methodology used–comparing a change in a rate in one group to a change in a rate in another–one might also wonder whether we are talking about a very small number of suicide attempts driving the results. In other words, you can get the same 70% change by having 17 suicide attempts in one group and 10 in another, or 1,700 in one and 1,000 in the other. For context, keep in mind that a recent CDC survey found that roughly 1 in 4 transgender and gender-questioning high school students attempted suicide in the past year (with 1 in 10 requiring medical treatment). For the age 13-17 group, Lee et al. saw essentially the same rate; for ages 13-24 it was roughly 1 in 5. The observed increases were on the order of 1 in 20 to 1 in 10 additional young people attempting suicide in the past year. Overall, that works out to a couple of thousand additional young people attempting suicide out of a study population of roughly 60,000.

We have previously discussed that gender-affirming healthcare has been associated with reduced suicidal thoughts among transgender people. So we might suppose the impact here is primarily from the lack of benefits from that care. However, I was surprised to discover that most of the laws included in the study (30 out of 48) were about sports participation compared to only seven about healthcare options. The study did not attempt to differentiate between different types of laws, presumably because there were so few examples of all the other types, so we can’t say from this data whether certain kinds of laws had more impact than others. But I would not have expected this big of an impact from mainly sports participation laws.

The authors discuss an interpersonal theory of suicide developed by other scientists. The basic idea is that feeling cutoff from other people or feeling like a burden on a community can increase suicidal desire, while experiences that cause pain or fear can reduced the barriers to suicidal behavior. I am reminded of Utah governor Spencer Cox’s letter when vetoing one of these sports-related bills, in which he points out that the data indicate there were 4 kids who would be excluded. I can imagine that being one of those four kids and having the weight of the state legislature brought to bear to keep you from playing sports would feel pretty isolating.

I also think about the folks who were the focus of an intensive ad campaign criticizing Vice President Harris for supporting gender-affirming surgeries for prisoners. I live in Allegheny County in Pennsylvania, so I saw a lot of those ads in the weeks prior to the election. While recognizing that one could have rational objections for that particular use of public funds and acknowledging that it was campaign money not tax dollars that funded the ads, I still have to wonder if more money was spent opposing the idea than it would cost to actual fund those surgeries*, and if so what it must feel like to be the indirect subject of such a campaign. For that matter, what must it feel like to have a president campaign specifically on the slogan that he is explicitly not for you?

Am I placing too much emphasis on feelings? Maybe. At the same time, emotions play an important role in our decision-making whether we are aware of it or not, and the decision to attempt suicide is unlikely to be exempt from that. So we need to reckon with the emotional level as well as the rational one. There may well be interventions we could implement that would help with processing emotions in a healthier way that is less likely to result in a suicide attempt. But that doesn’t let us off the hook for exacerbating the situation by creating circumstances that will generate negative emotional reactions. We can rhyme about sticks and stones all we want, but part of what makes us distinctly human is the fact that words and ideas can hurt us, just as they can encourage and unite and inspire us.

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*Actually, let’s do the math. Let’s set aside that there already is federal funding available for gender-affirming surgeries for prisoners in federal custody, as there was under the first Trump administration, and that only two people have ever used this funding. There are 157,806 people in federal custody at time of writing (that link provides a census updated weekly, so the number may change when you access it). Approximately 0.5% of adults in the United States identify as transgender; the percentage is higher among children, but only 8 people in federal custody are under 18. The rate depends on gender and type of surgery, but overall 25%-35% of transgender people get surgery of some kind. Total costs also vary by procedure and patients may receive different combinations of procedures; let’s assume $100K of expenditures per patient, which would cover multiple procedures at those rates. 35% of 0.5% of 157,806 people is 276 transgender people in federal custody who would elect procedures, so $27.6M would cover their surgeries.

By mid-October, the president-elect’s campaign had spent $19.9M on the ads criticizing the vice president’s support for federal funding for these surgeries. And that’s just on broadcast television; the ad also ran on streaming services. The ads continued to run, and later estimates put the spending around $40M. So it seems quite plausible that more money was spent on ads opposing these surgeries than it would cost to provide them if they were requested at rates consistent with national numbers. And far more money was spent on the ads than has actually been spent to provide surgeries for two people to date. Now again, I recognize that campaign funds are different from tax revenues and the campaign had other goals besides this specific issue. At the same time, that was the focus of ads that ran tens of thousands of times (again, maybe you did not experience that, but I saw them multiple times a day for weeks). I can only imagine how it must feel to have such a disproportionate effort put into telling a fairly small minority of people that the president of their country was not for them.