S1E2 / Switch or Die: Why Trans Teens Are At Such High Risk for Suicide / Ximena Lopez

Why are LGBTQ youth at such high risk of depression, anxiety and suicide?

Note: This season of American Diagnosis was originally published under the title In Sickness & In Health. 

This podcast was created by Just Human Productions. We’re powered and distributed by Simplecast. We’re supported, in part, by listeners like you.

Celine Gounder: This is “In Sickness and in Health.” I’m Dr. Celine Gounder.

In this episode, we’re going to talk about topics that some parents may find unsuitable for young children. Parental discretion is advised.

Ed Tully: Like a switch went off one day, and my child changed radically, at age 11 or 12, right in there. … Tons of friends in the neighborhood. Every kid played with Kayden. … So, very outgoing. The issue is that the personality just changed at the age of 11 or 12. And that’s when we went all of a sudden from an extrovert to an introvert. And we could never figure it out, to be honest. We tried, we just didn’t get it.

Celine Gounder: This is Ed Tully, talking to me about his daughter Kayden.

Ed Tully: But once turning into an introvert and changing inward, very limited in friends. Just the one or two. And I should say, before age 12, soccer, baseball. I don’t think we had her in football. Outgoing, super fast, super athletic, very good athlete. But at age 12, pretty much quit everything. At age 12, literally we’re talking door closed almost all the time. And then in middle school, that’s when all the homework stuff just fell apart. Grades were horrible.

Celine Gounder: Ed and his wife Linda really struggled to help Kayden.

Ed Tully: We never did really find a solution because, quite frankly, we never knew what the real problem was. No one else at school ever figured it out. … Kayden and I got into some really big fights. She was getting really rebellious. The F-words were going off at times, fighting with me about things. … And I could never figure out why that was all there. … I remember one time having a sit-down talk with my daughter in the kitchen, and I said, we’ve really got to talk about this school stuff. … I said, “if you’re me standing here in the future, and your child is doing what you’re doing, what do you say to them?” … “what would you do to help your child through this?” It didn’t work. My child went into tears.

Celine Gounder: Kayden had a secret. It took her years to share that secret with her family.

In this episode, we’ll focus on one group of young Americans that’s been in the news a lot lately and that’s at especially high risk for mental health issues like depression, anxiety and suicide: lesbian, gay, bisexual, transgender and queer youth. You’ll hear the story of a family caught in the crosshairs of these issues and from a doctor who’s doing what she can to help trans teens be themselves.

For a long time, we didn’t know all that much about mental health and suicide among LGBTQ persons. Part of the problem was that sexual orientation and gender identity aren’t reported on birth and death certificates or driver’s and marriage licenses. But the Centers for Disease Control and Prevention does conduct a regular survey of risk behaviors in high school students, and they recently put questions about sexual orientation on the list. They found that LGBTQ high school students are at least twice as likely as their peers to be bullied, threatened, assaulted, forced to have sex, or to feel sad or hopeless. And they’re five times more likely to have attempted suicide. In fact, about a third of  LGBTQ high school students report attempting suicide in the prior year.

But these stats don’t tell the whole story.

Ed Tully: I wish I had all the education I have today. Just go back a couple, three years. Four years ago. Four years ago would’ve been great, if I would have known what I know today. But that’s not the way life works, so. You learn the hard way.

Celine Gounder: Ed Tully is a businessman and a basketball coach who lives in Rockford, Minnesota — or Michelle Bachman Territory, as he and his wife, Linda, call it. He’s 55; 5 kids; 4 dogs.

Ed Tully: And a very close family. And that’s what I care about. … I would say I’m your average American family in the suburbs. … And of course, what makes us different is what we’ve gone through. With Kayden. And that’s when I see us not being the American family anymore. The normal American family. I hate to use that word. It’s a bad word. I should go back to average, but the way people like to see what an average American family is, we’re not it.

Celine Gounder: Ed is really close to his kids. Checking in was important to him as he was raising them, coaching them in sports, and helping them through difficult times in school and social situations. But his daughter Kayden was different from his other kids.

Ed Tully: If my whole family, my inlaws and my friends all said, who was the quietest, most introverted child I had? It was Kayden, they all thought. … She was an introvert and gonna be quiet.

Celine Gounder: Ed says that growing up, Kayden was unemotional, sardonic and largely kept to herself. Her grades weren’t great, but she made it through high school and then took some classes at the local community college. She got a part time job. And for a little while, Ed and his wife thought that Kayden was on track. But then things changed. She stopped going to school. She hid in her room. She slept all day. And she had a hard time keeping up at work.

Ed Tully: And grew out her hair, changed the style of the clothing — she was not goth, but close to goth? I hate to say — I guess you’d call it anime, in a way. She would order clothes from Japan. Hong Kong. Had a lot of black. Lot of chains, netting on it. Big boots. Black Boots. Got some makeup, and I figured it was a style. I didn’t know she was transgender, by any means, I just figured it was a style. I won’t lie, the long hair came out, I was a little embarrassed at first. Cause I didn’t know quite what was going on and it seemed kind of radical. And that went on for a few months, and her hair was way down. To the shoulder. And I didn’t know what was going on, but her friends were the same, so.

Celine Gounder: Ed is really honest about how he felt every step of the way — not just the stuff that makes him look good — but also about his ignorance, his confusion and his missteps.

In case you hadn’t already guessed, Kayden wasn’t born Kayden. She was born Tyler — in a male body, and raised as a boy. Ed told me that it never occurred to him that his daughter was his daughter. Growing up, Kayden liked girls. Ed thought he had a heterosexual son. Not a lesbian daughter.

Ed Tully: Just out of the blue, my wife just kind of disappeared and went upstairs and she was in talking to Kayden, and I don’t know the whole conversation that went on there but I know that she told my wife that she was a girl and had always been a girl since age 12.

Celine Gounder: Kayden was 20 when she came out to her mom, Linda. That’s eight years of knowing she was a girl, and keeping it mostly to herself. By the time she told her family, Kayden had already started hormone treatment. She was in therapy at the University of Minnesota, where she saw doctors who specialized in transgender care. And she had officially been diagnosed with gender dysphoria.

Ed Tully: I came in and I shut the door and I basically said, at the time it was Tyler’s name, but I said, hey, Tyler, let’s talk for a minute. And I said, hey, mom just told me what’s going on and said that you’re actually a girl and I understand this transgender thing, and anyway, I sat there on the bed with her and I said, flat out, 100-percent, I said, you know, I get this. It explains a lot of things that have gone on in your life. And I said, flat out, I love you, and I’ll support you 100-percent and you just tell me what you need. And I don’t think we said too much after that. It was kind of a short conversation. But I wanted to let her know I loved her and I would do whatever I could do to help her. And then I left the room, actually. Went down and talked to my wife and told her what I said to her and said, we’re good. We have some things to learn now.

Celine Gounder: Kayden was fortunate to have the loving support of both her parents and access to doctors who specialize in trans care. Such doctors remain in all too short supply.

Dr. Ximena Lopez: Uh, my name is Ximena Lopez. That’s X-i-m-e-n-a Lopez, and I’m a pediatric endocrinologist and an assistant professor at UT Southwestern Medical Center in Dallas, Texas.

Celine Gounder: Dr. Lopez started the first clinic for transgender youth in the state of Texas. The whole idea of a specific program for these kids is relatively new. The oldest, at Boston Children’s Hospital, is only a decade old. But the demand is there. When Lopez opened her clinic, a little over two years ago, she had around fifty patients. Now she has more than four hundred.

Only five years ago, Dr. Lopez had never cared for a young transgender patient. And then came Evan, a nine year-old who was born female… but who identified as a boy. He suffered from depression as a child. But his mother gave him the freedom, and the tools, to be socially male: the name, the clothes, the haircut. And his depression lifted. But when puberty hit, Evan started to develop breasts. He was on the verge of presenting as a female, and suddenly, the comfort he’d achieved in his identity as a boy started to slip away from him. So Evan’s mother took him to Dr. Lopez.

Dr. Ximena Lopez: She told me she had visited multiple pediatric endocrinologists and no one was willing to treat or see his kid and she said, I don’t mind if this is your first person, but I will do all I can for my child’s mental health.

Celine Gounder: Dr. Lopez happened to have trained to be a pediatric endocrinologist with the doctor who founded the first transgender adolescent program in Boston. So she already knew that transitioning — medical treatment to reassign gender — could be a necessary step for the psychological well being of trans people. So Dr. Lopez sent Evan to a psychiatrist, who confirmed that, yes, Evan definitely had gender dysphoria. And that doctor recommended puberty suppression.

Dr. Ximena Lopez: And it was a very special patient because, as a pediatric endocrinologist, I had never had that feeling of, I am helping someone to be who they know themselves to be, who they really are. It was really gratifying. Also, as a pediatric provider, you work a lot with the parents, not just with the child. And the trust that that parent had with me was really special.

Celine Gounder: Evan was just nine years old when he started treatment… and that may sound young. But just imagine: you’re a young boy… and you start developing breasts… or get your period… or you’re a young girl… and you’re growing facial hair and your voice drops. Your body would feel all wrong.

Dr. Lopez says that most of her patients have depression or anxiety… much of which is related to their gender dysphoria… but stigma, discrimination, harassment and family rejection also play an important role.

Dr. Lopez estimates that about 40 percent of her patients have attempted suicide. In fact, she started a program for transgender youth to help prevent those patients from getting to that point.

Once a patient is diagnosed with gender dysphoria, Dr. Lopez starts them on hormones to block puberty. Basically, it pauses the process and buys time. It’s reversible, but the patient avoids the distress that comes with unwanted physical changes. They get psychological support and a  game plan. Dr. Lopez says that it doesn’t really make sense for a pre-pubescent person to have gender-affirming surgery.  But that puberty pause is a really important step. Because there are some things, like broad masculine shoulders, that surgery just can’t undo. After the pause, cross-sex hormone therapy — with either testosterone or estrogen — allows someone to develop masculine or feminine features.

Dr. Ximena Lopez: What I hear from my patients, because I always ask them, you know, why do you want testosterone or estrogen? And the answer is normally, ‘Because I’m a guy.’ Or, ‘I’m a girl.’ And this is how I see myself. And this is how I see myself. And the exciting[sic] you see from starting is, or knowing they’re going to start it, is so amazing that you realize they really, really want and need this.

Celine Gounder: So Dr. Lopez plays a crucial step in peaceful transition for a lot of young people. Studies have shown that gender-affirming medical treatment relieves the psychological suffering many young trans people experience. But there is still a massive barrier for trans youth because these kids still have to be out in the world and there is often an inevitable public aspect to their process.

Dr. Ximena Lopez: Some people think that transgender people are sort of freaks, or perverted people, because before this became a hot topic, many people thought a transgender person would be a drag queen or some — we have preconceived notions of what we see in movies. And part of it, I think, is the fact that we know that when transgender people are not supported early on as young people, as adolescent, many of them go into high-risk behaviors, then run out of their houses, become homeless, don’t go to school, don’t have a job, end up getting into drug abuse, alcohol, prostitution in order to survive, get HIV, get STDs, so this sort of bad route of that has stigmatized this population. But the route of things is that it doesn’t have to be that way if these kids are supported early on.

Celine Gounder: Dr. Lopez says there is also a lack of understanding on the part of people who have never met — as far as they know — a transgender person. And many religious communities oppose the idea that someone could be a gender other than the one they were assigned at birth. But the most important thing — the step that could prevent a lot of this stigmatizing from happening in the first place — is for parents to totally accept and support their kids from the beginning.

Dr. Ximena Lopez: The really young kids, like school age kids, who are supported by their parents, they are doing fantastically. They don’t have any mental health issues, most of them, they are just normal kids. And the kids who came to use much later, because it took their parents a long time to understand and to support them, they’re the ones that have a much higher psychopathology. So, I really think that if we support these kids early on, the outcome is going to be so much better and that stigma is also going to go away.

Celine Gounder: Safe and welcoming school environments are also very important in combating stigma and reducing the risk of suicide. Researchers have found that being denied access to identity-appropriate bathrooms or campus housing at colleges and universities is associated with increased risk for suicidality.

But many states have considered bathroom bills to restrict the use of public bathrooms on the basis of someone’s birth sex. Transgender teens are now suing for their right to use the bathroom matching their gender identity.

Why the big deal about bathrooms? Bathrooms matter because they’re a litmus test for whether you really believe someone is the gender they say they are. And that acceptance is paramount.

[protest chant] Trans equality now, trans equality now […] save our schools! Protect trans students!

CNN: The ACLU is saying this is the antithesis of what the president ran on, they called those words empty words, when he promised to protect LGBTQ individuals.

Celine Gounder: Just a month into his presidency, Donald Trump’s administration rolled back Obama-era guidance to schools to let transgender students use whatever bathroom they want to use — the bathroom corresponding with their gender identity. The Obama Administration had instructed schools to treat transgender students consistent with their gender identity or risk being in violation of anti-discrimination laws. Trump says that these guidelines were issued without the input of parents, students and teachers, or the input of the states and local school districts, which have the primary role in establishing education policy.

The Trump Administration’s reversal doesn’t stop individual states or schools from making their own guidelines. But it does make room for people across the country to question whether those rights are really rights at all and to question the validity of a transgender identity. And that’s created a lot of anxiety for many transgender people and their families.

Again, Dr. Lopez:

Dr. Ximena Lopez: We’ve also seen that when something like this happens, there’s sort of, like, a trend of more discrimination among those who are already sort of against transgender people, and maybe kept it. And then it sort of flourishes when something like that happens. We also hear from kids being more bullied after something like that happens. We also get calls from them, and from the parents, saying they’re more anxious. And we’ve actually had to email letters to the whole patient population expressing our support because we know it’s a harder time for them.

Celine Gounder: Dr. Lopez’s patients have a support system that a lot of trans kids don’t get. It’s something that Ed Tully, the Minnesota dad you heard from earlier of this episode, tried to provide to his daughter, Kayden. But there was still the outside world, with the danger of judgement and harassment around every corner. Ed learned that lesson the hard way — the hardest way possible.

Ed Tully: Man, if I would have known this in the beginning, what a different parent I could have been. And I know it’s all hindsight, there’s nothing I could do about it. That’s what happens. It’s a hard learning thing, because we have such low education about this. Schools and other places just don’t share this information.

Celine Gounder: Because of that, there was a lot that Ed still didn’t know once his daughter, Kayden, had come out. And it wasn’t like everything changed for her. She had starting taking hormone treatment, but was still a female in a male body. And she wasn’t even legally Kayden. She was still Tyler Tully, living in a community where she’d been known as a boy. A community that wasn’t especially well-versed in the nuances of gender identity. It was when Kayden finally took the step of changing her name and registering as a woman, that Ed saw a shift in her. She filed all of the paperwork herself, and went before a judge in Buffalo, Minnesota.

Ed Tully: I knew the change of name was going to happen. I was cool with that. The judge allowed it. But was Kayden filled out on the application was to actually have the — a gender change. And she’d gotten letters from the psychologist and the therapist and the medication she was on to get labelled ‘female.’ And the driver’s license would be changed to female also. So, I was cool with it, but I was also surprised. I didn’t realize we were going that far. In terms of that day.

Celine Gounder: Even then, Ed hadn’t fully internalized how important it was to Kayden that the world recognize her as female.

Ed Tully: So we got breakfast, and luckily, my daughter got up and went to the bathroom and — I have to tell you this, but — a waitress came over and saw that she had left the table and asked us what we’d like and she said, do you know what you daughter wants? Which was very cool. So, they were seeing her as a girl. But anyway, things were great. My daughter went home, went on Facebook, put out a big deal, like, my name is changed, I’m now Kayden, I’m so happy. And, literally, we thought, wow. This is the first time I’m seeing my child smile again. Show emotion, really get out there with friends. So we really saw what I call, turning — going the right way.

Celine Gounder: Ed says he and his wife saw a happier kid. He encouraged her to go back to work, and she got a job at Walmart. For a couple of months, things seemed better. As Ed saw it, Kayden was getting what she needed. She was a young woman. Her driver’s license said so.

Ed Tully: I do know there was a frustration when my wife changed medical insurance about a year before that. And the coverage wasn’t going to be the same. And I know my daughter, I could tell, was bummed, when my wife talked about how we’re changing insurances and then she tried to buy her own insurance but it was too expensive. So I think she saw that as a delay to be converted. For future services. I think my daughter just saw, I’m not going to be changed. It’s going to be years. And I think she just gave up, to be honest.

Celine Gounder: Though doctors and scientists agree that transition-related care is medically necessary, many health insurance plans don’t cover cross-sex hormone therapy or gender-affirming surgery. Coverage varies by state. The average cost of transition-related care is about $30,000 to $45,000. That would be like paying for a back surgery or heart bypass surgery out of your own pocket. That’s a lot for one family to bear. But it’s not that much when you consider that gender dysphoria can be deadly.

Ed Tully: I’m going to blow the line here, but they say something like … not convert, but… it’s … either switch, or die. It’s one or the other. And if you can’t get switched, you might as well commit suicide.

Celine Gounder: Throughout our conversation, Ed acknowledged the clarity of hindsight. The things that may have been warning signs. But he still describes the night that Kayden died as completely unexpected.

Ed Tully: Out of the blue, we got down to October 26th, 25th, it was a Friday night of that weekend on 2013, and my kid said — God it was really late at night. It might have just been 8, or 8:30, but said, hey, I’m going out. And I — I still remember. I swear, all I said was, ‘Have a good time, we’ll talk to you later.’ You know. And took my van, took off for the night.

Celine Gounder: When Kayden wasn’t home by Saturday, Ed sent her a few text messages and assumed she was with a friend. When she wasn’t home on Sunday, he started to get concerned. But Kayden was twenty — an adult — and she had disappeared for the weekend in the past.

Ed Tully: And it was a Sunday night, and it was around 9:00. I had Nick, Brendan, my wife and I were out in the family room watching a movie together, lights off, popcorn, the whole bit. Kind of a family night get together. And that’s when the doorbell rang. And it was around 9:00 and I came over to the door and I just peeked out the window. And I saw two Wright County Sheriff guys and I saw two — at least one big truck. Sheriff truck. And then another sheriff vehicle in my driveway. And I opened the door and I just kind of looked at them, and they go, ‘Hey -’ I don’t know the exact words, but something to like, ‘Can you tell us if Kayden Tully lives here?’ And I said, ‘Yes, she does,’ and the one guy who was in the front said, ‘Do you mind if I come in.’ And uh, and he came in the door and that’s when he said something to the effect of, ‘I’m so sorry, but we found your daughter at Buffalo Lake, and she has committed suicide.’ … Anyway, that just started a whole breakdown. I went down the hallway. I don’t remember how loud I was, but I was yelling at Linda that Kayden — I don’t remember the words I used, but — Kayden — Kayden died. She committed suicide, something to that effect. And she was like, what? Kind of screaming. And kind of watched the whole family break down basically.

Celine Gounder: In the aftermath, Ed would learn that Kayden had ordered a gun online just a few weeks prior. Kayden even went to gun safety class to obtain a concealed carry permit. A friend of Kayden’s told Ed she’d gotten the gun to protect herself… because she was transgender.

Contacting friends and filtering through social media, Ed found evidence that Kayden had talked about committing suicide with fellow online gamers. She posted on Facebook that she wished people would just get over things and just love each other.

Ed Tully: I know he was sick of it. You could tell from comments on his Facebook. How he was just tired of it. He was tired of all the stuff out there out in the internet world, I guess. Things where people said things, things he dealt with day to day when he was in his car. The way people looked at him. I mean her. See, I always do this. It’s really bad. I keep saying ‘he’ instead of ‘she.’

Celine Gounder: Ed says that at Kayden’s funeral, people were confused. Many didn’t know Kayden was transgender, and most didn’t know she’d died by suicide. A handful were clearly uncomfortable. Ed attributes that to the politically conservative area of Minnesota where they live. But he hadn’t realized how in the dark he and his wife had also been until long after Kayden’s death.

Ed Tully: We were just oblivious parents. Like, got the hair, growing boobs, getting there. Got more therapy to go. I didn’t do my studying. I didn’t do my research. It took suicide. And not even that. It took suicide, months and months of pain, reaching out to figure out, God, Linda, we gotta talk to people, we gotta get out of the house, we gotta get through this. And I just happened to find PFLAG, went to a meeting or two, and next thing you know, as I’m digging into this, and then people are asking me, would you like to speak? Then I had to get prepared for speaking, and then I started doing my research, and I’m like, holy crap. I know it’s out there, but — my God, I had no clue that — and I don’t know what the exact number is, if it’s one-third that attempt, or one third that commit suicide, but it’s up there.

Celine Gounder: What became clear to Ed, only after grieving and rebuilding led him to do his research, was exactly how vital transitioning is to a transgender person. He says that he and his wife Linda thought they had years. The biggest mistake, he says, the one that may have been the difference between life and death for his daughter, was thinking that gender-affirming surgery could wait.

Ed Tully: If I could do it all again, I would have sold everything I had and got my child changed immediately.

Celine Gounder: Ed knows he can’t do it all over again. He said that to me over and over again. But what he can do, what he’s committed his life to doing, is share what he knows now… so that other kids, and other parents, don’t have to have an experience like his.

To counter the stigma and harassment, Ed Tully now spreads a message of welcome and support far and wide. He speaks at PFLAG meetings — that’s Parents, Families and Friends of Lesbians and Gays — to local schools, and to a homeschooling group that encourages open discussion about gender identity. But facilitating that conversation, normalizing the subject and making people comfortable with the idea, Ed says, starts at home. It starts with the parents of a transgender child.

Ed Tully: Here’s my number one piece of advice for a parent. Flat out, you have to come out. 100%. You have to be out. You can’t have hesitation. To me, the way you prove you support your child 100% is you’re willing to come out yourself 100%. That means you’re willing to pop out and tell any friend you’re out with, oh, by the way, my son’s gay. Get used to it. Oh, he’s got a partner. A lot of parents, and I did, too, for awhile, I hesitated. Especially with Kayden. Because you’re worried about what friends are going to say, what neighbors are going to say, and you hesitate. The problem is, your transgender, gay child, sees that, they read it, and they get you’re not 100% in. And they’ll know. They just know. And that’s what I feel I did with Kayden. I held on way too long, hiding it. There are comments I even made about, when he was first starting to go to work at Target, you’re not quite out, people don’t know who you are, you might have to hide your breasts for awhile, and you know, things like that. Which is wrong. Completely wrong. I know there are some things that I said that were completely wrong. You have to be 100% out, and I’ll be honest, if my son came out tomorrow, I would put it on Facebook.

Celine Gounder: Whether it’s surgery or the bathroom you use, having the rest of the world see you as the gender you think you are is so fundamental to your sense of self, your self-worth, your self-confidence and your self-determination.

And that’s why transgender teens are fighting for their right to use the bathroom that matches their gender identity. It’s a battle for their health and safety and themselves.

That fight continues at the federal, state and local levels across the country.

Between 2013 and 2016, at least 24 states considered bathroom bills. To date, only North Carolina successfully enacted restrictions to limit the use of bathrooms based on someone’s birth sex. North Carolina’s bathroom law was a response to legislation passed at an even more local level — in Charlotte, North Carolina — that allowed transgender people to use bathrooms corresponding with their gender identity. North Carolina then faced boycotts by businesses, sports leagues and musicians — losing money and jobs. The state finally bowed under that pressure and repealed its bathroom bill, but at the same time banned local governments in North Carolina from passing their own non-discrimination laws for the next three years, essentially punting the decision back to the federal courts.

Celine Gounder: In our next episode, we’ll talk about the adolescent microcosms that can cause feelings of depression, and suicidal ideation. Stress and isolation often have a disproportionate effect on young people. We’ll hear how young people get caught in these worlds and how to help them out.

If someone you know is in crisis or thinking of hurting themself:

• Do not leave them alone.

• Remove any firearms, alcohol, drugs or sharp objects that could be used in a suicide attempt.

• Take them to an emergency room or seek help from a medical or mental health professional.

• Call the U.S. National Suicide Prevention Lifeline at 800-273-TALK (8255).

• Or text the Crisis Text Line at 741-741.

• Another resource for LGBTQ youth is the Trevor Project’s Lifeline at 866-488-7386.

• Thank you for listening.

Credits: Today’s episode of “In Sickness and in Health” was produced by Dr. Celine Gounder and Hannah McCarthy. Our theme music is by Allan Vest.