Journal of LGBT Issues in Counseling

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The Moderating Role of Community Resiliency

on Suicide Risk in the Transgender Population

Chelsea M. Cogan, James A. Scholl, Hannah E. Cole & Joanne L. Davis

To cite this article: Chelsea M. Cogan, James A. Scholl, Hannah E. Cole & Joanne
L. Davis (2020) The Moderating Role of Community Resiliency on Suicide Risk in
the Transgender Population, Journal of LGBT Issues in Counseling, 14:1, 2-17,
DOI: 10.1080/15538605.2020.1711291

To link to this article: https://doi.org/10.1080/15538605.2020.1711291

Published online: 18 Feb 2020.

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JOURNAL OF LGBT ISSUES IN COUNSELING
2020, VOL. 14, NO. 1, 2–17
https://doi.org/10.1080/15538605.2020.1711291

The Moderating Role of Community Resiliency on

Suicide Risk in the Transgender Population
Chelsea M. Cogana , James A. Scholla, Hannah E. Coleb,
and Joanne L. Davisa
a
Department of Psychology, The University of Tulsa, Tulsa, OK, USA; bBehavioral
Sciences Division, National Center for PTSD, Boston, MA, USA

ABSTRACT KEYWORDS
Transgender individuals are disproportionately impacted by Community resilience;
negative mental and physical health outcomes, including minority stress; PTSD;
increased suicide risk. The gender minority stress theory suicide; transgender; trauma
pro- poses a potential pathway to suicide risk through distal
and proximal stressors. However, little research has
examined how resiliency impacts this relationship. The
present study explored the moderating role of resiliency in
the relationship between stressors, trauma exposure, and
suicide risk. Stressors and trauma exposure were
significantly associated with suicide risk, but community
resilience was not found to moderate this relationship. The
clinical implications of these findings are dis- cussed in
depth.

Death by suicide is considered a public health crisis, with over 47,000 indi-
viduals dying by suicide annually in the United States of America (Drapeau
& McIntosh, 2018). Furthermore, it is estimated that there are approxi-
mately 25 suicide attempts for every death by suicide (Drapeau &
McIntosh, 2018). These rates have prompted significant action in the
realms of detection, prevention, and intervention for individuals at risk of
dying by suicide. Particular interest has centered on identifying populations
at disproportionate risk of suicide, such as the lesbian, gay, bisexual, and
transgender (LGBT) community. Recent research has found that 10–20% of
individuals who identify as LGB have attempted suicide at least once in
their lives (Narang, Sarai, Aldrin, & Lippman, 2018). This rate drastically
increases in the transgender population, with up to 81% of transgender
individuals attempting suicide at least once (Narang, Sarai, Aldrin, &
Lippmann, 2018). Given that previous suicide attempts are one of the
strongest predictors of death by suicide (Bauer, Scheim, Pyne, Travers, &
Hammond, 2015), the elevated rates of attempts within the transgender
population suggests a significant need for further research within this area.

CONTACT Chelsea M. Cogan cmc486@utulsa.edu Department of Psychology, The University of Tulsa,

Tulsa, OK, USA.
© 2020 Taylor & Francis Group, LLC
 JOURNAL OF LGBT ISSUES IN COUNSELING 3

Suicide risk factors

In the general population, suicidology research has identified several factors
involved with increased suicide risk, including early adverse experiences,
mental illness, substance abuse, access to lethal methods, and chronic dis-
eases (Turecki & Brent, 2016). These factors occur at a higher rate in the
transgender population. For example, a number of studies have found that
transgender individuals are more likely than their cisgender peers to have
mental and physical health disorders (Reisner et al., 2016). This difference
in mental health and physical health problems is especially relevant when
considering the reported difficulty in accessing healthcare by this popula-
tion (Kenagy, 2005). In a sample of over 5,000 transgender individuals with
a history of suicide attempts, 60% of respondents reported being refused
medical care due to their gender identity and over half of the respondents
delayed medical appointments due to fear of being discriminated against
(Haas, Rodgers, & Herman, 2014). This suggests that transgender individu-
als are often not treated for mental or physical illness or may endure
harassment and/or discrimination in order to receive healthcare.
Furthermore, transgender individuals report high rates of adverse
experiences, including physical and sexual assaults, bullying, harassment,
and discrimination (Marshall, Claes, Bouman, Witcomb, & Arcelus, 2016).
These adverse experiences can begin at a young age, with individuals being
victimized in grade school for perceived differences from their peers (Wyss,
2004). This rejection and violence have been linked to an increased rate of
suicide attempts in transgender youths, with up to 76% of those who have
attempted suicide making their first attempt prior to the age of 21
(Yu€ksel, Ertekin, O€ ztu€rk, Bikmaz, & O˘gla˘gu, 2017). Additionally,
transgender indi- viduals face this adversity in multiple types of
relationships, ranging from
family members to law enforcement officers (Haas et al., 2014), which can
significantly impact the way in which transgender individuals interact with
the world around them.
Another factor potentially implicated in suicide risk in the transgender
population is that of trauma exposure and subsequent posttraumatic stress
disorder (PTSD) symptoms (Rood, Puckett, Pantalone, & Bradford, 2015).
There is a growing body of literature suggesting that transgender individu-
als experience traumatic events at higher rates than the general population
(e.g. Shipherd, Maguen, Skidmore, & Abramovitz, 2011). Rates of trauma
exposure vary depending on the population, with roughly 90% of the gen-
eral population having at least one traumatic experience (Kilpatrick et al.,
2013). In transgender individuals, the rate of exposure is significantly
higher, with up to 98% of individuals experiencing at least one traumatic
event and 91% reporting multiple exposures (Shipherd et al., 2011). In this
same sample, almost 18% of individuals reported significant PTSD
symptoms and 64% reported significant depressive symptoms. A more
recent study conducted by Scholl (2018) found that of 199 transgender
individuals, 100% reported experiencing a traumatic event, with a mean of
20.31 (SD¼5.12) traumas, suggesting that trauma exposure is pervasive in
this population. Of this sample, between 62 and 68% met the criteria for a
provisional diagnosis of PTSD (Scholl, 2018). In this same sample, the
number of traumatic experiences was found to be significantly related to
suicide risk (Cogan, Scholl, Lee, & Davis, 2018).

Suicide protective factors

In terms of suicide prevention and intervention, it is equally important to
identify protective factors in addition to risk factors. Protective factors can
be internal or external ways of defending against suicidal behavior and
lower the risk that an individual will die by suicide. In cisgender literature,
protective factors can include reasons for living, the ability to regulate sui-
cidal thoughts and feelings, social support, and optimism (Moody & Smith,
2013). However, there is relatively little research directly examining protect-
ive factors in the transgender population.
When considering the importance of social support, there are gender
identity-related factors that appear to be important for transgender individ-
uals. For example, having identity documentation that matches one’s lived
gender has been shown to reduce suicide risk (Bauer et al., 2015). The pro-
cess of realizing one’s gender identity to becoming one’s self has also been
found to be protective for individuals, especially when this process includes
acceptance of and comfortability with their identity (Moody, Fuks, Pel
´aez, & Smith, 2015). A number of transition-related protective factors
have been identified, such as coming out and/or disclosing their gender
identity to others, the process of transitioning, and the hope of transitioning
for individuals who wanted to transition (Moody et al., 2015). Studies have
also found that perceived support for gender-identity from parents or other
important individuals has been found to significantly reduce suicide risk
(Bauer et al., 2015; Moody et al., 2015; Moody & Smith, 2013).
Other factors, such as optimism, emotional stability, and reasons for a
living have demonstrated protection against suicide risk in the transgender
population (Moody et al., 2015; Moody & Smith, 2013). Some of the rea-
sons for living provided by individuals include the desire to be a positive
role model for others who may identify as transgender or a feeling of
responsibility for important individuals (Moody et al., 2015). Emotional
stability, such as the ability to deal with distressing emotions without think-
ing of suicide, and hope for the future in some capacity have also been
found to be protective (Moody et al., 2015; Moody & Smith, 2013).
Gender minority stress theory
There are a number of proposed reasons why minority individuals experi-
ence more adverse mental and physical health outcomes. One theory, in
particular, has been applied to gender minority individuals and provides a
possible explanation for this disparity. The gender minority stress theory
was adapted from Meyer’s (1995) minority stress theory to outline the
stressors that uniquely impact gender minority individuals (Hendricks &
Testa, 2012). This theory includes distal and proximal stressors and also
denotes specific resilience factors (Testa, Habarth, Peta, Balsam, &
Bockting, 2015). Distal stressors are external in nature and include gender-
based victimization, discrimination, rejection, and non-affirmation of gen-
der identity. Proximal stressors are more internal as they are experienced
within the psyche of an individual. They include internalized transphobia,
negative expectations related to gender identity (i.e. concerns about how
others may respond to their gender identity), and concealment of one’s
gender identity.
Testa et al. (2015) also proposed two possible community resilience fac-
tors involved in the gender minority stress theory. These factors, depending
on how the individual experiences them, may mitigate the impact of both
distal and proximal stressors. The identified community resilience factors
include community connectedness and pride. Community connectedness is
related to the individual’s cohesion within their gender minority commu-
nity and the amount of support the individual can garner through this
community. Pride refers to the comfort with and acceptance of one’s gen-
der identity. These factors have relatively little research supporting them in
comparison to distal and proximal stressors but are still important factors
to consider.
A number of studies have tested the gender minority stress theory as it
relates to mental health outcomes and suicide risk. Research on the gender
minority stress theory has found that gender-based victimization (a distal
stressor) is related to an increased suicide risk, such that individuals who
experience gender-based victimization were twice as likely to report suicidal
ideation within the past year and seven times more likely to have attempted
suicide (Scanlon, Travers, Coleman, Bauer, & Boyce, 2010). Individuals
who have experienced non-affirmation of gender identity, such as being
denied access to gender-appropriate bathrooms or housing, are 1.45–1.64
times more likely to attempt suicide than those who have not experienced
non-affirmation (Seelman, 2016). This increased suicide risk remains even
after controlling for interpersonal violence, suggesting that this form of
distal stressor may be particularly implicated with suicide risk.
A number of studies have also examined the role of proximal stressors in
relation to suicide risk in the transgender population. These findings
suggest that proximal stressors serve as mediators of the relationship
between distal stressors and suicide risk (Cogan, Scholl, Lee, Cole, & Davis,
2016 in press; Testa et al., 2017; Tucker et al., 2018) in both community
and Veteran samples of transgender individuals. This suggests that the
emotional distress associated with proximal stressors exacerbates the inher-
ent distress associated with experiencing distal stressors, which together can
increase suicide risk.
Despite the designation of community resilience factors within the gen-
der minority stress framework, little to no research has examined their
influence on suicide risk. A recent study conducted by Carter et al. (2019)
examined social support and connection in regards to the relationship
between experiences of discrimination and suicidal ideation in transgender
Veterans. This study found that social support moderates the relationship
between discrimination and suicidal ideation, such that high or average lev-
els of social support reduced suicidal ideation when the individual reported
low levels of discrimination.

Current study
Distal stressors, proximal stressors, and PTSD severity have been implicated
in suicide risk in transgender individuals. There is a small body of research
examining protective factors in the transgender population, but little
research has examined the community resilience factors specified in the
gender minority stress theory. Based on the gender minority stress theory,
it is suggested that community resiliency may provide a buffer against dis-
tal and proximal stressors (Hendricks & Testa, 2012). With the link
between distal and proximal stressors, traumatic experiences, and suicide
risk, it is possible that community resiliency may also buffer against suicide
risk within the transgender population. The present study sought to deter-
mine the role of community resiliency factors in moderating suicide risk in
a transgender population. Specifically, the present study had two hypothe-
ses: (1) community resiliency factors would moderate the relationship
between distal and proximal stressors and suicide risk, and (2) community
resiliency factors would moderate the relationship between trauma expos-
ure and suicide risk.

Method
Participants
A sample of 199 transgender individuals was recruited for a larger scale
study via Qualtrics survey panels through managed market research panels
and social media. Qualtrics survey panels utilize an existing database of
individuals who have consented to be contacted for research and have com-
pleted a brief demographic form. Once a survey has been created and
inclusion/exclusion criteria have been set, Qualtrics survey panels identify
individuals from their database who may meet the criteria and invites these
individuals to participate in the survey. To exclude duplication and ensure
validity, Qualtrics survey programming checked every IP address (however,
IP addresses were not provided to the researcher). Furthermore, to confirm
participant identity, Qualtrics utilized digital fingerprint technology.
Qualtrics replaced straight line responders and participants who finished in
less than one-third of the average survey completion length. At no time did
the research team participate in the recruitment procedures, beyond estab-
lishing the sample parameters. They also did not receive any identifying
information at any time. Eligible respondents were aged 18 years or older,
gender variant (any gender identity that varies from their sex assigned at
birth), English speaking, and consented to participate. No additional inclu-
sion or exclusion criteria were utilized for the study.
The final sample included 155 self-identified transgender individuals after
excluding 44 individuals due to non-response on suicide-related items. The
sample had a mean age of 29.86 years (SD¼12.05, range 18–67) and was
predominantly Caucasian (61.9%). Seventy-five percent of the sample
reported a designation of “female” on their birth certificate and the largest
proportion of individuals reported a current gender identity of non-binary
(25.2%). In total, there were 20 unique gender identities within the sample,
which did not allow for further analysis of differences between gender
identities. For a full description of the sample characteristics, see Table 1. The
sample reported an average of 19.81 traumatic events (SD 4.69), ¼ with every
participant reporting at least one traumatic experience. The mean SBQ-R
score was 9.17 (SD 3.69), with ¼ the majority of the sample report- ing scores
above the recommended cutoff score of 7 or above for general adult
populations. Approximately, 20% of the sample (n 30) reported ¼ thinking
about dying by suicide very often within the past year and 11.6% of the
¼
sample (n 18) reported it was likely that they would attempt sui- cide in the
future.

Procedure
Data collection occurred from October 2017 through November 2017.
Qualtrics identified individuals who met participation requirements and
sent out an email invitation offering the opportunity to complete a survey
for research purposes. To avoid self-selection bias, the survey invitation did
not include specific details about the contents of the survey. The only
information made available was how long the survey was expected to take
 Table 1. Sample
Characteristics
n (%)
Age, mean (SD) 29.86 (12.05)
Gender identity
Agender 12 (7.70)
Androgynous 5 (3.20)
Bi-gender 13 (8.40)
Crossdresser 6 (3.90)
Drag performer (King/Queen) 2 (1.30)
Female 3 (1.90)
Genderqueer 12 (7.70)
Gender fluid 26 (16.80)
Gender non-conforming 6 (3.90)
Intersex 1 (0.60)
Male 2 (1.30)
Multi-gender 1 (0.60)
Non-binary 39 (25.20)
Transgender 7 (4.50)
Transsexual 2 (1.30)
Transgender man (FTM, female to male) 1 (0.60)
Transgender woman (MTF, male to female) 10 (6.50)
Transvestite 1 (0.60)
Two-spirit 4 (2.60)
Gender not listed 2 (1.30)
Sexual orientation
Heterosexual 10 (6.50)
Gay 5 (3.20)
Lesbian 9 (5.80)
Bisexual 27 (17.40)
Asexual 20 (12.90)
Pansexual 39 (25.20)
Queer 27 (17.40)
Fluid 8 (5.20)
I do not identify as heterosexual, but I do not see my identity listed 8
(5.20) Missing 2
(1.30)
Ethnicity/Race
Caucasian 96 (61.90)
African American or Black 8 (5.20)
Asian 7 (4.50)
Alaskan/Native American 2 (1.30)
Latinx/Hispanic 11 (7.10)
Biracial 17 (11.00)
Multiracial 5 (3.20)
Unknown 2 (1.30)
Highest education level
Less than high school diploma 12 (7.70)
High school diploma or GED 28 (18.10)
Some college 40 (25.80)
Two year/technical college degree 16 (10.30)
Four year college degree 30 (19.40)
Some graduate/professional school9 (5.80)
Graduate or professional degree 19 (12.30)
Missing 1 (0.60)
Vocational status
Student 24 (15.50)
Disability 12 (7.70)
Unemployment 25 (16.10)
Unemployed student 1 (0.60)
Unemployed and disability 1 (0.60)
Retired 3 (1.90)
Retired disability 1 (0.60)
Full-time 47 (30.30)
Part-time 34 (21.90)
(continued)
 Table 1.
Continued.
n (%)
Part-time and student 3 (1.90
Part-time and disability 2 (1.30)
Student and disability 1 (0.60)
Missing 1 (0.60)
Current geographical location
Urban 61 (39.40)
Suburban 66 (42.60)
Rural 25 (16.10)
Other 2 (1.30)
Missing 1 (0.60)

and what incentives were available. If the identified individual chose to par-
ticipate, they were directed to an electronic informed consent form which
described the study, potential risks and benefits associated with participa-
tion, and compensation information. Participants were informed that they
had the option to skip any questions they did not feel comfortable answer-
ing or end the survey at any time. If participants still wished to continue,
they were instructed to click an “agree” button at the end of the form, indi-
cating their electronic consent. To assure confidentiality or anonymity of
the participants and the data collected, no identifying information was col-
lected as part of the study.

Measures
Demographics
Participants completed a basic demographics measure including questions
related to age, biological sex, gender identity, sexual orientation, race/ethni-
city, socioeconomic status, level of education, and marital status.
Participants were asked about their biological sex assigned at birth as well
as their current gender identity. All individuals who identified a difference
between their sex assigned at birth and current gender identity were
included in the study.

Gender minority stress and resilience measure (GMSR)

The GMSR (Testa et al., 2015)is a 58-item scale designed to assess 9 con-
structs via separate subscales: gender-related discrimination, gender-related
rejection, gender-related victimization, non-affirmation of gender identity,
internalized transphobia, negative expectations for future events, conceal-
ment, community connectedness, and pride. Participants respond to items
on a Likert-type scale ranging from 0 to 4 (0 ¼strongly disagree,
4 ¼strongly agree). Items 1–17 are scored 0 for never and 1 for any other
response. Total scores for each subscale related to proximal stressors, distal
stressors, and community resiliency factors were calculated by summing all
items in the subscale, with higher scores indicating higher levels of
endorsement. Once distal and proximal total scores were calculated, a com-
bined total stressor score was created to signify the total frequency and
severity of stressors experienced by the individual. The GMSR demon-
strated good internal consistency within this sample (A¼0.81).

Life events checklist for DSM-5 (LEC-5)

The LEC-5 (Weathers et al., 2013) was administered to assess the total
number of traumatic experiences reported by the individuals. This measure
includes 16 types of traumatic events, which the individual can state if they
have experienced, witnessed, learned about, or been exposed to it as part of
their work. For the present study, the LEC-5 was utilized to determine the
total number of traumatic events participants experienced.

Suicide behaviors questionnaire-revised (SBQ-R)

The SBQ-R (Osman et al., 2001) is a four-item self-report measure that
assesses for suicidal ideation, behaviors, communication, and likelihood of
future suicide attempts. The items are summed to yield a total score, which
allows individuals to be identified as potentially high risk for suicide. Total
scores on this measure can range from 3 to 18, with higher scores indicat-
ing higher suicide risk. In the general adult population, the recommended
cutoff score for high suicide risk is 7 or above, which has demonstrated
high levels of sensitivity and specificity. This measure demonstrated good
internal consistency within this sample (A¼0.84).

Data analysis plan

The Statistical Package for Social Sciences v.24 (SPSS; IBM, 2016) was uti-
lized to conduct the analyses for the present study. Descriptive analyses
were conducted to define sample characteristics, such as demographic
information (e.g. age, gender identity), the total number of traumatic events
experienced, and suicide risk. To test the hypotheses, two separate hierarch-
ical linear regressions were utilized with suicide risk serving as the criter-
ion. Prior to conducting analyses, all variables included in the regressions
were centered. To test the first hypothesis, the total stressors and total com-
munity resiliency scores were entered into the first step of the regression,
and an interaction term of total stressors and total community resiliency
scores was entered into the second step. To test the second hypothesis, total
traumatic events and total community resiliency scores were entered into
the first step, and an interaction term of traumatic events and community
resiliency scores were entered into the second step. All assumptions of the
 multiple linear regression analysis were passed prior to conducting analyses.
Bivariate correlations and means of all variables can be found in Table 2.

Results
The first hypothesis proposed that the community resiliency factors
described in the gender minority stress theory would moderate the relation-
ship between distal and proximal stressors and suicide risk. The first step
of the hierarchical multiple regression included total stressors (i.e., distal
and proximal stressors) and community resiliency factors with suicide risk
as to the criterion. The model was significant (F[2, 152] ¼2 21.67, p <
0.001)
and explained 22.2% of the variance in suicide risk (R ¼ 0.222). Within
this model, total stressors were found to be significant ( b ¼ 0.47,
p < 0.001), but community resiliency factors were not significant
(b ¼0.04,
— p 0.60). Next, the interaction term of total stressors and
community resiliency factors was added to the regression model (see
Table 3 for full model information). This model was found to be significant
(F[3, 151] ¼ 14.57, p 0.001), however, the interaction term was not sig-
nificant (b¼ —0.05, p 0.48), and only accounted for an additional 0.2%
of the variance in suicide risk (R2 0.224).
¼
The second hypothesis proposed that community resiliency factors from
the minority stress theory would moderate the relationship between the
number of traumatic events and suicide risk. The first step of the hierarch-
ical multiple regression included total traumatic events and community
resiliency factors with suicide risk as the criterion. The model was signifi-
cant (F[2,152] ¼ 4.12, p 0.02) and explained 5.1% of the variance
2
(R ¼0.051). Total number of traumatic events was found to be significant (b
¼ p 0.005), but community resiliency factors were not significant
0.23,
(b ¼ —0.03, p 0.68). An interaction term of traumatic events and commu-
nity resiliency factors was entered in the second step of the regression (see
Table 4 for full model information). The model was significant
(F[3,151] ¼ 2.83, p < 0.05). However, the interaction term was not found to
be significant (b ¼ —0.04, p ¼ 0.59) and accounted for an additional 0.02%
of the variance in suicide risk (R2 ¼ 0.053).

Table 2. Bivariate Correlations and Means

Numbe
Commun r of
Stressors ity SBQ-R trauma Mean
total resiliency total tic (SD)
total experie
nces
Stressors total – 0.01 0.22 61.44
(21.97)
Community resiliency 0.17 – 32.97
Note. mp < .
01.
Discussion
The present study examined the relationships between trauma exposure,
distal and proximal stressors, community resilience factors, and suicide risk
in a transgender and gender nonconforming sample. Our findings indicate
that the community resilience factors specified in the gender minority
stress theory (i.e. community connectedness and pride) were not sufficient
to mitigate the risk of suicide (Table 4). Community resilience did not sig-
nificantly moderate the relationships between minority stressors, trauma
exposure, and suicide risk. These findings are inconsistent with findings by
Moody et al. (2013, 2015) that suggest familial support, comfort, and
acceptance of one’s identity can buffer against suicide risk in transgender
samples. However, these findings are in line with a 2013 study by Moody
and Smith which found that social support from friends, which may be
analogous to community resilience, was not associated with decreased sui-
cide risk. It should be noted that the present study examined only one facet
of resiliency, specifically community resiliency, as compared to the more
individualized resiliency factors explored by other researchers (Bauer et al.,
2015; Moody et al., 2015; Moody & Smith, 2013). It is possible that com-
munity resilience alone is not sufficient to protect against increased suicide
risk and should be supplemented by other more internalized forms of
resiliency. Furthermore, given the high rates of suicidal behaviors within

Table 3. The Impact of the Relationship Between Minority Stressors and Community Resilience
on Suicide Risk
B SEB b sr2 R2D
Step 1 0.22
Stressors 0.08 0.01 0.47 0.47m
Community —0.02 0.03 —0.04 —0.04
Resiliency
Step 2 0.22
Stressors 0.08 0.01 0.47 0.47m
Community resiliency —0.02 0.03 —0.05 —0.05
Stressors × community resiliency —0.001 0.001 —0.05 —0.05
Note. mIndicates significance at p < 0.001.

Table 4. The Impact of the Relationship Between Trauma Exposure and Community Resilience
on Suicide Risk
B SEB b sr2 R2D
Step 1 0.05
Trauma exposure 0.18 0.06 0.23 0.23m
Community —0.01 0.03 —0.03 —0.03
resiliency
Step 2 0.002
Trauma exposure 0.17 0.06 0.22 0.22m
Community —0.02 0.03 —0.04 —0.04
resiliency
Trauma exposure × community resiliency —0.004 0.01 —0.04 —0.04
Note. mIndicates significance at p < 0.01.
this population, it is possible that the loss of a community member due
to suicide could ripple throughout the community and increase suicide
risk in other individuals (Maple, Cerel, Sanford, Pearce, & Jordan, 2017).
In other words, greater community involvement may lead to increased
exposure to suicidal behavior and suicide, which may be perceived as
traumatic and adversely impact the mental health of surviving commu-
nity members. This could further decrease the impact of community
resilience as a protective factor for individuals. An important part of
suicide prevention is identifying protective factors, such as resilience,
and incorporating this into a tangible prevention program (Caldwell,
2008). If the community resilience factors within the gender minority
stress model are not sufficient to mitigate suicide risk, there is additional
work to be done in the identification and cultivation of other protective
factors within this population outside of the gender minority stress the-
ory framework.
When interpreting these findings, it is important to consider the external
nature of these resilience factors. As demonstrated within the present study
as well as previous literature (e.g., Marshall et al., 2016), transgender indi-
viduals are at a drastically increased risk of experiencing gender-based dis-
crimination, harassment, and violence. It is possible that accessing these
external forms of resilience and engaging with the broader transgender
community requires a certain level of disclosure and visibility, which
exposes transgender individuals to the potential for additional stress, dis-
crimination, and even violence. Also, as described above, increased commu-
nity involvement may have negative consequences on the mental health of
transgender individuals by increasing their exposure to the potentially trau-
matic suicides of fellow community members (Maple et al., 2017). As such,
greater endorsement of community resilience may be associated with
greater endorsement of stressors and higher levels of distress. However, this
relationship has not been thoroughly investigated and requires further
exploration in order to better understand the complex interplay of
these factors.
These findings demonstrate the dire situation facing the transgender
community and emphasize the need for improved services and external
support systems. To achieve these goals and confront the alarming epi-
demic of violence and suicide threatening the transgender community, con-
crete steps must be taken to educate the public, provide more accessible
and sensitive healthcare, and to enact public policy reform, particularly in
the area of legal protections. Through these changes, additional protective
factors aside from community resiliency may be developed which
would subsequently decrease the risk of suicide within the trans-
gender population.
Implications for counselors
These findings demonstrate the necessity of not only assessing for the pres-
ence of suicidal ideation and/or behaviors but also assessing for the degree
to which gender minority stressors are causing distress and impairment in
this population. Counselors know the importance of assessing for suicide
risk in all clients, but due to the increased risk within the transgender
population, it is important to ask additional questions regarding the experi-
ence of distal and proximal stressors, as our results indicate these increase
suicide risk.
Furthermore, our findings suggest that although community resiliency
factors may decrease suicide risk, these decreases were not significant.
Based upon this, it would likely be beneficial for counselors working with
transgender individuals to spend time during a suicide risk assessment
identifying client strengths and working to develop resiliency factors unique
to their client. This is not to say that community resiliency factors should
not be incorporated into safety planning, but it is likely that additional cli- ent-
specific factors should be identified to effectively decrease suicide risk.

Limitations
The present study utilized a single measure which only captured two forms
of community resilience related to gender minority stress theory. It is pos-
sible that other forms of resilience which were not examined may play a
more significant role in mitigating the risk of suicide within this sample.
As stated in the introduction, a number of other protective factors such as
gender-consistent identity documentation, optimism, emotional stability,
and reasons for living have been examined in previous literature and found
to reduce suicide risk in this population (Bauer et al., 2015; Moody et al.,
2015; Moody & Smith, 2013). Additionally, this study was cross-sectional
in nature, which does not allow for causation to be explored. To that end,
this study was only able to examine significant associations between varia-
bles given the lack of temporal distance between these factors. Due to the
vast number of gender identities endorsed within this sample, we were
unable to examine potential differences between gender identities. Finally,
the sample included in this study were a convenience sample of individuals
who chose to participate in the study. For this reason, it is possible that
these results may not be generalizable to the many unique transgender
individuals not included in this study. Furthermore, the final sample
included in this study was limited to 155 individuals who responded to sui-
cide-related questions, which may limit the ability the detect fully detect
moderation given the low statistical power inherent in traditional moder-
ation analyses (Shieh, 2018).
Future directions
Future research should examine a wider range of internal protective factors
such as the ability to regulate suicidal thoughts and feelings, reasons for liv-
ing, and optimism within a transgender population. There is a wealth of
research on these protective factors within cisgender individuals (e.g.
Moody & Smith, 2013) and it is critical that these factors and other poten-
tially protective factors be researched and identified to contribute to suicide
prevention efforts within the transgender population. Further investigation
into community-level protective factors is also warranted. The additive
impact of community-level protective factors to more internal protective
factors should be considered, as together they may increase overall resili-
ency to suicide risk. Qualitative studies may provide important insights
into both internal and external sources of resilience that may be more
impactful and provide greater protection from suicide risk.

ORCID
Chelsea M. Cogan http://orcid.org/0000-0003-1225-713X

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