Ella was 14 when she attempted suicide for the first time.
She had always known she was different. Ever since she was a child, growing up in South Asia, she felt uncomfortable in her own skin. She would get beat up at school, and family members would make "weird comments" about her behaviour. After her family immigrated to Toronto when she was 11, it was even harder. "I had an accent, I dressed differently, I was shy … I was an easy target," she says.
She was 13 when things started to make sense. Physically, Ella had been born a boy, but she knew that on the inside, she was a girl.
"I woke up and realized one day, you know what, I have to stop lying to myself," she says. "Life is too short and I really want to be who I am. I've always been a girl, I am a girl, and I want to be that person physically to match who I am inside."
She told her parents everything, and "they didn't understand at all."
The suicide attempt was a cry for help, she says. She would try, and fail, again.
A new study by Western University researchers suggests those attempts may have been preventable.
The study, published June 2 in the journal BMC Public Health, found a connection between the risk of suicide amongst transgender people and factors such as parental support, transphobia and ease of access to a medical transition, if the person desires one.
This is the first evidence that transgender people could be at a higher risk of suicide because of modifiable factors in their lives, rather than because of innate discomfort at being transgender, the study's authors say.
About 35 per cent of transgender people in Ontario seriously considered suicide in the past year, and about 11 per cent attempted suicide, the study found. Those numbers far outstrip the statistics for the base population: 3.7 per cent and 0.6 per cent, respectively.
The study is based on a survey of 380 trans people in Ontario aged 16 or older. At the time the data was collected, "There were no survey data on trans people from anywhere in Canada," says Greta Bauer, an associate professor of epidemiology and biostatistics at Western and the study's lead author.
Bauer's team looked at 13 modifiable factors in the lives of trans people. They found that strong parental support for expressed gender "corresponds to a potential prevention of 170 trans persons per 1000" from seriously considering suicide, and those who reported experiencing lower levels of transphobia were 66 per cent less likely to have seriously considered suicide in the past year.
Among those who wanted a medical transition, people who had begun hormone therapy were "about half as likely to have seriously considered suicide." About one-quarter of trans people in Ontario don't want a medical transition, the researchers say.
The study also found a significant decrease in suicide risk among those who had identity documents – such as a driver's licence, health card or passport – matching their expressed gender. Having proper ID was found to have the potential to prevent 90 in 1000 trans people from seriously considering suicide.
"If somebody lives as a male, and has only 'F' on their identity documents, then they're not able to go out to the bar with friends, or travel, or feel safe driving in the case that they get pulled over," Bauer says.
This was certainly the case for Ella (she asked to be identified by a pseudonym in this story, because not everyone in her life knows about her past). When she was in university – after she had started taking hormones and presenting as a woman, but before completing her medical transition – her ID still had an M on it. Her friends, who didn't know about her past, didn't understand why she didn't want to go out with them.
"I literally stopped doing things and living life because I didn't have proper documentation," she says.
It took years for Ella, 26, to get sex reassignment surgery, which was completed in 2012. Long before that, as a teenager, she attempted suicide again and ran away from home. She lived in a homeless shelter for several months, where she says she "saw stuff that no child that age should see or experience."
"It was definitely trying to seek attention," she says of the suicide attempts.
But three years after her surgery, Ella is happy. She has reconciled with her parents, who now love and accept her as their daughter, and she has a job in the fashion industry in Toronto. The bad memories of the past almost feel "like a dream," she says.
"I'm a woman, a human being, wanting to live life just like everyone else."