A crowd participates in a group hug at the end of a candle light vigil in January 2015 to remember the life of Leelah Alcorn, a 17-year-old transgender girl who committed suicide in Kings Mills, Ohio. (Meg Vogel/Cincinnati Enquirer/AP)

She picked up the phone and repeated these words, which had grown familiar, like the refrain of a song she never wanted to sing: “We’re listening. We hear you. We’ve gone through similar things.”

The person on the other end of the line, she said, “had typically just come out to themselves and really wanted to talk to someone.” Isolation in that moment, said Greta Gustava Martela, can be dire.

She would know. Martela, a transgender woman, has been hospitalized five times for “suicidality,” a term that encompasses suicidal ideation, planning, gestures, attempts and completed suicide. The first time was in 1995, said Martela, who is now 49.

She was lying in bed, awakened by a panic attack, she recalled. “I had an internal dialogue with myself for the first time about what it would be like to be trans and live that way,” she said, remembering a thought process that ultimately landed her in a psychiatric ward. But she has lived that way, coming out publicly as transgender and working as a software engineer and activist, after a stint in the military and a job as a metal welder, among other work.

Her own experience led her to found a hotline for transgender people in crisis called Trans Lifeline, based in Oakland, Calif.

New evidence of the need for such services arrived this week in a study in the September issue of Pediatrics, the flagship journal of the American Academy of Pediatrics. It shows that transgender adolescents attempt suicide at a much higher rate than young people whose gender identity matches the sex on their birth certificates.

Fifty-one percent of transgender male adolescents reported at least one suicide attempt — the highest rate in the study. The second highest was among young people who are nonbinary — those who do not identify exclusively as male or female — at 42 percent, while 30 percent of transgender female adolescents reported attempting suicide.

The study, “Transgender Adolescent Suicide Behavior,” analyzed data drawn from a “Profiles of Student Life: Attitudes and Behaviors” survey, which collected information from 120,617 young people, ages 11 to 19, across three years beginning in 2012. Less than 1 percent of surveyed adolescents identified as transgender.

Overall, about 14 percent said they had attempted suicide, which is the second-leading cause of death among young people ages 15 to 19, according to the Center for Disease Control. The leading cause is accidents.

The findings align with other accounts of the alarming rate at which transgender people try to kill themselves. For instance, a 2014 study by the American Foundation for Suicide Prevention and the Williams Institute, using results from the National Transgender Discrimination Survey, found that 41 percent of transgender people attempt suicide at least once. It also suggested that reported suicide attempts decrease with age.

Occasionally, individual cases have given names and faces to these numbers, casting a spotlight on what advocates say is a problem that remains in the shadows. A suicide note posted on Leelah Alcorn’s Tumblr page in 2014 before the transgender girl took her own life attracted global attention. Calls went out to make good on the 17-year-old’s own declaration: “The only way I will rest in peace is if one day transgender people aren’t treated the way I was, they’re treated like humans, with valid feelings and human rights.”

The study in Pediatrics shows just how disparately that sense of dehumanization affects transgender youth.

“Beyond providing additional and robust evidence for a disparity in suicide behavior for transgender and questioning adolescents,” the study is the first of its scale to reveal disparities “across diverse gender identities,” wrote the authors, whose expertise combines family studies and quantitative research. The study answered calls from the National Academy of Medicine, the authors note, “to examine within-group variability among transgender populations,” that is, how different segments of the transgender population experience problems.

Martela questioned that approach, saying it obscured the crisis facing the transgender community at large. “For every transgender group, it’s orders of magnitude too high,” she said. “And there’s nothing shocking about it. If you look at the things that cause people to be suicidal, whether it’s social rejection or homelessness, they all affect trans people more.”

A desire to help address these problems led her to volunteer for TransGender San Francisco, a social and support group. When she began managing the voice mailbox for the group’s 800 number, mainly used to field media inquiries, she realized there was a backlog of crisis calls — “people needing help who had found this number just by googling,” she said.

That led her to start the crisis hotline in 2014, a year after she had come out. Within three years, she said, the hotline had an 18-member staff and a million-dollar budget. She left the group after it gained accreditation in 2017 and is now a “semiretired housewife,” she said.

Raised in a Mormon family, Martela said almost all of her relatives turned their backs on her. “There’s one person in my family, my sister, who still talks to me,” she said.

Taking crisis calls, Martela said, gave her additional perspective on the importance of parental support. She said she heard from transgender youth who were “excited that they were starting to understand themselves and worried about sharing it with their parents.”

“A significant number of those kids call back after talking to their parents with their worlds shattered,” she said. “We would try to tell them to remember that they wouldn’t be 15 or 16 forever and that if they could hang in there, they could plan a future for themselves.”

If anything, the results understate the risk of suicide among young transgender people, the study’s authors acknowledged. Suicidal behavior was assessed based on a single question: “Have you ever tried to kill yourself?” But, as the study observed, “self-reported suicide behaviors are not consistently reported across time.”

The study shed light on additional factors examined in efforts to grapple with the problem of self-harm. While racial background and parental educational attainment, as well as whether the adolescent lives in a more urban area, were influential among the youth population at large, these were not meaningful factors among transgender youth, the study showed.

Having parents with higher education levels was not a mitigating factor. Nor did living in urban spaces, as opposed to rural places or small cities, reduce the odds of suicidal behavior.

Notably, there was no “exacerbating effect” for transgender youth identifying as a racial or ethnic minority, the study found.

“Our finding that transgender youth of color were not at a higher risk compared with white transgender adolescents reveals the need (as others have found in studies of sexual minority youth of color) to reconsider double-jeopardy narratives of intersectionality and examine the unique protective factors that may emerge at the intersection of multiple oppressions,” the authors wrote, though they recognized potential drawbacks from the “small size of intersecting subgroups.”

The study concluded that, “Suicide prevention efforts can be enhanced by attending to variability within transgender populations, particularly the heightened risk for female to male and nonbinary transgender adolescents.”

Martela said something more basic is required: “Human connection at that moment of crisis. It’s just about listening like you would to your friends.”

Along with the flood of desperate calls she managed, there were also people who had come to accept themselves and simply wanted to share their new self-understanding.

“We’re fine with that,” she said. “You don’t have to be suicidal to call.”

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