Amsterodamská klinika, 1972–2017: míra sebevražd 3–4krát nad úrovní populace, s úmrtími v každé fázi tranzice

Trendy rizika úmrtí na sebevraždu u transgenderových lidí: výsledky amsterodamské kohortové studie genderové dysforie (1972–2017)

Kohortové & registry studie Duševní zdraví & sebevražednost

Authors: C.M. Wiepjes, M. den Heijer, M.A. Bremmer, N.M. Nota, C.J.M. de Blok, B.J.G. Coumou, T.D. Steensma
Journal: Acta Psychiatrica Scandinavica
Year: 2020
Source: https://doi.org/10.1111/acps.13164

Summary

Researchers at Amsterdam's gender clinic, the largest in the Netherlands, went through the records of everyone referred there over 45 years and checked who had died by suicide. Of 8,263 people, 49 died by suicide, mostly trans women. In recent years the suicide rate was three to four times that of the Dutch population. The rate among trans women fell slightly over the decades, while among trans men it did not change. Suicides happened before, during and after medical transition: 16 were people who had finished genital surgery and only came in for check-ups. The authors conclude that suicide risk stays high at every stage and needs attention throughout care. The study has no matched comparison group and no mental-health data, so it shows the risk but cannot show whether treatment helps or harms.

Key findings

Z 8 263 lidí viděných v amsterdamské klinice v letech 1972 až 2017 (typicky sledovaných 7,5 roku) zemřelo 49 sebevraždou (0,6 %).
Ročně zemřelo sebevraždou asi 64 ze 100 000 trans žen (41 úmrtí, 0,8 %) a 29 ze 100 000 trans mužů (8 úmrtí, 0,3 %); trans ženy měly asi dvojnásobné riziko.
V letech 2013 až 2017 byla roční míra sebevražd mezi pacienty kliniky 40 na 100 000, oproti 11 v běžné nizozemské populaci.
Riziko sebevraždy u trans žen v průběhu let mírně kleslo a u trans mužů nevykázalo žádnou zřetelnou změnu.
Z 49 lidí, kteří zemřeli, bylo 17 posuzováno nebo na hormonech, 2 podstupovali operaci, 16 dokončilo operaci a docházelo jen na kontroly a 14 již nebylo v kontaktu s klinikou.
Lidé poprvé odeslaní před 18. rokem věku měli nižší podíl sebevražd (0,2 %, 4 úmrtí) než ti odeslaní jako dospělí (0,7 %).
Autoři uzavírají, že riziko sebevraždy přetrvává v každé fázi tranzice, a doporučují mu věnovat pozornost v průběhu celé péče.

Abstract

OBJECTIVE: This study explored the overall suicide death rate, the incidence over time, and the stage in transition where suicide deaths were observed in transgender people. METHODS: A chart study, including all 8263 referrals to our clinic since 1972. Information on death occurrence, time, and cause of death was obtained from multiple sources. RESULTS: Out of 5107 trans women (median age at first visit 28 years, median follow-up time 10 years) and 3156 trans men (median age at first visit 20 years, median follow-up time 5 years), 41 trans women and 8 trans men died by suicide. In trans women, suicide deaths decreased over time, while it did not change in trans men. Of all suicide deaths, 14 people were no longer in treatment, 35 were in treatment in the previous two years. The mean number of suicides in the years 2013-2017 was higher in the trans population compared with the Dutch population. CONCLUSIONS: We observed no increase in suicide death risk over time and even a decrease in suicide death risk in trans women. However, the suicide risk in transgender people is higher than in the general population and seems to occur during every stage of transitioning. It is important to have specific attention for suicide risk in the counseling of this population and in providing suicide prevention programs.

Conclusion

We observed no increase in suicide death risk over time and even a decrease in suicide death risk in trans women. However, the suicide risk in transgender people is higher than in the general population and seems to occur during every stage of transitioning. It is important to have specific attention for suicide risk in the counseling of this population and in providing suicide prevention programs, and to create a safe environment in which these feelings can be discussed at all stages of treatment. Further research is needed into the motives behind suicides to develop adequate prevention programmes.

Methodological limitations

No matched comparison group: The comparison with the general public used rough national suicide rates for 2013–2017 only, not people matched by age and sex. So how much higher the risk is, is only approximate.
Some suicides may be missed: This study looked back through records. Dates of death came from national records, but causes of death came from hospital, medical and psychology files, so suicides among people no longer in touch with the clinic may be missed or wrongly recorded. The authors admit some data may be missing.
No mental-health data: There was no information on other mental-health conditions, past self-harm, drug or alcohol use or social support, the main known warning signs for suicide.
Cannot judge whether treatment helps: The breakdown by stage of transition only describes where deaths happened. Without a comparison group or time spent in each stage, it cannot show whether hormones or surgery raise or lower suicide risk. It does show suicides continued after surgery was finished (16 of 49).
Patients changed over time: Trends by year of first visit mix changes in who was referred (younger patients, more trans men, a wider range of people) with any real change in risk. Recent patients were followed only briefly.
Waiting list left out: People on the waiting list before their first appointment were not included, though this group may be at high risk.
Small numbers in some groups: Only 8 suicides among trans men and 4 among those referred as children make the figures for these groups uncertain.
Clinic judging itself: All authors work at the clinic whose patients were studied. They declared no conflicts of interest, but the analysis was not independent.

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Summary

Key findings

Abstract

Conclusion