19-fach höhere Suizidrate nach Geschlechtsumwandlung als in der Vergleichsbevölkerung: schwedische 30-Jahres-Kohorte

Langzeit-Nachbeobachtung transsexueller Personen nach geschlechtsangleichender Operation: Kohortenstudie in Schweden

Kohorten- & Registerstudien Operationen Psychische Gesundheit & Suizidalität

Authors: Cecilia Dhejne, Paul Lichtenstein, Marcus Boman, Anna L. V. Johansson, Niklas Långström, Mikael Landén
Journal: PLOS ONE
Year: 2011
Source: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0016885

Summary

Swedish researchers used national records to follow everyone who had sex reassignment surgery and changed legal sex between 1973 and 2003. They compared each person with ten random people of the same age and sex. Over about 11 years, the reassigned group died about three times as often and died by suicide about 19 times as often. They were about five times as likely to attempt suicide and three times as likely to be admitted for psychiatric care, even after allowing for earlier psychiatric admissions. The gaps in deaths and suicide attempts were mainly among people treated before 1989. The authors concluded that surgery, while easing gender distress, is not enough on its own, and better long-term care is needed. Because the comparison was with the general public, not trans people who did not transition, the study cannot say whether surgery made things better or worse.

Key findings

Alle 324 Personen in Schweden, die zwischen 1973 und 2003 eine geschlechtsangleichende Operation hatten und ihr rechtliches Geschlecht änderten (191 von männlich zu weiblich, 133 von weiblich zu männlich), wurden mit 3.240 Personen aus der Allgemeinbevölkerung gleichen Geburtsjahrs und Geschlechts verglichen.
Todesfälle aus allen Ursachen waren etwa 3-mal so häufig wie bei Personen gleichen Geburtsgeschlechts, wobei sich der Unterschied nach etwa 10 Jahren zeigte.
Tod durch Suizid war etwa 19-mal so häufig, bei 10 Suiziden unter den 324 gegenüber 5 in der Vergleichsgruppe. Die wahre Größe ist sehr unsicher (irgendwo zwischen etwa dem 6- und 63-Fachen).
Suizidversuche waren etwa 5-mal und psychiatrische Klinikaufenthalte etwa 3-mal so häufig, selbst unter Berücksichtigung psychiatrischer Aufenthalte vor der Operation, die in der angeglichenen Gruppe etwa 4-mal so häufig waren.
Todesfälle durch Herz-Kreislauf-Erkrankungen waren etwas erhöht (etwa das 2,5-Fache; 9 Todesfälle), und Krebstodesfälle möglicherweise erhöht (etwa das 2-Fache). Die Autoren warnen, dass die Zahlen klein waren, und machten nicht die Hormone verantwortlich.
Bei den von 1989 bis 2003 Behandelten könnten die zusätzlichen Todesfälle und Suizidversuche Zufall gewesen sein, auch wenn psychiatrische Klinikaufenthalte weiterhin etwa 2,5-mal so häufig waren.
Menschen von weiblich zu männlich hatten mehr strafrechtliche Verurteilungen als andere Frauen, etwa so viele wie Männer; Menschen von männlich zu weiblich unterschieden sich nicht von anderen Männern.
Die Autoren sagen, die Studie könne nicht zeigen, ob die Geschlechtsangleichung als Behandlung wirkt, und dass die Ergebnisse ohne sie möglicherweise noch schlechter gewesen wären.

Abstract

Context: The treatment for transsexualism is sex reassignment, including hormonal treatment and surgery aimed at making the person's body as congruent with the opposite sex as possible. There is a dearth of long term, follow-up studies after sex reassignment.

Objective: To estimate mortality, morbidity, and criminal rate after surgical sex reassignment of transsexual persons.

Design: A population-based matched cohort study.

Setting: Sweden, 1973-2003.

Participants: All 324 sex-reassigned persons (191 male-to-females, 133 female-to-males) in Sweden, 1973-2003. Random population controls (10:1) were matched by birth year and birth sex or reassigned (final) sex, respectively.

Main Outcome Measures: Hazard ratios (HR) with 95% confidence intervals (CI) for mortality and psychiatric morbidity were obtained with Cox regression models, which were adjusted for immigrant status and psychiatric morbidity prior to sex reassignment (adjusted HR [aHR]).

Results: The overall mortality for sex-reassigned persons was higher during follow-up (aHR 2.8; 95% CI 1.8-4.3) than for controls of the same birth sex, particularly death from suicide (aHR 19.1; 95% CI 5.8-62.9). Sex-reassigned persons also had an increased risk for suicide attempts (aHR 4.9; 95% CI 2.9-8.5) and psychiatric inpatient care (aHR 2.8; 95% CI 2.0-3.9). Comparisons with controls matched on reassigned sex yielded similar results. Female-to-males, but not male-to-females, had a higher risk for criminal convictions than their respective birth sex controls.

Conclusions: Persons with transsexualism, after sex reassignment, have considerably higher risks for mortality, suicidal behaviour, and psychiatric morbidity than the general population. Our findings suggest that sex reassignment, although alleviating gender dysphoria, may not suffice as treatment for transsexualism, and should inspire improved psychiatric and somatic care after sex reassignment for this patient group.

Conclusion

Persons with transsexualism, after sex reassignment, have considerably higher risks for mortality, suicidal behaviour, and psychiatric morbidity than the general population. Our findings suggest that sex reassignment, although alleviating gender dysphoria, may not suffice as treatment for transsexualism, and should inspire improved psychiatric and somatic care after sex reassignment for this patient group.

Methodological limitations

No untreated comparison group: The comparison was with the general public, not people with gender dysphoria who did not have surgery. So the study cannot judge whether treatment made things better or worse. The authors say the results should not be read as showing that surgery itself causes illness or death.
Few other factors allowed for: The analysis only took account of earlier psychiatric hospital stays and being an immigrant. Earlier outpatient mental health problems, drug and alcohol use, smoking, poverty, HIV and discrimination were not accounted for.
Older treatment era: Most of the group were treated in the 1970s and 1980s. For those treated from 1989 to 2003, extra deaths and suicide attempts could have been chance, so the overall figures may overstate the risk for later patients.
Few deaths, uncertain figures: The 19-times suicide figure rests on 10 suicides (versus 5 in the comparison group), so the true figure could be anywhere from about 6 to 63 times higher. There were only 9 heart deaths, and the authors note the study was too small to be precise.
Hospital stays only: Mental illness was measured only by psychiatric hospital stays, because reliable outpatient data were not available. This undercounts mental illness, and differences in who gets admitted could skew the comparison.
Surgery worked out indirectly: Who had surgery was worked out from hospital diagnosis codes plus a change of legal sex. The exact operations were not recorded, and the diagnosis code used was not specific.
No hormone or lifestyle data: Type, dose and length of hormone use and smoking were not recorded, so the extra heart and cancer deaths cannot be blamed on cross-sex hormones. The authors note most cancers seen were unlikely to be hormone-related.
No measures of benefit: The study did not measure gender distress, quality of life or satisfaction, so it says nothing about whether surgery relieved distress.
Small subgroups: Comparisons between male-to-female and female-to-male groups, including the crime results, were too small to be reliable, as the authors admit.
May not apply today: Patients were mostly adults treated under strict Swedish rules before 2004, mainly born male. Results may not apply to today's larger, younger, mostly female patients or to people who transition without surgery.
Rough start date: The date of surgery was estimated from hospital records. According to the authors, this could slightly undercount some events but not deaths.
Often misquoted: The lead author has said publicly that the paper is often wrongly cited as proof that transition causes suicide (TransAdvocate interview 2015; Reddit Q&A 2017). The paper itself does not claim cause either way.

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Summary

Key findings

Abstract

Conclusion