Gender-Surgery Patients Had 4–12x More Suicide Attempts Than Controls — But Prior Mental Health Wasn't Controlled

Risk of Suicide and Self-Harm Following Gender-Affirmation Surgery

Cohort & registry studies Surgery Mental health & suicide

Authors: John J. Straub, Krishna K. Paul, Lauren G. Bothwell, Sterling J. Deshazo, Georgiy Golovko, Michael S. Miller, Dietrich V. Jehle
Journal: Cureus
Year: 2024
Source: pmc.ncbi.nlm.nih.gov/articles/PMC11063965/

Summary

Researchers searched a large US health-record database for adults whose records noted a past sex-change surgery and who had an emergency visit. They compared five years of records with those of other emergency patients. Recorded suicide attempts, deaths, self-harm and post-traumatic stress were all several times more common in the surgery group. Suicide attempts were 12 times more common than among all emergency patients, and nearly 5 times more common than among people who had a vasectomy or had their tubes tied. The study shows this group carries a heavy mental health burden. But it cannot say whether surgery raised, lowered or did not change it. It did not compare trans people with and without surgery, and did not account for past mental health. In June 2024 the journal's editors corrected the conclusions to remove wording linking the risk to the surgery itself.

Key findings

Among 1,501 adults whose records noted past gender surgery and an emergency visit, 3.47% had a recorded suicide attempt within five years, compared with 0.29% of 15.6 million other emergency patients, about 12 times higher.
Compared with 1,489 matched patients who had a vasectomy or had their tubes tied, suicide attempts were 3.50% versus 0.74%, nearly 5 times higher.
Against the same sterilisation group, recorded death (4.9% vs 1.1%), suicide or self-harm (4.5% vs 0.9%) and post-traumatic stress (9.2% vs 2.8%) were also higher.
Groups were matched only on age, sex, race and ethnicity; past mental health diagnoses, past suicide attempts, hormone use and income were not taken into account.
People were found by a record code meaning 'personal history of sex reassignment', so the type and date of surgery are unknown, and the start of the five-year window is unclear.
A comparison with sore-throat patients gave broadly similar results (about 8 times more suicide attempts before matching), though too few events occurred to report a matched figure.
In June 2024 the journal's editors corrected the summary and conclusions, removing wording that said surgery itself was linked to higher suicide-attempt risk and instead saying patients who had surgery are at higher risk.
The authors admit the study shows links, not causes, and conclude that full mental health care is needed in the years after gender surgery.

Abstract

Introduction With the growing acceptance of transgender individuals, the number of gender affirmation surgeries has increased. Transgender individuals face elevated depression rates, leading to an increase in suicide ideation and attempts. This study evaluates the risk of suicide or self-harm associated with gender affirmation procedures.

Methods This retrospective study utilized de-identified patient data from the TriNetX (TriNetX, LLC, Cambridge, MA) database, involving 56 United States healthcare organizations and over 90 million patients. The study involved four cohorts: cohort A, adults aged 18-60 who had gender-affirming surgery and an emergency visit (N = 1,501); cohort B, control group of adults with emergency visits but no gender-affirming surgery (N = 15,608,363); and cohort C, control group of adults with emergency visits, tubal ligation or vasectomy, but no gender-affirming surgery (N = 142,093). Propensity matching was applied to cohorts A and C. Data from February 4, 2003, to February 4, 2023, were analyzed to examine suicide attempts, death, self-harm, and post-traumatic stress disorder (PTSD) within five years of the index event. A secondary analysis involving a control group with pharyngitis, referred to as cohort D, was conducted to validate the results from cohort C.

Results Individuals who underwent gender-affirming surgery had a 12.12-fold higher suicide attempt risk than those who did not (3.47% vs. 0.29%, RR 95% CI 9.20-15.96, p < 0.0001). Compared to the tubal ligation/vasectomy controls, the risk was 5.03-fold higher before propensity matching and remained significant at 4.71-fold after matching (3.50% vs. 0.74%, RR 95% CI 2.46-9.024, p < 0.0001) for the gender affirmation patients with similar results with the pharyngitis controls.

Conclusion Patients who have undergone gender-affirming surgery are associated with a significantly elevated risk of suicide, highlighting the necessity for comprehensive post-procedure psychiatric support.

Conclusion

The results of this study indicate that patients who have undergone gender affirmation surgery are associated with significantly higher risks of suicide, self-harm, and PTSD compared to general population control groups in this real-world database. With suicide being one of the most common causes of death for adolescent and middle-aged individuals, it is clear that we must work to prevent these unfortunate outcomes. This further reinforces the need for comprehensive psychiatric care in the years that follow gender-affirmation surgery.

Methodological limitations

Wrong comparison for the key question: Controls were non-trans emergency, sterilisation or sore-throat patients. So the study compares trans people with the general public, not trans people who did or did not have surgery. It cannot show whether surgery changes suicide risk. Critics including Erin Reed (Erin in the Morning, May 2024) pointed this out.
Past mental health ignored: Groups were matched only on age, sex, race and ethnicity. Past mental health diagnoses, past suicide attempts, drug or alcohol use, hormone treatment and income were not considered, even though trans people are known to have more mental health problems before any surgery.
Surgery defined by a vague record code: The surgery group was found by a code meaning 'personal history of sex reassignment'. It records neither the type of operation nor its date. So it is unclear whether problems happened after surgery, how long after, or whether the code catches only some people who had surgery.
Unclear starting point: The five-year window starts from an event that is not clearly defined (the code being entered, the surgery, or an emergency visit). People who had the outcome before the window were left out, which can distort the timing.
Only emergency patients: Every group was limited to people with an emergency visit. This is a select group, and reasons for going to emergency, including mental health crises, may differ between groups.
Headline figure not matched: The 12-times figure comes from an unmatched comparison with 15.6 million patients, because the system could not match a group that large.
How results were recorded: 'Suicide attempt' relied on a single record code, and 'death' meant death from any cause, not confirmed suicide. How codes are used and how complete records are may differ between groups and hospitals.
Numbers don't add up: The surgery group's suicide-attempt rate was 3.5% in the main analyses but 1.5% in the sore-throat analysis run four months later. The discussion also quotes a matched post-traumatic stress figure (3.74 times) that is actually the unmatched one; the matched table gives 3.23. These gaps are not explained.
Results swing with the comparison group: Suicide-attempt risk ranged from about 5 to 12 times higher depending on which control group was used. This shows the figures depend heavily on who the comparison is.
Journal corrected the framing: The authors say they expected higher risk after surgery and that results 'confirmed the hypothesis'. The editors later corrected the summary and conclusions to remove wording implying surgery had an effect (Cureus correction c182, June 2024).
No advance plan or bias checks: No study plan was published in advance, and no checks were reported on how much hidden factors could explain the results. The journal (Cureus) publishes quickly.
Limited reach: Data come from US healthcare organisations in one research network and only cover adults aged 18 to 60.

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Summary

Key findings

Abstract

Conclusion