Suicide Deaths 19 Times Higher After Sex Reassignment Than in Matched Population: 30-Year Swedish Cohort

Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden

Cohort & registry studies Surgery Mental health & suicide

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

All 324 people in Sweden who had sex reassignment surgery and changed legal sex between 1973 and 2003 (191 male-to-female, 133 female-to-male) were compared with 3,240 people from the general public of the same birth year and sex.
Deaths from all causes were about 3 times higher than in people of the same birth sex, with the difference opening up after about 10 years.
Death by suicide was about 19 times higher, based on 10 suicides among the 324 compared with 5 in the comparison group. The true figure is very uncertain (anywhere from about 6 to 63 times).
Suicide attempts were about 5 times higher and psychiatric hospital stays about 3 times higher, even after allowing for psychiatric stays before surgery, which were about 4 times as common in the reassigned group.
Deaths from heart and blood vessel disease were somewhat raised (about 2.5 times; 9 deaths), and cancer deaths were possibly raised (about 2 times). The authors warn the numbers were small and did not blame hormones.
For people treated from 1989 to 2003, the extra deaths and suicide attempts could have been chance, though psychiatric hospital stays were still about 2.5 times higher.
Female-to-male people had more criminal convictions than other women, about the same as men; male-to-female people did not differ from other men.
The authors say the study cannot show whether sex reassignment works as a treatment, and that results might have been even worse without it.

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