Registre danois : tentatives de suicide ×7,7 et décès par suicide ×3,5 chez les personnes trans sur 42 ans

Identité transgenre, tentatives de suicide et mortalité au Danemark

Études de cohorte & registres Santé mentale & suicide

Authors: Annette Erlangsen, Anna Lund Jacobsen, Anne Ranning, Alex Lauridsen Delamare, Merete Nordentoft, Morten Frisch
Journal: JAMA
Year: 2023
Source: https://doi.org/10.1001/jama.2023.8627

Summary

Danish researchers linked national records covering 6.7 million people over 42 years. They found 3,759 transgender people from hospital diagnoses or legal gender changes and compared their suicide attempts and deaths with everyone else's. Taking only age, birth sex and time period into account, transgender people had about 7.7 times the rate of hospital-treated suicide attempts, 3.5 times the suicide rate (12 deaths) and about twice the death rate from any cause. The gaps shrank over time but were still there in the latest decade, when transition care was widely available. The authors partly blame the stress of being a minority. But the study did not account for the much higher rates of mental illness in the transgender group, had no data on hormones or surgery, and found people mostly through hospital diagnoses. It shows higher risk, not its cause.

Key findings

Sur 6,66 millions de personnes nées au Danemark suivies pendant 42 ans, 3 759 (0,06 %) ont été identifiées comme transgenres, typiquement à 22 ans.
Les tentatives de suicide traitées à l'hôpital ont eu lieu à 498 contre 71 pour 100 000 personnes par an, soit environ 7,7 fois plus souvent, d'après 92 personnes transgenres ayant fait une tentative.
Les décès par suicide étaient de 75 contre 21 pour 100 000 personnes par an, soit environ 3,5 fois plus souvent, d'après 12 décès parmi les personnes transgenres, toutes nées hommes.
Les décès toutes causes confondues étaient environ deux fois plus fréquents, surtout à cause de 245 décès sans rapport avec le suicide (environ 1,9 fois plus fréquents).
En 2010-2021, les taux restaient plus élevés : tentatives de suicide environ 6,6 fois, décès par suicide environ 2,8 fois (2000-2021) et tous les décès environ 1,7 fois plus fréquents.
Les personnes repérées uniquement par un changement légal de genre avaient plus de tentatives de suicide (environ 5 fois plus) mais pas de décès supplémentaires d'autres causes ni au total, contrairement à celles repérées par les dossiers hospitaliers.
La maladie mentale et physique n'a volontairement pas été prise en compte, si bien que les chiffres montrent des liens d'ensemble, et non l'effet du fait d'être transgenre en soi.

Abstract

IMPORTANCE: Prior studies have suggested that transgender individuals may be a high-risk group with respect to suicide attempt and mortality, but large-scale, population-based investigations are lacking. OBJECTIVE: To examine in a national setting whether transgender individuals have higher rates of suicide attempt and mortality than nontransgender individuals. DESIGN, SETTING, AND PARTICIPANTS: Nationwide, register-based, retrospective cohort study on all 6 657 456 Danish-born individuals aged 15 years or older who lived in Denmark between January 1, 1980, and December 31, 2021. EXPOSURE: Transgender identity was determined through national hospital records and administrative records of legal change of gender. MAIN OUTCOMES AND MEASURES: Suicide attempts, suicide deaths, nonsuicidal deaths, and deaths by any cause during 1980 through 2021 were identified in national hospitalization and causes of death registers. Adjusted incidence rate ratios (aIRRs) with 95% CIs controlling for calendar period, sex assigned at birth, and age were calculated. RESULTS: The 6 657 456 study participants (50.0% assigned male sex at birth) were followed up during 171 023 873 person-years. Overall, 3759 individuals (0.06%; 52.5% assigned male sex at birth) were identified as transgender at a median age of 22 years (IQR, 18-31 years) and followed up during 21 404 person-years, during which 92 suicide attempts, 12 suicides, and 245 suicide-unrelated deaths occurred. Standardized suicide attempt rates per 100 000 person-years were 498 for transgender vs 71 for nontransgender individuals (aIRR, 7.7; 95% CI, 5.9-10.2). Standardized suicide mortality rates per 100 000 person-years were 75 for transgender vs 21 for nontransgender individuals (aIRR, 3.5; 95% CI, 2.0-6.3). Standardized suicide-unrelated mortality rates per 100 000 person-years were 2380 for transgender vs 1310 for nontransgender individuals (aIRR, 1.9; 95% CI, 1.6-2.2), and standardized all-cause mortality rates per 100 000 person-years were 2559 for transgender vs 1331 for nontransgender individuals (aIRR, 2.0; 95% CI, 1.7-2.4). Despite declining rates of suicide attempts and mortality during the 42 years covered, aIRRs remained significantly elevated in recent calendar periods up to and including 2021 for suicide attempts (aIRR, 6.6; 95% CI, 4.5-9.5), suicide mortality (aIRR, 2.8; 95% CI, 1.3-5.9), suicide-unrelated mortality (aIRR, 1.7; 95% CI, 1.5-2.1), and all-cause mortality (aIRR, 1.7; 95% CI, 1.4-2.1). CONCLUSIONS AND RELEVANCE: In this Danish population-based, retrospective cohort study, results suggest that transgender individuals had significantly higher rates of suicide attempt, suicide mortality, suicide-unrelated mortality, and all-cause mortality compared with the nontransgender population.

Conclusion

In this Danish population-based, retrospective cohort study, results suggest that transgender individuals had significantly higher rates of suicide attempt, suicide mortality, suicide-unrelated mortality, and all-cause mortality compared with the nontransgender population. Despite declining rates over 42 years, adjusted rate ratios remained elevated through 2021. The authors suggest the excess may partly reflect minority stress, and recommend suicide-prevention efforts including encouraging help-seeking and reducing structural discrimination.

Methodological limitations

Mental illness not taken into account: The authors saw mental and physical illness as possible steps between being transgender and dying, so they did not account for them. Mental illness was far more common in the transgender group (about 43% vs 7%, according to an analysis of the paper's tables by the Society for Evidence-Based Gender Medicine). So the study cannot separate the role of gender identity from that of other mental health conditions.
No treatment data: There is no information on puberty blockers, hormones or surgery, so the study says nothing about whether transition changes suicide risk. Higher risk continued in 2010–2021, when such care was widely available in Denmark.
Very few suicides: The suicide figure rests on 12 deaths, all among people born male. The true figure could be anywhere from about 2 to 6 times the normal rate, and figures for separate time periods are even less certain.
Mostly found through hospitals: 93% were found through hospital diagnoses, so the group over-represents people in contact with services, who may be more unwell. People found only through legal gender change had no extra deaths from other causes, which suggests hospital contact explains part of the gap.
Suicide attempts under-recorded: Only attempts treated in hospital were counted, and the authors note Danish records miss some. If one group seeks help more than the other, the comparison could be skewed either way.
Counted only from first record: People counted as transgender only from their first diagnosis or legal change, and anyone with an attempt before then was dropped from that part. This may miss attempts that came before, or led to, the diagnosis.
Almost nothing taken into account: Only time period, birth sex and age were allowed for. Income, drug and alcohol use, and the shift after 2015 toward more teenage girls among patients were not.
May not apply widely: Immigrants were excluded, and the findings may not apply to transgender people who never use hospital care or change legal gender.
Many comparisons made: Because so many comparisons were made, the authors say the results should be treated as a first look, not firm conclusions.
Author ties: One author works for counselling services at LGBT+ Denmark, an advocacy group. The discussion mainly blames the stress of being a minority without testing this.

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Summary

Key findings

Abstract

Conclusion