Suicidi 19 volte più alti dopo la riassegnazione del sesso che nella popolazione di confronto: coorte svedese di 30 anni

Follow-up a lungo termine di persone transessuali sottoposte a intervento di riassegnazione del sesso: studio di coorte in Svezia

Studi di coorte e registro Chirurgia Salute mentale e suicidio

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

Tutte le 324 persone in Svezia che tra il 1973 e il 2003 hanno fatto la chirurgia di riassegnazione del sesso e il cambio legale di sesso (191 da maschio a femmina, 133 da femmina a maschio) sono state confrontate con 3.240 persone della popolazione generale dello stesso anno di nascita e sesso.
I decessi per tutte le cause erano circa 3 volte più alti rispetto alle persone dello stesso sesso di nascita, con una differenza che emergeva dopo circa 10 anni.
Il suicidio era circa 19 volte più alto, sulla base di 10 suicidi tra le 324 persone contro 5 nel gruppo di confronto. Il valore reale è molto incerto (da circa 6 a 63 volte).
I tentativi di suicidio erano circa 5 volte più alti e i ricoveri psichiatrici circa 3 volte più alti, anche tenendo conto dei ricoveri psichiatrici precedenti alla chirurgia, che erano circa 4 volte più comuni nel gruppo che aveva fatto la riassegnazione.
I decessi per malattie cardiache e dei vasi sanguigni erano in qualche misura aumentati (circa 2,5 volte; 9 decessi) e quelli per cancro forse aumentati (circa 2 volte). Gli autori avvertono che i numeri erano piccoli e non hanno attribuito la colpa agli ormoni.
Per chi era stato trattato tra il 1989 e il 2003, l'eccesso di decessi e di tentativi di suicidio poteva essere dovuto al caso, anche se i ricoveri psichiatrici restavano circa 2,5 volte più alti.
Le persone da femmina a maschio avevano più condanne penali rispetto alle altre donne, circa quanto gli uomini; le persone da maschio a femmina non differivano dagli altri uomini.
Gli autori affermano che lo studio non può dire se la riassegnazione del sesso funzioni come trattamento, e che i risultati avrebbero potuto essere persino peggiori senza di essa.

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