성전환 수술 후 자살 사망이 일치 대조군의 19배: 스웨덴 30년 코호트

성전환 수술을 받은 성전환자의 장기 추적: 스웨덴 코호트 연구

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

1973년부터 2003년 사이 스웨덴에서 성전환 수술을 받고 법적 성별을 바꾼 324명 전원(남성에서 여성 191명, 여성에서 남성 133명)을 출생 연도와 성별이 같은 일반인 3,240명과 비교했습니다.
모든 원인의 사망은 출생 성별이 같은 사람보다 약 3배 높았고, 그 차이는 약 10년 후부터 벌어졌습니다.
자살 사망은 약 19배 높았는데, 324명 중 10건의 자살과 비교 집단의 5건에 근거한 것입니다. 실제 수치는 매우 불확실합니다(약 6배에서 63배까지).
자살 시도는 약 5배, 정신과 입원은 약 3배 높았으며, 수술 전 정신과 입원(성전환 집단에서 약 4배 흔했음)을 고려한 뒤에도 마찬가지였습니다.
심장 및 혈관 질환 사망은 다소 높았고(약 2.5배, 9건), 암 사망은 높았을 가능성이 있습니다(약 2배). 저자들은 숫자가 작다고 경고했고 호르몬을 원인으로 지목하지 않았습니다.
1989년부터 2003년 사이 치료받은 사람들의 경우, 사망 및 자살 시도 증가는 우연일 수 있지만 정신과 입원은 여전히 약 2.5배 높았습니다.
여성에서 남성으로 간 사람은 다른 여성보다 범죄 유죄 판결이 많았고 남성과 비슷했으며, 남성에서 여성으로 간 사람은 다른 남성과 차이가 없었습니다.
저자들은 이 연구가 성전환 수술이 치료로서 효과가 있는지 보여줄 수 없으며, 수술이 없었다면 결과가 더 나빴을 수도 있다고 말합니다.

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