Finland: høyere selvmordsrate hos unge henvist for kjønn forklart av psykiatrisk sykelighet, hevder registerstudie

Dødelighet av alle årsaker og selvmord blant ungdom og unge voksne som tok kontakt med spesialiserte kjønnsidentitetstjenester i Finland 1996–2019: en registerstudie

Kohort- og registerstudier Psykisk helse og selvmord Autisme, traumer og samsykdom

Authors: Sami-Matti Ruuska, Katinka Tuisku, Timo Holttinen, Riittakerttu Kaltiala
Journal: BMJ Mental Health
Year: 2024
Source: https://doi.org/10.1136/bmjment-2023-300940

Summary

Finnish researchers used national records to follow every young person (under 23) who came to Finland's two gender identity services between 1996 and 2019, comparing them with matched peers from the general population. Suicide was rare but more common in the gender-referred group (7 of 2,083, or 0.3%, versus 0.1%). Once the researchers accounted for how much specialist psychiatric care each person had received, the difference could easily have been chance, and those who did or did not have hormones or surgery did not clearly differ from controls. The authors conclude that mental illness, not gender dysphoria itself, drives suicide risk, and that transition has not been shown to prevent suicide. Because the result rests on a handful of deaths, and psychiatric care may partly result from gender distress, it is suggestive rather than proof.

Key findings

Studien inkluderte alle 2 083 under 23 år henvist til Finlands kjønnsidentitetstjenester fra 1996 til 2019 og 16 643 matchede jevnaldrende. Gjennomsnittsalderen ved henvisning var 18,5 år og folk ble fulgt i 6,5 år i gjennomsnitt.
Det var 55 dødsfall totalt, 20 av dem selvmord. 7 selvmord (0,3 %) var i gruppen henvist for kjønn og 13 (0,1 %) blant jevnaldrende.
Når man bare tok hensyn til kjønn og fødselsår, hadde gruppen henvist for kjønn omtrent 4 ganger selvmordsraten til jevnaldrende.
Etter også å ha tatt hensyn til mengden spesialisert psykiatrisk hjelp krympet selvmordsforskjellen til under 2 ganger og kunne lett være tilfeldig. Dødsfall av alle årsaker var ikke forskjellig.
71 % av ungdommene henvist for kjønn hadde vært hos psykiatriske spesialister (26 % mer enn 100 ganger) mot 26 % av jevnaldrende. Svært omfattende psykiatrisk hjelp var knyttet til omtrent 11 ganger selvmordsrisikoen.
38 % fikk hormoner eller kirurgi. Selvmordsrisikoen deres var ikke høyere enn jevnaldrendes, mens de uten behandling hadde omtrent 3 ganger risikoen, noe forfatterne vurderte kunne være tilfeldig under deres strenge test.
Forfatterne konkluderer med at overgang ikke reduserte selvmordsdødsfall og at det å finne og behandle psykisk sykdom er det viktigste.

Abstract

BACKGROUND: All-cause and suicide mortalities of gender-referred adolescents compared with matched controls have not been studied, and particularly the role of psychiatric morbidity in mortality is unknown. OBJECTIVE: To examine all-cause and suicide mortalities in gender-referred adolescents and the impact of psychiatric morbidity on mortality. METHODS: Finnish nationwide cohort of all <23 year-old gender-referred adolescents in 1996-2019 (n=2083) and 16 643 matched controls. Cox regression models with HRs and 95% CIs were used to analyse all-cause and suicide mortalities. FINDINGS: Of the 55 deaths in the study population, 20 (36%) were suicides. In bivariate analyses, all-cause mortality did not statistically significantly differ between gender-referred adolescents and controls (0.5% vs 0.3%); however, the proportion of suicides was higher in the gender-referred group (0.3% vs 0.1%). The all-cause mortality rate among gender-referred adolescents (controls) was 0.81 per 1000 person-years (0.40 per 1000 person-years), and the suicide mortality rate was 0.51 per 1000 person-years (0.12 per 1000 person-years). However, when specialist-level psychiatric treatment was controlled for, neither all-cause nor suicide mortality differed between the two groups: HR for all-cause mortality among gender-referred adolescents was 1.0 (95% CI 0.5 to 2.0) and for suicide mortality was 1.8 (95% CI 0.6 to 4.8). CONCLUSIONS: Clinical gender dysphoria does not appear to be predictive of all-cause nor suicide mortality when psychiatric treatment history is accounted for. CLINICAL IMPLICATIONS: It is of utmost importance to identify and appropriately treat mental disorders in adolescents experiencing gender dysphoria to prevent suicide.

Conclusion

Clinical gender dysphoria does not appear to be predictive of all-cause or suicide mortality when psychiatric treatment history is accounted for. The authors state that suicide in this population appears to be explained by psychiatric morbidity, that medical gender reassignment did not show an impact on suicide risk, and that the risk of suicide attributed to transgender identity or gender dysphoria per se may have been overestimated. It is of utmost importance to identify and appropriately treat mental disorders in adolescents experiencing gender dysphoria to prevent suicide, and health policies should ensure professionals receive accurate information along these lines.

Methodological limitations

Very few deaths: Only 7 suicides happened in the gender-referred group, and 55 deaths overall. The figures are very uncertain, and the comparison by treatment is far too small to be reliable.
May have adjusted away a real link: Psychiatric care may partly result from gender dysphoria rather than being a separate cause. Accounting for it could hide a real link. The authors admit this, and critics (such as TransLucent and epidemiologist Gideon Meyerowitz-Katz, 2024) argue it undermines the main conclusion.
Timing of psychiatric care mixed up: Psychiatric visits were counted over the whole follow-up, including after referral and close to death, not just before. This blurs whether mental illness was a separate cause or part of the path to suicide.
Rough measure of mental illness: Mental illness was measured by the number of specialist visits, not by diagnoses, severity or past self-harm, so it is an imperfect stand-in.
Unusually strict test: The authors used a stricter-than-usual bar to call the higher suicide risk in untreated youth (about 3 times) possibly chance. Sullins (2024, an unreviewed commentary) argues that by normal standards this finding should not be dismissed.
Treated people were selected: Doctors chose who got hormones or surgery. In Finland's cautious system, people with more serious mental health problems may have been less likely to get treatment, so differences by treatment cannot be read as cause and effect.
No split by birth sex: The records do not track changes in registered sex, so results could not be split by birth sex, even though suicide rates differ by sex.
Few other factors, short follow-up: Peers were matched only on age and home town. Social support, drug and alcohol use and income were not accounted for, and 6.5 years is short for studying deaths.
May not apply elsewhere: Results apply to young people referred to clinics in Finland and may not apply to other countries or to trans-identifying youth who never seek services.
Author's views: The senior author leads teen gender identity work at Tampere University Hospital, one of the two services studied. She is a well-known critic of affirmation-first care, served on the Cass Review advisory board and has given keynote talks at SEGM (a group critical of youth gender medicine).

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Summary

Key findings

Abstract

Conclusion