Clínica de Amsterdã, 1972–2017: taxa de suicídio 3 a 4 vezes a da população, com mortes em todas as etapas da transição

Tendências no risco de morte por suicídio em pessoas transgênero: resultados do estudo da coorte de Amsterdã sobre disforia de gênero (1972–2017)

Estudos de coorte e registros Saúde mental e suicídio

Authors: C.M. Wiepjes, M. den Heijer, M.A. Bremmer, N.M. Nota, C.J.M. de Blok, B.J.G. Coumou, T.D. Steensma
Journal: Acta Psychiatrica Scandinavica
Year: 2020
Source: https://doi.org/10.1111/acps.13164

Summary

Researchers at Amsterdam's gender clinic, the largest in the Netherlands, went through the records of everyone referred there over 45 years and checked who had died by suicide. Of 8,263 people, 49 died by suicide, mostly trans women. In recent years the suicide rate was three to four times that of the Dutch population. The rate among trans women fell slightly over the decades, while among trans men it did not change. Suicides happened before, during and after medical transition: 16 were people who had finished genital surgery and only came in for check-ups. The authors conclude that suicide risk stays high at every stage and needs attention throughout care. The study has no matched comparison group and no mental-health data, so it shows the risk but cannot show whether treatment helps or harms.

Key findings

Das 8.263 pessoas atendidas na clínica de Amsterdã de 1972 a 2017 (tipicamente acompanhadas por 7,5 anos), 49 morreram por suicídio (0,6%).
A cada ano, cerca de 64 em 100.000 mulheres trans (41 mortes, 0,8%) e 29 em 100.000 homens trans (8 mortes, 0,3%) morreram por suicídio; as mulheres trans tinham cerca de duas vezes o risco.
De 2013 a 2017, a taxa anual de suicídio entre os pacientes da clínica foi de 40 por 100.000, contra 11 na população geral holandesa.
O risco de suicídio diminuiu ligeiramente ao longo dos anos nas mulheres trans e não mostrou mudança clara nos homens trans.
Das 49 pessoas que morreram, 17 estavam sendo avaliadas ou em uso de hormônios, 2 estavam fazendo cirurgia, 16 haviam concluído a cirurgia e só vinham para consultas de controle e 14 já não tinham contato com a clínica.
As pessoas encaminhadas pela primeira vez antes dos 18 anos tinham uma parcela menor de suicídios (0,2%, 4 mortes) do que as encaminhadas na idade adulta (0,7%).
Os autores concluem que o risco de suicídio persiste em todas as etapas da transição e recomendam atenção a ele ao longo de todo o atendimento.

Abstract

OBJECTIVE: This study explored the overall suicide death rate, the incidence over time, and the stage in transition where suicide deaths were observed in transgender people. METHODS: A chart study, including all 8263 referrals to our clinic since 1972. Information on death occurrence, time, and cause of death was obtained from multiple sources. RESULTS: Out of 5107 trans women (median age at first visit 28 years, median follow-up time 10 years) and 3156 trans men (median age at first visit 20 years, median follow-up time 5 years), 41 trans women and 8 trans men died by suicide. In trans women, suicide deaths decreased over time, while it did not change in trans men. Of all suicide deaths, 14 people were no longer in treatment, 35 were in treatment in the previous two years. The mean number of suicides in the years 2013-2017 was higher in the trans population compared with the Dutch population. CONCLUSIONS: We observed no increase in suicide death risk over time and even a decrease in suicide death risk in trans women. However, the suicide risk in transgender people is higher than in the general population and seems to occur during every stage of transitioning. It is important to have specific attention for suicide risk in the counseling of this population and in providing suicide prevention programs.

Conclusion

We observed no increase in suicide death risk over time and even a decrease in suicide death risk in trans women. However, the suicide risk in transgender people is higher than in the general population and seems to occur during every stage of transitioning. It is important to have specific attention for suicide risk in the counseling of this population and in providing suicide prevention programs, and to create a safe environment in which these feelings can be discussed at all stages of treatment. Further research is needed into the motives behind suicides to develop adequate prevention programmes.

Methodological limitations

No matched comparison group: The comparison with the general public used rough national suicide rates for 2013–2017 only, not people matched by age and sex. So how much higher the risk is, is only approximate.
Some suicides may be missed: This study looked back through records. Dates of death came from national records, but causes of death came from hospital, medical and psychology files, so suicides among people no longer in touch with the clinic may be missed or wrongly recorded. The authors admit some data may be missing.
No mental-health data: There was no information on other mental-health conditions, past self-harm, drug or alcohol use or social support, the main known warning signs for suicide.
Cannot judge whether treatment helps: The breakdown by stage of transition only describes where deaths happened. Without a comparison group or time spent in each stage, it cannot show whether hormones or surgery raise or lower suicide risk. It does show suicides continued after surgery was finished (16 of 49).
Patients changed over time: Trends by year of first visit mix changes in who was referred (younger patients, more trans men, a wider range of people) with any real change in risk. Recent patients were followed only briefly.
Waiting list left out: People on the waiting list before their first appointment were not included, though this group may be at high risk.
Small numbers in some groups: Only 8 suicides among trans men and 4 among those referred as children make the figures for these groups uncertain.
Clinic judging itself: All authors work at the clinic whose patients were studied. They declared no conflicts of interest, but the analysis was not independent.

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Summary

Key findings

Abstract

Conclusion