Registro dinamarquês: tentativas de suicídio 7,7 vezes e suicídios 3,5 vezes maiores em pessoas trans em 42 anos

Identidade transgênero, tentativas de suicídio e mortalidade na Dinamarca

Estudos de coorte e registros Saúde mental e suicídio

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

Das 6,66 milhões de pessoas nascidas na Dinamarca acompanhadas por 42 anos, 3.759 (0,06%) foram identificadas como transgênero, tipicamente aos 22 anos.
As tentativas de suicídio tratadas em hospital ocorreram a 498 contra 71 por 100.000 pessoas por ano, cerca de 7,7 vezes mais frequentes, com base em 92 pessoas transgênero que fizeram uma tentativa.
As mortes por suicídio foram 75 contra 21 por 100.000 pessoas por ano, cerca de 3,5 vezes mais frequentes, com base em 12 mortes entre pessoas transgênero, todas nascidas do sexo masculino.
As mortes por qualquer causa foram cerca de duas vezes mais comuns, principalmente por causa de 245 mortes não relacionadas ao suicídio (cerca de 1,9 vez mais comuns).
Em 2010–2021, as taxas ainda eram mais altas: tentativas de suicídio cerca de 6,6 vezes, mortes por suicídio cerca de 2,8 vezes (2000–2021) e todas as mortes cerca de 1,7 vez mais comuns.
As pessoas identificadas apenas por mudança legal de gênero tiveram mais tentativas de suicídio (cerca de 5 vezes mais), mas nenhuma morte extra por outras causas nem no geral, ao contrário das encontradas por registros hospitalares.
A doença mental e física foi deliberadamente não levada em conta, de modo que os números mostram ligações gerais, não o efeito de ser transgênero em si.

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