Key Findings

• First nationwide population-based long-term follow-up of sex-reassigned transsexual persons
• 324 sex-reassigned persons compared with random population controls matched by age and gender
• Overall mortality nearly 3 times higher than controls (aHR 2.8)
• Suicide mortality approximately 19 times higher than controls (aHR 19.1)
• Risk of suicide attempts nearly 5 times higher (aHR 4.9)
• Risk of psychiatric hospitalization nearly 3 times higher (aHR 2.8)
• Female-to-males had higher criminal conviction risk than birth sex controls
• Survival divergence from controls became apparent approximately 10 years post-reassignment
• Study design does not address whether sex reassignment is an effective treatment

Abstract

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]). 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.

Summary

This landmark population-based cohort study from Sweden followed all 324 individuals who underwent sex reassignment surgery between 1973 and 2003, using national registry data matched with population controls. The study found that sex-reassigned persons had nearly three times higher mortality, nineteen times higher suicide mortality, and significantly elevated rates of suicide attempts and psychiatric hospitalizations compared to the general population. The authors concluded that while sex reassignment alleviates gender dysphoria, it may not be sufficient as a treatment for transsexualism, calling for improved psychiatric and somatic care following reassignment.

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.