研究称手术使心理健康治疗每年减少8%——其2020年更正发现与不做手术相比没有益处

跨性别者在性别肯定手术后心理健康治疗使用的减少：一项全人群研究

Authors: Richard Bränström, John E. Pachankis
Journal: American Journal of Psychiatry
Year: 2020
Source: https://doi.org/10.1176/appi.ajp.2019.19010080

Summary

This Swedish study was widely reported in 2019 as showing that gender surgery improves long-term mental health. Using national health records, it found that people diagnosed with gender incongruence used far more mental health care than the general population. Among those who had surgery, people whose last operation was longer ago were less likely to be in treatment in 2015. Hormone treatment showed no such link. Critics pointed out that the data were a one-year snapshot rather than real follow-up, people who had died were left out, and there was no comparison with diagnosed people who had no surgery. When the authors added that comparison, surgery showed no mental health advantage. The journal published a correction in 2020 saying the original conclusion was too strong. As corrected, it gives no evidence that surgery reduces mental health care or suicide attempts.

Key findings

在瑞典970万居民中，有2,679人在2005至2015年间被诊断为性别不一致。略多于70%接受了激素，48%（1,018人）做了手术。
2015年，被诊断者因抑郁或焦虑而就诊的可能性约为普通人群的6倍，获得抗抑郁或抗焦虑药物的可能性为3至4倍，自杀未遂后住院的可能性为6.8倍（22人，0.8%对0.1%）。
开始使用激素后的时间对心理健康治疗没有影响。
自上次手术以来每过一年，2015年接受抑郁或焦虑治疗的几率降低8%。该研究将其呈现为一种长期益处。
即使在手术10年或更久之后，心理健康治疗仍远高于普通人群的水平。
在七封已发表的信函批评其设计之后，作者比较了做过手术和没有做手术的人。手术在任何指标上都没有显示出优势，2020年8月的更正称原始结论过于强烈。
最初的新闻报道和未经更正的结论至今仍被广泛引用，作为手术能改善心理健康的证据。

Abstract

OBJECTIVE: Despite professional recommendations to consider gender-affirming hormone and surgical interventions for transgender individuals experiencing gender incongruence, the long-term effect of such interventions on mental health is largely unknown. The aim of this study was to ascertain the prevalence of mood and anxiety disorder health care visits and antidepressant and anxiolytic prescriptions in 2015 as a function of gender incongruence diagnosis and gender-affirming hormone and surgical treatment in the entire Swedish population. METHODS: This study used the Swedish Total Population Register (N=9,747,324), linked to the National Patient Register and the Prescribed Drug Register. Among individuals who received a diagnosis of gender incongruence (i.e., transsexualism or gender identity disorder) between 2005 and 2015 (N=2,679), mental health treatment in 2015 was examined as a function of length of time since gender-affirming hormone and surgical treatment. Outcome measures were mood and anxiety disorder health care visits, antidepressant and anxiolytic prescriptions, and hospitalization after a suicide attempt. RESULTS: Compared with the general population, individuals with a gender incongruence diagnosis were about six times as likely to have had a mood and anxiety disorder health care visit, more than three times as likely to have received prescriptions for antidepressants and anxiolytics, and more than six times as likely to have been hospitalized after a suicide attempt. Years since initiating hormone treatment was not significantly related to likelihood of mental health treatment (adjusted odds ratio=1.01, 95% CI=0.98, 1.03). However, increased time since last gender-affirming surgery was associated with reduced mental health treatment (adjusted odds ratio=0.92, 95% CI=0.87, 0.98). CONCLUSIONS: In this first total population study of transgender individuals with a gender incongruence diagnosis, the longitudinal association between gender-affirming surgery and reduced likelihood of mental health treatment lends support to the decision to provide gender-affirming surgeries to transgender individuals who seek them.

Conclusion

Original conclusion (2019): in this first total population study of transgender individuals with a gender incongruence diagnosis, the longitudinal association between gender-affirming surgery and reduced likelihood of mental health treatment lends support to the decision to provide gender-affirming surgeries to transgender individuals who seek them. Correction (Am J Psychiatry, August 2020): after letters raised methodological concerns, the journal obtained further statistical review. The authors reanalysed the data comparing individuals diagnosed with gender incongruence who had received surgery with those who had not. This comparison was retrospective and not part of the original question, but the results 'demonstrated no advantage of surgery' for subsequent mood or anxiety disorder-related care visits, prescriptions, or hospitalisations after suicide attempts, and the original conclusion was judged too strong.

Methodological limitations

Conclusion was corrected: The August 2020 correction says comparing diagnosed people who had surgery with those who did not 'demonstrated no advantage of surgery' for depression and anxiety care, prescriptions or hospital stays after suicide attempts. The original conclusion was judged too strong (Correction, Am J Psychiatry 2020; editor's comment by Kalin, 2020).
A snapshot, not follow-up: Mental health treatment was measured only in 2015. 'Years since surgery' compares different people at one time, not the same people before and after surgery, so it cannot show surgery caused any change.
No comparison group at first: The original study did not compare people who had surgery with similar people who didn't. When this was added, the apparent benefit disappeared.
People who died were left out: Only people alive at the end of 2014 were included, and suicide deaths were not counted. People who had surgery and later died, including by suicide, were missing from the 'years since surgery' groups.
Healthier people may get surgery sooner: People with better mental health may be more likely to be approved for surgery and to have had it earlier. There was no data on mental health before surgery, and several of the seven letters raised this.
Few people at long follow-up: The trend relied on small groups whose surgery was many years earlier. Critics noted that a handful of people changing would erase it, and only 22 people in total were hospitalised after a suicide attempt.
Many tests without adjustment: Several outcomes and definitions were tested without allowing for the number of tests, a point raised in SEGM's analysis of the correction.
Using care is not the same as mental health: People longer after surgery may simply have less contact with health services, which the authors acknowledge.
Records only start in 2005: Surgery and hormone records only went back to 2005 (prescriptions to July 2005), so 'years since' stopped at about 10. Earlier treatments, birth sex, legal sex history and gender identity were unknown.
Overstated title and claims: The title ('Reduction…After Gender-Affirming Surgeries') and the claim that the findings 'lend support' to surgery went beyond what a one-year snapshot of links can show. The title was not changed after the correction.

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Summary

Key findings

Abstract

Conclusion