Key Findings

• All 324 sex-reassigned persons in Sweden 1973-2003 were included (191 male-to-females, 133 female-to-males)
• Overall mortality was nearly 3 times higher for sex-reassigned persons than for controls of the same birth sex
• Death from suicide was approximately 19 times higher in sex-reassigned persons compared to controls
• Risk of suicide attempts was nearly 5 times higher after sex reassignment
• Risk of psychiatric inpatient care was nearly 3 times higher after sex reassignment
• Female-to-males had higher risk for criminal convictions than birth sex controls; male-to-females did not
• Survival curves suggest mortality divergence began approximately 10 years after sex reassignment
• Sex reassignment alleviates gender dysphoria but does not address elevated rates of morbidity and mortality

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 population-based matched cohort study followed all 324 sex-reassigned persons in Sweden from 1973 to 2003, comparing them with randomly selected population controls. The study found substantially higher rates of overall mortality, suicide death, suicide attempts, and psychiatric hospitalizations in sex-reassigned individuals compared to the general population. The findings suggest that while sex reassignment may alleviate gender dysphoria, it does not reduce the elevated psychiatric morbidity and mortality risk in this population, and improved post-reassignment care is needed.

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.