Transgender and high suicide rates

Studies that have been done of transgendered people who have had sex reassignment surgery, people who have been followed for 20 or so years have found that after 10 years from the surgery, that their suicide mortality rate was actually 20 times higher than the non-transgendered population. So I’m very concerned that here we are encouraging young people to do things to their bodies … like chest binding for young girls … [and] penis tucking … Now this is taking kids on a trajectory that may well cause them to want to take radical action, such as gender reassignment surgery… – Lyle Shelton, managing director of the Australian Christian Lobby, speaking on Q&A on February 29, 2016.

Australia’s Safe Schools Coalition program has been accused of “promoting a radical view of gender and sexuality” in schools.

The program’s architects say it aims to boost acceptance of same sex attracted, intersex and gender diverse students, staff and families.

Critics have correctly said that the program directs children to groups such as Minus18, a youth-led network for lesbian, gay, bisexual, transgender and intersex people. Among the hideous resources on Minus18’s website is information about appearance modification for transgender people such as:

Changing your appearance is another way you can express your gender. Things like makeup, the clothes or school uniform you wear, binding your chest, tucking/packing your pants, or the way you do your hair can all help you better express yourself.

Crazy stuff right?

Speaking on Q&A, the Australian Christian Lobby’s Lyle Shelton stressed that respect is essential and that no one should be bullied at school. He said that in Victoria, the Bully Stoppers program does address homophobic bullying.

However, Shelton said he would prefer anti-bullying programs didn’t include “contested gender ideology” that may lead to gender reassignment surgery.

He also said research showed that people who had undergone sex reassignment surgery were 20 times more likely to suicide than the general population a decade after their surgery.

Checking the research

Shelton referred to a Swedish study of over 300 people over about 30 years between 1973 and about 2003 that found that the suicide mortality rate was 20 times higher than the non-transgendered population – so it seems likely he is referring to a 2011 published in the journal PLOS ONE.

That study, led by researcher Cecilia Dhejne, tracked 324 sex-reassigned people in Sweden between 1973 and 2003 to estimate their mortality, morbidity, and criminal rate after surgery. The researchers also included a comparison group. In that group, for every transgender person studied, the researchers included a non-transgendered person the same age and the same sex as the transgender person was before surgery.

The researchers found that:

Persons with transsexualism, after sex reassignment, have considerably higher risks for mortality, suicidal behaviour, and psychiatric morbidity than the general population.

The authors did not find that surgery was the cause of increased suicide risk, writing in their paper that:

the results should not be interpreted such as sex reassignment per se increases morbidity and mortality. Things might have been even worse without sex reassignment.

Why are post-surgery transgender people at higher risk of suicide than the general population?

It is possible that Shelton was not implying any causal relationship between sex reassignment surgery and a higher suicide risk. 

As Mr Shelton phrases it, it may sound as if sex reassignment increased suicide risk 20 times. The risk of suicide was increased 19 times compared to the general population, but that is because gender dysphoria is a distressing condition in itself. 

When asked why people who have had sex reassignment surgery may be more prone than the general population to suicide later in life, Landén said:

Gender dysphoria is a distressing condition. We have known for a long time that it is associated with other psychiatric disorders (such as depression) and increased rate of suicide attempts. Sex reassignment is the preferred treatment and outcome studies suggest that gender dysphoria (the main symptom) decreases. But it goes without saying that the procedure is a stressful life event. And that the surgery and medical treatment is not perfect. It is thus not surprising that this group of patients will continue to suffer from stress-related psychiatric disorders. There might be lingering professional and relational problems. It is also possible (but unproven) that gender dysphoria is somehow etiologically related to depression. In that case, fixing the first with a cure would not automatically fix the latter.

Medical transition alone won’t resolve the effects of crushing social oppression: social anxiety, depression and post-traumatic stress.

What does other research say?

This intensely felt sense of being transgendered constitutes a mental disorder in two respects. The first is that the idea of sex misalignment is simply mistaken—it does not correspond with physical reality. The second is that it can lead to grim psychological outcomes.

The transgendered suffer a disorder of "assumption" like those in other disorders familiar to psychiatrists. With the transgendered, the disordered assumption is that the individual differs from what seems given in nature—namely one's maleness or femaleness. Other kinds of disordered assumptions are held by those who suffer from anorexia and bulimia nervosa, where the assumption that departs from physical reality is the belief by the dangerously thin that they are overweight.

With body dysmorphic disorder, an often socially crippling condition, the individual is consumed by the assumption "I'm ugly." These disorders occur in subjects who have come to believe that some of their psycho-social conflicts or problems will be resolved if they can change the way that they appear to others. Such ideas work like ruling passions in their subjects' minds and tend to be accompanied by a solipsistic argument.

For the transgendered, this argument holds that one's feeling of "gender" is a conscious, subjective sense that, being in one's mind, cannot be questioned by others. The individual often seeks not just society's tolerance of this "personal truth" but affirmation of it. Here rests the support for "transgender equality," the demands for government payment for medical and surgical treatments, and for access to all sex-based public roles and privileges.

With this argument, advocates for the transgendered have persuaded several states—including California, New Jersey and Massachusetts—to pass laws barring psychiatrists, even with parental permission, from striving to restore natural gender feelings to a transgender minor. That government can intrude into parents' rights to seek help in guiding their children indicates how powerful these advocates have become.

How to respond? Psychiatrists obviously must challenge the solipsistic concept that what is in the mind cannot be questioned. Disorders of consciousness, after all, represent psychiatry's domain; declaring them off-limits would eliminate the field. Many will recall how, in the 1990s, an accusation of parental sex abuse of children was deemed unquestionable by the solipsists of the "recovered memory" craze.

You won't hear it from those championing transgender equality, but controlled and follow-up studies reveal fundamental problems with this movement. When children who reported transgender feelings were tracked without medical or surgical treatment at both Vanderbilt University and London's Portman Clinic, 70%-80% of them spontaneously lost those feelings. Some 25% did have persisting feelings; what differentiates those individuals remains to be discerned.

We at Johns Hopkins University—which in the 1960s was the first American medical center to venture into "sex-reassignment surgery"—launched a study in the 1970s comparing the outcomes of transgendered people who had the surgery with the outcomes of those who did not. Most of the surgically treated patients described themselves as "satisfied" by the results, but their subsequent psycho-social adjustments were no better than those who didn't have the surgery. And so at Hopkins we stopped doing sex-reassignment surgery, since producing a "satisfied" but still troubled patient seemed an inadequate reason for surgically amputating normal organs.

It now appears that our long-ago decision was a wise one. A 2011 study at the Karolinska Institute in Sweden produced the most illuminating results yet regarding the transgendered, evidence that should give advocates pause. The long-term study—up to 30 years—followed 324 people who had sex-reassignment surgery. The study revealed that beginning about 10 years after having the surgery, the transgendered began to experience increasing mental difficulties. Most shockingly, their suicide mortality rose almost 20-fold above the comparable nontransgender population. This disturbing result has as yet no explanation but probably reflects the growing sense of isolation reported by the aging transgendered after surgery. The high suicide rate certainly challenges the surgery prescription.

There are subgroups of the transgendered, and for none does "reassignment" seem apt. One group includes male prisoners like Pvt. Bradley Manning, the convicted national-security leaker who now wishes to be called Chelsea. Facing long sentences and the rigors of a men's prison, they have an obvious motive for wanting to change their sex and hence their prison. Given that they committed their crimes as males, they should be punished as such; after serving their time, they will be free to reconsider their gender.

Another subgroup consists of young men and women susceptible to suggestion from "everything is normal" sex education, amplified by Internet chat groups. These are the transgender subjects most like anorexia nervosa patients: They become persuaded that seeking a drastic physical change will banish their psycho-social problems. "Diversity" counselors in their schools, rather like cult leaders, may encourage these young people to distance themselves from their families and offer advice on rebutting arguments against having transgender surgery. Treatments here must begin with removing the young person from the suggestive environment and offering a counter-message in family therapy.

Then there is the subgroup of very young, often prepubescent children who notice distinct sex roles in the culture and, exploring how they fit in, begin imitating the opposite sex. Misguided doctors at medical centers including Boston's Children's Hospital have begun trying to treat this behavior by administering puberty-delaying hormones to render later sex-change surgeries less onerous—even though the drugs stunt the children's growth and risk causing sterility. Given that close to 80% of such children would abandon their confusion and grow naturally into adult life if untreated, these medical interventions come close to child abuse. A better way to help these children: with devoted parenting.

At the heart of the problem is confusion over the nature of the transgendered. "Sex change" is biologically impossible. People who undergo sex-reassignment surgery do not change from men to women or vice versa. Rather, they become feminized men or masculinized women. Claiming that this is civil-rights matter and encouraging surgical intervention is in reality to collaborate with and promote a mental disorder.
Recent literature reviews, including a literature review colleagues and I conducted reviewing Australian literature until the end of 2012, found a greater prevalence of suicidal behaviours among sexual minorities in general. Which point to cause.

Risk factors for suicidal behaviours specific to LGBTI people include “coming out" in adolescence and early adulthood, prejudice, discrimination, shame, hostility, and self-hatred. 

A 2011 Dutch study found that male-to-female transsexuals had a risk of suicide 5.7 times higher than the general population.

However, suicide risk was found not to be significantly higher in female-to-male transsexuals compared to the general population in an 18 year follow-up of 996 male-to-female and 365 female-to-male transexuals.

Again, those studies do not indicate the cause of increased suicide risk.

It’s possible that a number of other lifestyle factors, combined with lack of social support, discrimination and stigmatisation increase the risk of suicidal behaviour in the trans population

Verdict

Shelton was correct to say that research shows that transgendered people who have had sex reassignment surgery had a suicide mortality rate later in life that was roughly 20 times higher than the non-transgendered population.