On suicide

Suicide by Clinic-Referred Transgender Adolescents in the United Kingdom

Michael Biggs

Surveys show that adolescents who identify as transgender are vulnerable to suicidal thoughts and self-harming behaviors (dickey & Budge, 2020; Hatchel et al., 2021; Mann et al., 2019). Little is known about death by suicide. This Letter presents data from the Gender Identity Development Service (GIDS), the publicly funded clinic for children and adolescents aged under 18 from England, Wales, and Northern Ireland. From 2010 to 2020, four patients were known or suspected to have died by suicide, out of about 15,000 patients (including those on the waiting list). To calculate the annual suicide rate, the total number of years spent by patients under the clinic’s care is estimated at about 30,000. This yields an annual suicide rate of 13 per 100,000 (95% confidence interval: 4–34). Compared to the United Kingdom population of similar age and sexual composition, the suicide rate for patients at the GIDS was 5.5 times higher. The proportion of patients dying by suicide was far lower than in the only pediatric gender clinic which has published data, in Belgium (Van Cauwenberg et al., 2021). Read more

Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden

Cecilia Dhejne, Paul Lichtenstein, Marcus Boman, Anna L. V. Johansson, Niklas Långström, Mikael Landén

Context: 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]).

Results: 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.

Conclusions: 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. Read more

Mental Healthcare Utilization of Transgender Youth Before and After Affirming Treatment

Elizabeth Hisle-Gorman, Natasha A Schvey, Terry A Adirim, Anna K Rayne, Apryl Susi, Timothy A Roberts, David A Klein

Objective: Transgender and gender-diverse (TGD) adolescents experience increased mental health risk compared to cisgender peers. Limited research suggests improved outcomes following gender-affirmation. This study examined mental healthcare and psychotropic medication utilization among TGD youth compared to their siblings without gender-related diagnoses and explored utilization patterns following gender-affirming care.

Method: This retrospective cohort study used military healthcare data from 2010-2018 to identify mental healthcare diagnoses and visits, and psychotropic medication prescriptions among TGD youth who received care for gender dysphoria before age 18, and their siblings. Logistic and Poisson regression analyses compared mental health diagnosis, visits, and psychotropic prescriptions of TGD youth to their siblings, and compared healthcare utilization pre- and post-initiation of gender-affirming pharmaceuticals among TGD adolescents.

Results: 3,754 TGD adolescents and 6,603 cisgender siblings were included. TGD adolescents were more likely to have a mental health diagnosis (OR 5.45, 95% CI [4.77-6.24]), use more mental healthcare services (IRR 2.22; 95% CI [2.00-2.46]), and be prescribed more psychotropic medications (IRR = 2.57; 95% CI [2.36-2.80]) compared to siblings. The most pronounced increases in mental healthcare were for adjustment, anxiety, mood, personality, psychotic disorders, and suicidal ideation/attempted suicide. The most pronounced increased in psychotropic medication were in SNRIs, sleep medications, anti-psychotics and lithium. Among 963 TGD youth (Mage: 18.2) using gender-affirming pharmaceuticals, mental healthcare did not significantly change (IRR = 1.09, 95% CI [0.95-1.25]) and psychotropic medications increased (IRR = 1.67, 95% CI [1.46-1.91]) following gender-affirming pharmaceutical initiation; older age was associated with decreased care and prescriptions.

Conclusion: Results support clinical mental health screening recommendations for TGD youth. Further research is needed to elucidate the longer-term impact of medical affirmation on mental health, including family and social factors associated with the persistence and discontinuation of mental healthcare needs among TGD youth. Read more