FactCheck Q A: was Lyle Shelton right about transgender people and a higher suicide risk after surgery?

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Excerpt from Q&A, February 29, 2016.

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 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 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.

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.

Let’s take a closer look at what the research says.

Checking the research

Shelton did not respond to The Conversation’s request for comment and clarification. However, later in the program he 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. The Conversation asked him to clarify what he wanted to convey by mentioning the study, but he did not reply.

It is also possible some viewers may have been left with the impression that the study showed sex reassignment surgery causes a higher risk of suicide later in life. That is not the case.

The Conversation asked the authors of that study how they felt about the way Shelton had represented their findings. One of the authors, Mikael Landén from the Department of Clinical Neuroscience at Stockholm’s Karolinska Institutet medical university, told The Conversation that:

As Mr Shelton phrases it, it may sound as if sex reassignment increased suicide risk 20 times. That is not the case. 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. Our study does not inform us whether sex reassignment decreases (which is likely) or increases (which is unlikely) that risk.

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.

As some Q&A viewers, including @BayneMacGregor, pointed out on Twitter as the program aired, the lead author of the study has been asked about this before.

In November 2015, Cecilia Dhejne told the website The TransAdvocate that, “Medical transition alone won’t resolve the effects of crushing social oppression: social anxiety, depression and post-traumatic stress.”

(Dhejne also confirmed to The Conversation that the transcript of her interview on The TransAdvocate website is accurate).

What does other research say?

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.

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 recent review of literature focused on suicidal behaviours – including suicidal thought, suicide attempts and suicide rates – among trans people (the term used by the authors of that review) between 1966 and April 2015. The authors concluded that the prevalence of suicidal behaviours differs depending on the different stages of transition, but they are still overall greater than the general population.

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.

However, it is also possible some viewers may have been left with the impression that the study showed sex reassignment surgery causes a higher risk of suicide later in life. That is not what the Swedish study showed. In fact, the researchers wrote that things might have been even worse without sex reassignment.

Nevertheless, there is lack of research on the topic and his comment appears to be based on one study from Sweden. – Kairi Kõlves

Review

This FactCheck a good overview of the current research literature. It looks at both international literature on suicide risk and suicidal behaviours in sexual minority populations and, importantly, results of Australian studies.

Three conclusions spring to mind. First, we still have limited insight into the actual causes of the increased suicide risk in the sexual minority groups. Secondly, we need more Australian studies on suicide in the transgender people, ideally designed in close collaboration with people with the lived experience of suicidality. Last, we should remember that despite the higher statistical risk, the majority of transgender people do not attempt suicide or die by suicide.

A better understanding of resilience and protective factors could significantly contribute to improved quality of life and well-being. – Karolina Krysinska

• Lifeline 13 11 14 • Suicide Call Back Service 1300 659 467

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