A recently published study from Denmark compared the rate of suicide attempts, suicide-related deaths, non-suicide-related deaths, and all-cause mortality between non-transgender and transgender-identifying individuals. The study spanned 42 years, however the average follow-up for transgender-identified individuals was less than six years. The study found that transgender-identifying individuals in Denmark had significantly elevated rates of all four adverse outcomes.
The absolute risk of death by suicide among transgender-identified individuals was estimated as 75 suicides per 100,000 patient-years (standardized adjusted rate). A clinician would need to treat 1,333 transgender-identified patients for a year to encounter one patient death by suicide (100,000/75). Compared to the general population, transgender-identified individuals were 7-8 times more likely to attempt suicide, 3.5 times more likely to die by suicide, and twice as likely to die from non-suicide related causes.
The study considered an individual to be transgender after they changed their legal sex marker or obtained a gender-related diagnosis. It is unclear whether individuals with adverse outcomes have been treated with “gender-affirming” hormonal and/or surgical interventions. However, the authors note that “in 2017, new guidelines were implemented to make transgender health care more accessible.” Thus, it is likely safe to assume that most of those who desired “gender-affirming” interventions had the opportunity to access them.
Several other key findings were apparent in the data but were not elaborated by the authors. The data reveal that Denmark experienced an influx of gender-dysphoric adolescents beginning in 2015-2017 that was disproportionately female. The data also show that trans-identified individuals in Denmark have a markedly elevated rate of psychiatric illness compared to non-trans-identified individuals (43% vs 7%).
The study authors focused on minority stress as the explanation for the increased rate of adverse outcomes in trans-identifying populations (e.g., the deleterious effects of bullying, discrimination, exclusion, and prejudice). Consistent with this interpretation, they recommended suicide-prevention measures such as fighting structural discrimination, and encouraging trans-identified people in distress to seek help. The authors did not mention that there is a strong link between psychiatric illness and suicidality, nor did they comment on the need to provide evidence-based psychiatric care to better address psychiatric conditions that were highly prevalent among the transgender-identified individuals in the study.
The study has several strengths and limitations. Its strengths include obtaining follow-up data on all individuals (as opposed to losing a significant proportion of participants to follow-up); use of objective outcome measures (rather than subjective self-reported measures); focus on serious suicidal behaviors (as opposed to combining serious suicide attempts with non-suicidal self-harm, as is often the case in recent studies); and reporting the absolute risk of suicide among trans-identified individuals (rather than only reporting relative risk, which can be used to exaggerate risk).
The study’s limitations are lack of information about the hormonal or surgical interventions for the transgender cohort; limiting the study to persons age 15 years or older, which eliminates a significant proportion of the population that seeks and receives “gender-affirming” care; lack of representation of transgender-identified individuals who do not seek medical services and do not pursue legal sex marker change; and exclusion of transgender-identified individuals who attempted suicide before their transgender identification was documented, which may have resulted in underestimation of suicide attempts and completed suicides.
Another limitation is a lack of clarity of how the statistical adjustments by decade, age, and sex were conducted, and whether they were sufficient to control for marked epidemiological shift in the presentation of gender dysphoria starting in the mid-2010s. While previously most cases undergoing gender transition were natal males, since about 2015, the sex ratio has shifted strongly toward females, and there has been a sharp rise in the incidence of gender dysphoria in adolescents and young adults, many of whom struggle with pre-existing mental illness and neurocognitive difficulties, such as autism and ADHD. Further, the authors did not control for mental illness when assessing suicidal attempts and deaths. In view of the marked changes in the epidemiology of gender dysphoria since 2015, a separate focus on this novel patient cohort would have allowed for findings that are more applicable to current clinical dilemmas.
Studies in the field of gender medicine often produce conflicting findings (in part due to a lack of rigor in the study designs), yet one finding remains remarkably consistent: transgender-identified individuals continue to suffer from elevated rates of morbidity and mortality, including deaths by suicide. Other studies have reported persistently elevated rates of suicide regardless of the stage of an individual’s transition (from pre-transition assessment to the post-surgical period). Research into suicidality in gender-diverse youth suggests that while their suicidality is elevated, it is comparable to youth who suffer from psychiatric symptoms but do not have gender dysphoria, and that the absolute risk of death by suicide remains low. These facts underscore the need to treat suicidality as a complex multifactorial phenomenon, and strongly point to the conclusion that gender transition should not be viewed as suicide-prevention measure.
The Danish treatment guidelines, which broadened access to gender transition for youth in 2017, will be revised this year (2023), according to the Danish health authority’s website. Over the last 24-26 months, following systematic evidence reviews which found the evidence of benefits of youth gender transition to be highly uncertain, England, Sweden, and Finland have sharply restricted eligibility for youth gender transitions, confined hormonal interventions to research settings, and asserted that psychotherapeutic approaches should be the first line of treatment for gender-dysphoric youth.
It remains to be seen whether the Danish health authority will take a cautious approach to the treatment of gender-dysphoric youth like the growing number of their European counterparts, or whether Denmark will choose to align with the current direction supported by a number of U.S. medical societies that assert that medical gender transition should be widely available for all youths who desire it.
Study findings in detail
There were a total of 12 suicide deaths among 3,759 transgender-identifying individuals (0.3%) over 42 years. This translates into 75 suicides per 100,000 (standardized adjusted rate). All the completed suicides were among natal males; there were no suicide deaths among female trans-identified individuals.
A comparison between transgender- and non-transgender populations revealed that transgender-identified individuals had significantly worse outcomes. Specifically, the rate of suicide attempts among transgender-identified individuals was 7.7 times higher (6.6 times higher in the last decade), suicide mortality was 3.5 times higher (2.8 times higher in the last decade), suicide-unrelated mortality was 1.9 times higher (1.7 times higher over the last decade), and all-cause mortality was two times higher (1.7 times higher over the last decade).
The finding that Danish transgender-identified individuals have elevated rates of psychiatric illness and elevated death rates, including deaths by suicide, is consistent with findings from population studies in other countries. Similarly troubling long-term health outcomes have been found among transgender-identified Dutch, Swedish, and English individuals.
Some of the more notable findings are discussed below.
Findings related to suicide attempts, suicides, and deaths:
The data in Table 1 of the study corroborate the disproportionately high prevalence of young people in the trans-identified cohort: 15-24-year-olds account for 25% of the transgender cohort over the last 42 years compared to only 16% of the non-transgender cohort. These numbers are likely even more skewed toward youth in the cases identified since 2015-2017 due to the influx of young individuals since about 2015-2017 (See Figure 2).
Strengths and limitations of the study
In a field that has developed a penchant for deriving its knowledge base from non-comparative studies that rely on online surveys promoted by activist organizations and induced by cash prizes for participation, or from “affirmative” youth gender clinics that often sacrifice the quality of their research to further what they perceive to be social-justice causes, the latest JAMA study is a reminder that objective research is still possible.
The study has a number of strengths, elaborated below:
The authors identified some of the study limitations, including the fact that the study was limited to Danish-born individuals (excluding immigrants), as well as individuals who either had a medical diagnosis of gender dysphoria or a legal change of their sex markers. The authors also noted other study limitations, including the fact that serious suicide attempts, as well as transgender identity of the presenting individuals, may be underreported by the Danish hospitals, which may have led to an underestimation of risk.
The study’s limitations, including those not discussed by the authors, are elaborated below:
We will not speculate about why the authors reasoned that such an exclusion was justifiable, but we do note that had they included such individuals in the dataset, and had they attributed their suicide attempts to the “transgender” cohort, this would have further increased the rate of suicide attempts and possibly suicide deaths in the trans-identified population, and it would have further exacerbated the differential in suicidality between non-transgender and transgender-identified individuals.
For example, it is unclear whether the sharply declined incidence of death by suicide among trans-identified individuals reported in Table 3 (from 161 per 100,000 prior to year 2000, to 40 per 1000,000 between 2001- 2023) represents improved outcomes, or if this improvement is unduly influenced by the recent influx of young natal females who are less likely to experience adverse events due to the recency of their transgender identification. Typically, adverse outcomes in trans-identifying individuals take a decade or more to manifest.
While studies in gender medicine often produce conflicting results, one finding remains remarkably consistent across multiple studies: despite the wide availability of “gender-affirming” care and especially in recent years, individuals who identify as transgender continue to struggle with a significant burden of psychiatric symptoms and remain at significantly elevated risk of morbidity and mortality.
The key question, which has become the subject of heated debates in medicine, is how to best help the rapidly growing numbers of youth presenting with gender dysphoria. Many of such youths’ transgender identity emerged after puberty, following months and years of struggling with psychiatric illness or neurocognitive conditions, such as ADHD or autistic-spectrum disorders.
The question of the risk of suicide, and the efficacy of “gender-affirmative” medical interventions as suicide prevention measures, remains front and center in this debate. The JAMA study, which centered the question of suicide, will likely be referenced by both, the proponents of wide availably of medical gender transition services for minors, and by those who opposed it.
Those promoting wide access to “gender-affirming” hormonal and surgical interventions for youth may point to the results of the study to reinforce the notion that trans-identified individuals are at markedly high risk of death by suicide if they do not transition. Our analysis above shows that this assertion cannot be supported by the current study (or by other studies in the field).
Those opposing the proliferation of “gender-affirming” care may observe that the absolute risk of suicide among trans-identified individuals is relatively low (1 in 1,333 individuals per year) and that despite the wide availability of “gender-affirming” interventions in Denmark, the rate of death by suicide among trans-identified individuals continues to significantly exceed the general population. They may point to the very high rate of psychiatric comorbidity in the trans-identified population, and question whether it is the underlying untreated psychiatric comorbidity that is the key contributor to the elevated suicidality. They also may emphasize that the study raises questions about the elevated non-suicidal mortality in the trans-identifying population and whether “gender-affirming” hormones and surgery contribute to these adverse outcomes.
Unfortunately, because the study tells us little about the outcomes of youth presenting with a previously atypical, post-pubertal onset of gender dysphoria since 2015-2017, and because of the other significant limitations discussed earlier (notably, a lack of exploration of the significant burden of mental health comorbidity in the trans-identifying population), the study findings have very little applicability to current clinical dilemmas.
While the current JAMA study sheds little light on health outcomes of trans-identified youth, other research does. For example, a recent study using data from the largest pediatric gender clinic in the world, the Tavistock in the UK, shows that, while suicides among trans-identified are elevated, thankfully they remain rare events—there were a total of four suicide deaths among 15,032 patients over a 10-year period (0.03%, or an annualized rate of 13 per 100,000). Importantly, there was no observed difference in the suicide rate between those on the waitlist versus those receiving active evaluation and treatment at the gender clinic.
Further, according to the first principle of evidence-based medicine, treatment decisions should be based on systematic reviews of evidence of treatment effects. To date, every systematic evidence review has concluded that the evidence of psychological benefit of “gender-affirming” puberty blockers, cross-sex hormones and surgery for youth is of very low certainty. In contrast, the harms of hormonal interventions, including infertility, sterility, and adverse effects on bone and cardiovascular health are much better established.
For those concerned with the long-term health of the adolescents and young adults who began to present with gender dysphoria in clinical settings in unprecedented numbers since 2015, this signals the need to de-exceptionalize care of this population. This is consistent with the direction undertaken by a growing number of European countries (England, Sweden, and Finland), which have sharply restricted the eligibility for youth gender transitions, and which now state that psychotherapeutic interventions to control psychiatric illness and explore the nature of gender distress should be the first—and in many cases the only—treatment available outside of research settings.
The Danish treatment guidelines, which broadened access to gender transition for youth in 2017, will be revised this year (2023), according to the Danish health authority’s website. It remains to be seen if Denmark will course-correct, taking a more cautious approach to the treatment of gender-dysphoric youth, following in the footsteps of a growing number of its European counterparts—or whether it will continue to pursue the medicalized approach favored by the North American medical societies.