The Myth of Post-Op Regret And Suicidality

There is a popular myth going around that attempts to quote from this 2003 Swedish study:

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

People using this study do so selectively. Let me explain the statistical manipulation going on with gender surgery detractors and the myth they try to construct.

First they note that general population rates for suicidality are around 1.6% in the United States. Then they note that suicidality rates for post-op transsexual people are about 4.1%. They then claim that since this is “hundreds of percent higher” that surgery does not work.

But let’s talk about the reality. What is that reality? It is that the pre-op suicidality rate for transsexuals is 41%!!!

Yep, that’s right. Pre-op rates of suicidality for transsexuals are 1000% higher than post-op rates. How do we know this? From the UCLA Williams Institute study Suicide Attempts among Transgender and Gender Non-Conforming Adults. (Warning! PDF!)

And the Swedish study actually supports gender surgery. Their conclusion?

This study found substantially higher rates of overall mortality, death from cardiovascular disease and suicide, suicide attempts, and psychiatric hospitalisations in sex-reassigned transsexual individuals compared to a healthy control population. This highlights that post surgical transsexuals are a risk group that need long-term psychiatric and somatic follow-up. Even though surgery and hormonal therapy alleviates gender dysphoria, it is apparently not sufficient to remedy the high rates of morbidity and mortality found among transsexual persons. Improved care for the transsexual group after the sex reassignment should therefore be considered.

Note what is said very, very gently and in careful scientific language: “This highlights that post surgical transsexuals are a risk group that need long-term psychiatric and somatic follow-up.”

So what detractors are doing is selective statistical selection to “prove” their biased point. When we take the entire picture, we see that gender surgery actually reduces suicide rates to 1/10th of what they were pre-op. And, as the Swedish study concludes, what trans people need is more support, not because they are trans, but because too many people in society today are just ignorant assholes.

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17 thoughts on “The Myth of Post-Op Regret And Suicidality

  1. I think what the Swedish study proves is that people need therapy and support after transition. The rate for suicide after transition is too high. Suicide is always horrible.

    People don’t need to panic; most people did not commit suicide. We should look for more and better treatments, however.

    We can’t compare the Swedish study to the study from the Williams Institute however. The Williams Institute is based on data about suicide attempts. The Swedish study was about the rate of actual suicide. We have no data on suicide attempts for Sweden.

    The most important lesson from the Williams Institute study is that the rate of suicide attempts is much too high among transgender and gender non-conforming adults.

    We can’t use the data to make any conclusions about transition, however, because the survey did not ask people when they attempted suicide – i.e. was it before or after transition.

    The National Transgender Discrimination Survey that collected the data with online surveys found that people who had transitioned had a higher rate of attempted suicide than people who had not. They had not asked when the attempt was, so it is unclear what this means.

    The Williams Institute study broke down the data further by who wanted physical transition and who did not. They found that:

    a) people who wanted transition related health care had a higher rate of suicide attempts than people who did not. This makes sense; they probably have more or worse gender dysphoria.

    b) there was basically no difference between the lifetime rate of suicide attempts for the people who had had surgery and those who wanted to have surgery but had not yet done so. The exception was FtM phalloplasty (which most people didn’t want in the first place).

    c) the lifetime rate for suicide attempts was higher for people who had had hormone treatment than those who had not but wanted it.

    d) the lifetime rate for suicide attempts was also higher for people who had had counseling than for those who wanted it but had not had it.

    The last two are especially troubling. It is possible that the people who had gotten hormone treatments or counseling had worse gender dysphoria than the people who said they wanted treatments but had not yet gotten them. It might also be that there was an age difference.

    The bottom line is that we don’t have any evidence that the treatments prevent suicide attempts.

    Because the survey did not ask about when people attempted suicide, we can’t come to any conclusions about whether or not the treatment helped.

    What we can be sure of is that far too many people attempt suicide and we need to do something about it!

    • The AMA and APA disagree with your conclusion. Both the AMA and the APA recommend transition, HRT, and when required, GCS as appropriate therapies for gender dysphoria. You appear to be trying to suggest that these organizations made biased choices in defiance of total data. Even the Swedish study concludes that GCS is a beneficial therapy. How you can conclude otherwise is mind boggling.

      • I think you have misunderstood my comment. I am not suggesting that people not transition. The Swedish study concluded that people who transition need more support afterwards because the suicide rate is still too high. They are not against transition.

        I think it’s vitally important to face this issue. We should not deny that suicide after transition occurs and is a problem. I understand that people want to defend transition, but it should not be done by minimizing the suicides of people who have transitioned.

        The rest of my comment is related to the science about suicide and transition. The article suggests that suicide rates after transition are lower than before. We do not actually have data to support that claim.

        This article compared the suicide rate after transition in Sweden to the rate of attempted suicide before transition in America; you can’t compare the rates of suicide and attempted suicide.

        In addition, the study on attempted suicide rates does not support the idea that transition decreased attempted suicides. People who had had transition related health care had rates of attempted suicide as high as or higher than people who wanted to but had not. As I said more than once, they did not ask if the people attempted suicide before or after transition and so we can’t draw conclusions from this data.

        It’s very important to be careful in how you use science. If you are not, conservatives will easily attack your argument.

        We need more studies to address the question of how physical transition affects rates of suicide and attempted suicide.

        At this point, the most important thing is that the rates of suicide and attempted suicide are much too high.

      • Page 8 of the Williams Institute report – “The survey did not provide information about the timing of reported suicide attempts in relation to receiving transition-related health
        care, which precluded investigation of transition-related explanations for these patterns.”

        Therefore your conclusion is incorrect. The study even says your conclusion, that pre and post transition rates were the same, is not true. The study clearly states that we do not know so I agree more work needs done but that is a start. But for you to leap and claim they are the same is incorrect (especially when the study specifically denies this).

        And did you even read the Swedish study? I refer specifically to Table 2. Risk of various outcomes among sex-reassigned subjects in Sweden (N = 324) compared to population controls matched for birth year and birth sex. Suicide attempt rate is included as well. So the suicide attempt rate among post-op transsexuals, especially in the post-1989 group, is only double the national rate (translation – about 3% versus the 41% rate established in multiple studies in multiple nations). So my article is most definitely relevant. GCS/transition does drop suicide attempt rate by over 90%!! NOTE: Actual numbers in the study are presented as adjusted hazard ratios. General population suicide attempt rate is 1.0 while the adjusted hazard ratio for the post-1989 GCS group was an adjusted hazard ratio of 2.0. Since we know the suicide attempt rate in Sweden was 1.4% (other sources) that would imply the 2.0 in the post-1989 group translates to roughly 2.8. Still not perfect but far better than the general 41% rate. And that is the basis for the conclusion in the study that GCS helps gender dysphoria. That conclusion is specifically in the study so don’t say we don’t know. The Swedish study did know and cited that fact.

        Also, those most likely to transition are those most severely suffering from GID, so it is not unreasonable to expect that the most severe sufferers might also have the highest psychological distress rates.

        As for more studies, they are being done. FtMs taking HRT have been shown to have lower levels of suicidality than pre-HRT FtMs. The Effects of Hormonal Gender Affirmation Treatment on Mental Health in Female-to-Male Transsexuals

      • In response to your reply below – please re-read my comments. Your quote from the Williams Institute is exactly my point. As I said repeatedly, they did not ask when the people attempted suicide, so we can’t know what affect treatment has on suicide. That is my conclusion – “We can’t use the data to make any conclusions about transition.”

        I do not conclude that pre- and post-op rates of suicide attempts are the same; I say over and over again that they did not ask when the attempts were made.

        It is also true that we do not have proof that treatment prevents suicide attempts.

        I did not realize that you were talking about the rate of suicide attempts in Sweden rather than the increased rate of suicide. However, you still can’t compare the Swedish data to the American data for a number of reasons.

        Please don’t take this as an attack on transition. This is about science and being careful to be accurate. In the long run, if you are not accurate, you will have problems when you are talking to people who oppose transition.

        Why you can’t compare the Swedish study and the American survey:

        1. Again, the American survey did not ask when people had attempted suicide. Therefore, you can not say that the rate of attempted suicide in America represents what happens without treatment.

        2. The study and the survey got their rates of suicide attempts in different ways. The Swedish data is based on reviewing national health care records, not talking to people directly. They might have missed some suicide attempts. The American survey asked people directly and could therefore include more suicide attempts.

        3. The Swedish study looked at everyone in their country who had legally transitioned during a certain time period. There was no possibility of selection bias. The American survey recruited people to respond to an online survey. That means there was a possibility of selection bias. It is possible that people who have worse problems are more likely to take the time to respond to a survey. This might also make the American survey include a higher rate of attempted suicide.

        Given the large difference in the rate of suicide attempts between the Swedish study and the American survey, I would be surprised if it was completely due to different ways of collecting the statistics.

        However, we can’t say that “gender surgery actually reduces suicide rates to 1/10th of what they were pre-op.”

        First and most importantly, you don’t know if the survey data on suicide attempts is about people who were pre- or post-op when they attempted suicide.

        Second, there’s no way to separate potential effects of gender surgery in Sweden from other aspects of transition such as hormones or counseling.

        Third, you’re looking at data on suicide attempts, not suicide rates. (This could be fixed by simply adding the word “attempted” somewhere.)

        Again, I have never said that pre- and post- transition rates of attempted suicide are the same. I am saying that we do not have data comparing them. We do not know the answer. Claiming that we do is not good science.

  2. The angle here is providing evidence of treatment outcome. Suicide is an indirect measure unlike reported satisfaction with treatment. Those studies generally support treatment – something insurers tend to want to supress.

  3. II must call you on your hogwash. I do not believe that you are by any means qualified to call post-op regret and suicide a myth especially since you are addressing a single study which is by no means conclusive “proof” one way or another for the scientific thesis on which the study was conducted. That is why studies of this kind are presented as papers for peer review in Medical Journals such as The AMA and New England Journals of Medicine. Even if you had examined 20 or more studies of a similar nature, you still can’t legitimately call it a myth. It is simply your biased opinion with no peer review whatsoever that I can see.

    • You are misreading and misunderstanding that blog entry. It was written in response to those who claim that suicides go up after SRS rather than down. The “myth” of post op regret is pushed by anti-science transgender haters who claim that the majority of trans women regret their SRS and that SRS increases the chances of suicide. Perhaps I should have been clearer, but that blog entry was written as a reply and then posted as a reply to others who were making those claims.

      The study I referenced was chosen because that was the same study that was being misquoted by the person to whom I replied. It’s a huge peer reviewed study, the largest in history, over 30 years in Sweden. What it showed was that before SRS, suicide attempt rates were as high as 41%, and after SRS they were down around 4.6%. And for people who transitioned and had SRS after 1993, the suicide attempt rate dropped to 2.8%. That’s compared to a background rate for the general population of 1.6%.

      There are also dozens and dozens of other studies that tackle the “post op regret” myth. And it is a myth because detractors try to use that myth and misquoted statistics to argue that medical coverage should be actively denied for SRS, even if you pay for it yourself.

      So that’s what I was answering, Deanna. And the Swedish study was peer reviewed, and there are several dozen other studies I can cite as well that are also peer reviewed. Post op regret consistently seems to be below 2% across all studies and many larger studies suggest it’s below 1%.

      Your reaction and post, calling my post “hogwash” appears to be perhaps because I was not as clear as I could have been on the intent of that blog post entry. But the post stands. And it is factually correct. Assholes like Walt Heyer are quacks, liars, and con men who try to play up post op regret to deny all trans women any access to SRS at all.

  4. Pingback: A Quick Note On The Statistics Of “Post-Surgery Trans Regret” | Rani Bakr Digs You.

  5. *
    Liz, your concluding statement from your original blog said it best. We all have our share of them. They are what destroy us if we let them do it during a moment of our weakness.

    Maybe it is not scientific, that post-operative feeling of suicide is part of our cumulative rush releasing a multitude of emotions following the ultimate operation and not true suicidal ideation. That was my experience because of the entirety of my transition process – my family being the ‘@ssholes’ who wanted nothing of me and I was going to show them. That post-op suicidal thought was transitory – I chose to live and live I do. My post-op perspective was the reversal of my pre-transition mindset which had been filled with frustration, anger, fear, doubt, and thoughts of suicide.

    Certainly I do not diminish the reality of those who experience actual suicidal thoughts or attempts and need our help.
    *

    • Suicidal thoughts are one thing, but true long term persistent post op regret is another matter entirely. The anti-SRS crowd argues that all post-ops are miserable and on the verge of suicide. To get that false statement, they twist data, studies, and even the words of the occasional person who does have regret to pain a completely different picture.

  6. The reason why post op rates are high is a.) the stigma with being transsexual and the fact they get employment discrimination, discrimination on somewhere to live, discrimination by the state that in the UK refuses to accept the assigned gender in law but still classes them as if they had never changed gender despite the Gender Recognition Act 2004.

    Discrimination is also high because of the above stresses and the use of the mental health label because if your a transsexual you are mentally ill

    That sort of mentality leads to suicide and early death. Loneliness is also a big contributor. Being Transexual hurts.

    Very few post op’s even the very passable one’s can lead stealth lives in the age where the government knows everything about it’s citizen’s stealth sadly is out of the window. Even with relationships it’s hard no matter how good or passable you think you are

    You have to be mentally strong and be prepared to take a lot of knock back’s and sadly not everyone is made of steel and you should not have to be in 2015.

    • Post op rates of suicidality are higher than the general population. But the famous and very large and very long Swedish study showed that I linked in the main post demonstrates that post-1992 suicidality was approximately the same as the general population.

      In 2015, it is a myth to say that post-op suicidality rates are exceedingly high. The available data do not support this conclusion.

  7. It appears to me that this blog post misreads the Swedish study in a number of ways. Read more carefully, the study does not support Ms. Ramsey’s conclusions (though it does not conclusively rebut them either).

    From table 2, the hazard ratio for suicides, not suicide attempts, for the entire 1973-2003 period of the study is not 2 but 19.1. No separate hazard ratio is given for later period due to sparsity of data.

    The rate of suicides (not attempts) is 2.7 per 1000 person years (line 2). 1000 person-years is about 12 lifetimes at the current Swedish life expectancy. 2.7 suicides per 12 lifetimes implies a lifetime suicide rate of 22 percent. Actually, that’s not quite right. The average person in the study was of age 35 on treatment, so they only live 57 percent of a life after treatment. This cuts the expected lifetime suicide rate to about 13 percent – roughly 10 times the average Swedish national suicide rate.

    Table 2 shows suicide attempts at a rate of about 3 times the rate of successful suicides (4 times if you include successful suicides as attempts). This means that lifetime post-treatment suicide attempt rates are about 37 percent, not 2 percent. So lifetime post-treatment combined rates of attempts and actual suicides is about 50 percent (as measured over the combined 1973-2003 period).

    But the attempts reported in this study are those that are reported as health events to the national health system. It is not a survey result, and attempts not contemporaneously reported to a doctor are not included. Which is to say, these attempt numbers will be only a fraction of the numbers reported by survey. So I think your attempt to compare a Swedish reported reported attempts amount to a U.S. survey-based percentage (41 percent) is ill-advised). Of course, the survey-based estimate also excludes actual suicides. Dead men (and women) return no surveys.

    It does appear that suicide attempts (in Sweden) have fallen significantly since 1988. This is good news. But we have no idea how much pre-treatment suicide rates in Sweden have fallen over the same period. So we have no idea, at least from this study, whether the post-treatment rate of suicide attempts, as measured during the 1989-2003 period, is higher or lower than the pre-treatment suicide attempt rate for that period. You can not conclude that it is from the fact that it is lower than the total-lifetime estimated suicide attempt rate, measured a different way, from a different country.

    Please do not read this as opposing a person’s right to harmonize their self-perceived and public gender identity. I believe this right should be recognized whether or not gender reassignment surgery (or hormone treatments, etc.) lead to a higher suicide rate.

    • Look at column 1 in table 2. There were 10 suicides among sex reassigned persons out of a pool of 324 total and 5 suicides among 3240 controls. That’s a flat 3.0% committed suicide. Period. Versus 0.15% for the controls. The study also completely fails to compare pre-operative transsexual suicide rates to post-operative. Your calculations do not remotely come close to the reality so I doubt they merit consideration.

      The hazard ratio is the ratio of transsexual suicide rates (3.0% roughly) to control suicide rates (0.15% roughly). That’s where the 19.1 comes in.

      And as I referenced from elsewhere, the overall suicide attempt rate among transgender persons is 41% (or higher depending on specific subgroup) in the US and I’ve been repeatedly told that it’s similar worldwide. So you’re really looking at a drop of, as one APA member told me, about 90%. It’s still higher than the general population but it’s not as high as the pre-operative situation by a long shot.

      The study itself clearly states: “In other words, 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.” Ergo, your implication that trans surgeries increase suicidality should be ignored.

      Further, again in column 1, there were 29 suicide attempts. That’s 29 out of 324 or 8.9% of the transsexual population in the study actually attempted suicide, not 50% as you try to assert.

      Please do not further waste my time with clearly bogus and easily refuted calculations intended to reinforce your personal biases. I will not accept them.

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