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

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          Abstract

          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.

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          Most cited references39

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          Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes.

          Victor Montori, Susana Garcia, Rebecca Mullan … (2010)
          To assess the prognosis of individuals with gender identity disorder (GID) receiving hormonal therapy as a part of sex reassignment in terms of quality of life and other self-reported psychosocial outcomes. We searched electronic databases, bibliography of included studies and expert files. All study designs were included with no language restrictions. Reviewers working independently and in pairs selected studies using predetermined inclusion and exclusion criteria, extracted outcome and quality data. We used a random-effects meta-analysis to pool proportions and estimate the 95% confidence intervals (CIs). We estimated the proportion of between-study heterogeneity not attributable to chance using the I(2) statistic. We identified 28 eligible studies. These studies enrolled 1833 participants with GID (1093 male-to-female, 801 female-to-male) who underwent sex reassignment that included hormonal therapies. All the studies were observational and most lacked controls. Pooling across studies shows that after sex reassignment, 80% of individuals with GID reported significant improvement in gender dysphoria (95% CI = 68-89%; 8 studies; I(2) = 82%); 78% reported significant improvement in psychological symptoms (95% CI = 56-94%; 7 studies; I(2) = 86%); 80% reported significant improvement in quality of life (95% CI = 72-88%; 16 studies; I(2) = 78%); and 72% reported significant improvement in sexual function (95% CI = 60-81%; 15 studies; I(2) = 78%). Very low quality evidence suggests that sex reassignment that includes hormonal interventions in individuals with GID likely improves gender dysphoria, psychological functioning and comorbidities, sexual function and overall quality of life.
          Article 0 comments Cited 146 times – based on 0 reviews     Review now
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            Excess mortality in bipolar and unipolar disorder in Sweden.

            U Ösby, L. Brandt, N. Correia … (2001)
            Selected groups of patients with bipolar and unipolar disorder have an increased mortality rate from suicide and natural causes of death. However, there has been no population-based study of mortality of patients followed up from the onset of the illness. All patients with a hospital diagnosis of bipolar (n = 15 386) or unipolar (n = 39 182) disorder in Sweden from 1973 to 1995 were identified from the inpatient register and linked with the national cause-of-death register to determine the date and cause of death. Overall and cause-specific standardized mortality ratios (SMRs) and numbers of excess deaths were calculated by 5-year age classes and 5-year calendar periods. The SMRs for suicide were 15.0 for males and 22.4 for females with bipolar disorder, and 20.9 and 27.0, respectively, for unipolar disorder. For all natural causes of death, SMRs were 1.9 for males and 2.1 for females with bipolar disorder, and 1.5 and 1.6, respectively, for unipolar disorder. For bipolar disorder, most excess deaths were from natural causes, whereas for unipolar disorder, most excess deaths were from unnatural causes. The SMR for suicide was especially high for younger patients during the first years after the first diagnosis. Increasing SMR for suicide during the period of study was found for female patients with unipolar disorder. This population-based study of patients treated in the hospital documented increased SMRs for suicide in patients with bipolar and unipolar disorder. The SMR for all natural causes of death was also increased, causing about half the excess deaths.
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              Sex reassignment of adolescent transsexuals: a follow-up study.

              Joshua Cohen, Doorlene van Tienoven (1997)
              To investigate postoperative functioning of the first 22 consecutive adolescent transsexual patients of our gender clinic who underwent sex reassignment surgery. The subjects were interviewed by an independent psychologist and filled out a test battery containing questionnaires on their psychological, social, and sexual functioning. All subjects had undergone surgery no less than 1 year before the study took place. Twelve subjects had started hormone treatment between 16 and 18 years of age. The posttreatment data of each patient were compared with his or her own pretreatment data. Postoperatively the group was no longer gender-dysphoric; they scored in the normal range with respect to a number of different psychological measures and they were socially functioning quite well. Not a single subject expressed feelings of regret concerning the decision to undergo sex reassignment. Starting the sex reassignment procedure before adulthood results in favorable postoperative functioning, provided that careful diagnosis takes place in a specialized gender team and that the criteria for starting the procedure early are stringent.
              Article 0 comments Cited 104 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                : Role: Editor
                Journal
                Journal ID (nlm-ta): PLoS One
                Journal ID (publisher-id): plos
                Journal ID (pmc): plosone
                Title: PLoS ONE
                Publisher: Public Library of Science (San Francisco, USA )
                ISSN (Electronic): 1932-6203
                Publication date Collection: 2011
                Publication date (Electronic): 22 February 2011
                Volume: 6
                Issue: 2
                Electronic Location Identifier: e16885
                Affiliations
                [1 ]Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden
                [2 ]Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
                [3 ]Centre for Violence Prevention, Karolinska Institutet, Stockholm, Sweden
                [4 ]Institute of Neuroscience and Physiology, The Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
                The University of Queensland, Australia
                Author notes

                Conceived and designed the experiments: CD PL AJ NL ML. Performed the experiments: MB AJ. Analyzed the data: CD PL MB AJ NL ML. Contributed reagents/materials/analysis tools: PL NL AJ. Wrote the paper: CD PL MB AJ NL ML.

                Article
                Publisher ID: PONE-D-10-02950
                DOI: 10.1371/journal.pone.0016885
                PMC ID: 3043071
                PubMed ID: 21364939
                SO-VID: 391bd2de-7aed-4529-b659-71e957decd1f
                Copyright © Dhejne et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
                History
                Date received : 30 September 2010
                Date accepted : 9 January 2011
                Page count
                Pages: 8
                Categories
                Subject: Research Article
                Subject: Medicine
                Subject: Endocrinology
                Subject: Reproductive Endocrinology
                Subject: Epidemiology
                Subject: Mental Health
                Subject: Psychiatry
                Subject: Sexual Dysfunction
                Subject: Surgery
                Subject: Reconstructive Surgery

                ScienceOpen disciplines: Uncategorized
                Data availability:
                ScienceOpen disciplines: Uncategorized

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