The truth about claims concerning “that Swedish study.”

 

Hearsay makes the kind of trouble that troublemakers love.  Vocal opponents of transgender people have at various times spoken of “that Swedish study” which they claim is proof that transition not only offers no real benefit but actually causes suicide.  It’s a cheap shot because claimants know that the vast majority of their audience will take their word for it and won’t bother to read the study.  For that matter, most of these “critics” probably haven’t read it either.  But “that Swedish study,” properly titled, Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden is available to the public online and actually makes different claims than those infected with anti-transgender agendas have purported.1

Dr. Cecilia Dhejne who led the study published in 2011, went to some personal trouble in her own efforts to debunk false claims about the study conducted by Karolinska University Hospital including an interview with Cristan Williams of Transadvocate in which she cited these claims as “abuse of data”.2

But what Dr. Dhejne said in the Transadvocate article can be understood by simply reading the extract.  The basic data it offers can be summarized in 2 tables in which we can view calculated risk factors for transsexuals: 3

S1

S2

The committee based their tables upon 2 sets of controls:  the first compared to population based upon birth date and sex and the second based upon birth date and final sex, giving a kind of before-and-after picture.  Both use bold numbers to summarize  risk factors when compared to others in the general population in Sweden based upon data collected on 324 transsexuals including 191 male to female transsexuals and 133 female to male transsexuals.

Here’s how to read the tables:  The bold numbers in each box (except in the green column) represent the average risk as a factor of corresponding risk faced by post-operative transsexuals to the rest of the population.  The numbers in parentheses represent the ranges that contribute to these averages.

The green column represents aggregate data concerning each of the events with bold numbers representing the number of transsexual cases and numbers in parentheses representing the numbers male-to-female and female-to-male respectively.  For example, the researchers learned of 27 deaths occurring out of 324 post-operative transsexuals during the study period.  10 of those deaths were suicides, 9 due to cardiovascular disease, and 8 due to “neoplasms” or malignancies.  One could see that suicide attempts, apparently those not successful, had been reported as slightly more than successful suicides.  These outcomes were also tracked in terms of psychiatric hospitalizations apart from gender identity disorder, substance abuse, accidents, and convictions for crimes including convictions for violent crimes.

The white columns represent calculated risk factors for all post-operative transsexuals, the pink columns for those male-to-female, and the blue for female-to-male.  The dramatic 19.1 in Table S1 for suicides for all cases seems to have been given the most press.  One may look at this and simply declare “that Swedish study said transsexuals end up 20 times likely to commit suicide than if they didn’t transition.”  But that’s not what the numbers represent.  Consider the words from the study itself:

“It is therefore important to note that the current study is only informative with respect to transsexuals persons health after sex reassignment; no inferences can be drawn as to the effectiveness of sex reassignment as a treatment for transsexualism. 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. As an analogy, similar studies have found increased somatic morbidity, suicide rate, and overall mortality for patients treated for bipolar disorder and schizophrenia.[39][40] This is important information, but it does not follow that mood stabilizing treatment or antipsychotic treatment is the culprit.”4

So just what are we supposed to infer from these risk factors?  Do they have anything constructive to tell us about treatment of gender dysphoria?

They do indeed.  The researchers stated their conclusions thus:

“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.”5

Transgender activists have concluded similarly aside from this study.

These results from over a period of over 3 decades can be compared to another study on this subject conducted by the Williams Institute at the University of California, Los Angeles and the American Foundation for Suicide Prevention in 2014 using data from the National Transgender Discrimination Survey (NTDS) conducted in 2008, results of which were published in 2011, the same year as Dhejne et al.  The two studies came to similar conclusions concerning elevated risk for suicide.  But the 2014 study did 2 things that the Swedish study did not:  (1) examine the details in the demographics of 5885 transgender people surveyed pertaining to suicide attempts and (2) apply chi square statistical tests to probe likely stressors contributing to suicide attempts.  Briefly stated, these stressors inferred from these statistics included apart from variations within trans demographics themselves:

  1. 41% of respondents to the NTDS reported experiencing housing discrimination.  Those who experienced these problems also reported higher rates of suicide attempts.  The highest prevalence (69%) occurred among those who became homeless because of anti-transgender bias.6
  2. School Experience. Some astonishing numbers emerged in cases of bullying 50% attempting suicide who had been harassed or bullied in elementary and junior high schools, rising to 54% in college.  The numbers increased in cases of physical assault: 63% in elementary school to 68% in college.  They increase even further with sexual assault:  73% in elementary school to 79% in college.7
  3. Workplace Experiences: These ranged from 50% for those who experienced unemployment due to anti-transgender bias to 65% for those who had been physically assaulted on the job.8
  4. Family Acceptance: The lowest incidence of suicide attempts occurred when families accepted the transgender family member (33%) and high when families broke apart.  The highest occurred when the transgender family member faced domestic violence against him or her (65%).9
  5. Experiences With Medical Providers: 51% of those who attempted suicide either had to postpone treatment or had to instruct their own medical providers. The numbers rose to 60% when physicians refused to treat due to anti-transgender bias.10
  6. Interactions With Law Enforcement: Those who were treated with respect by law enforcement had the lowest incidence of suicide attempts (41%). These numbers rise to 60% for those physically assaulted by law enforcement to 61% for those harassed by law enforcement to 70% for those sexually assaulted by law enforcement.11
  7. Quality of Life: Not all who transition truly feel their quality of life had improved because of their transition, a simple fact mental health professionals try to prevent by their psychological assessments for candidates for hormone replacement therapy (HRT) and surgery.  The lowest suicide rates occurred for those who feel their condition had not affected the quality of their lives (31%).  The highest occurred for those who felt their lives had become much worse (56%).12

Even these proposed stressors related to anti-transgender bias did not prove a direct causal relationship.  Researchers of the Williams Institute study cautioned while citing other research:

“The survey data did not allow us to determine a direct causal relationship between experiencing rejection, discrimination, victimization, or violence, and lifetime suicide attempts. Drawing on minority stress theory (Meyer, 2003) and recent research on the development of suicidal thinking and behavior following victimization (Espelage & Holt, 2013; Klomek et al., 2011), we hypothesized that mental health factors may be an important factor in helping to explain the strong and consistent relationship observed between stressors related to anti-transgender bias and lifetime suicide attempts among NTDS respondents. Although the limited NTDS data related to mental health precluded a full testing of this hypothesis, many specific experiences of rejection, discrimination, victimization, and violence were found to be significantly related to having a disabling mental health condition.”13

In which case, the conclusions of Dhejne et al that follow-up care needs to be improved for transitioning people are confirmed.  But do these studies affirm the validity of anti-transgender bias in hiring practices and tenant screening?  No.  Neither study indicates that all who transition have a disabling health condition that impacts work performance or tenant harmony.  But they do indicate that better follow-up care would greatly help those who are at risk due to a disabling mental health condition so they can live productive and harmonious lives.

One other fact concerning “that Swedish study” needs emphasis concerning the calculated risk factors:  that these are aggregate numbers of 2 groups:  a group studied from 1973 to 1988 and a group studied from 1989-2003.  The aggregate numbers refer to both groups together.  But the difference between the earlier and later group are as striking as the elevated risk factors published:

“Even though the overall mortality was increased across both time periods, it did not reach statistical significance for the period 1989–200314

In other words, the elevated risks diminished greatly in the latter group.  To account for this, Dr. Dhejne told Cristan Williams in the Transadvocate interview:

“The difference we observed between the 1989 to 2003 cohort and the control group is that the trans cohort group accessed more mental health care, which is appropriate given the level of ongoing discrimination the group faces. What the data tells us is that things are getting measurably better and the issues we found affecting the 1973 to 1988 cohort group likely reflects a time when trans health and psychological care was less effective and social stigma was far worse.”15

So if the overall risk factors didn’t appear in the latter group who had access to this care, what does this say about those who abuse these findings to perpetuate the climate of anti-transgender bias?

What we may safely infer from this abuse is an automatic presumption of evil by these abusers concerning transgender people.  Every one of these people has taken these risk factors at face value without further scrutiny to draw careful conclusions of their own.  Their judgment of transgender people has been preconceived, based either upon religio-political agendas, the agendas of trans-exclusionary radical feminists, or simply to bully other people just because of a psychopathological rush of false-superiority by slamming other people such as what we often find in the comments Internet trolls love to post just to be hurtful.

These are agendas and practices designed to perpetuate a culture of hate and transphobia, the very culture against which transgender people have struggled throughout the 16 centuries of the Abrahamic Oppression.

But these studies, coupled with the increased visibility of transgender people, seem to have inspired the prestigious medical journal Lancet to begin a landmark series of articles on transgender health care, announced in June 2016.  The report, estimating a population of 25 million transpeople worldwide, cites “a population that remains “grossly underserved” by public health even though they face a heightened risk of everything from depression and homicide to HIV.”16

This is the proper context of the discussion of heightened risk factors.  As Lancet releases its articles in this series we can examine further the reforms in transgender health care that need to be made without preconceived bias.

This represents much needed change, a form of care that’s genuinely therapeutic, not the punitive kind of care proposed by anti-transgender propagandists that has characterized medieval approaches and even the Spanish Inquisition that never completely went away.  The latter fosters that same devilish spirit that also oppressed those who turned to scientific inquiry for answers and twisted their studies out of their true context out of a similar presumption of evil.

In which case, science is what it always has been:  the greatest ally of transgender people.

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REFERENCES:

Images: (featured image) Detail of front gate of the Karolinska Institute, Solna, Sweden from Wikimedia Commons. (tables) Data from Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden quoted in this article.  Tables color enhanced by the blog writer to facilitate readability.

  1. Dhejne, Cecilia; Lichtenstein, Paul; Boman, Marcus; Johansson, Anna L.V., Långström, Niklas; and Landėn. Mikael.  Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden (February 22, 2011)  Web: PLOS. http://dx.doi.org/10.1371/journal.pone.0016885. Retrieved June 18, 2016.
  2. Williams, Cristan. Fact Check: Study Shows Transtion Makes Trans P eople Suicidal. (n.d.) Web: Transadvocate. http://transadvocate.com/fact-check-study-shows-transition-makes-trans-people-suicidal_n_15483.htm.  Retrieved June 18, 2016.
  3. Op cit.
  4. Ibid. Italics supplied by the blog writer.
  5. Ibid. Italics supplied by the blog writer.
  6. Haas, Ann P.,PhD; Rodgers, Philip L., PhD; and Herman, Jody L., PhD. Suicide Attempts among Transgender and Gender Non-Conforming Adults: Findings of the National Transgender Discrimination Survey (January 2014)  Executive Summary: The Willliams Institute, University of California, Los Angeles School of Law and the American Foundation for Suicide Prevention.  No ISBN. Web: http://williamsinstitute.law.ucla.edu/wp-content/uploads/AFSP-Williams-Suicide-Report-Final.pdf, p. 11.
  7. Ibid.
  8. Ibid, pp. 11,12.
  9. Ibid, p. 12.
  10. Ibid.
  11. Ibid, p. 13.
  12. Ibid, p. 14.
  13. Ibid, p. 13.
  14. Dhejne et al.  Italics supplied by the blog writer.
  15. Williams.  Italics supplied by the blog writer.
  16. Yang, Jennifer.  Influential Medical Journal Devotes Series to Transgender Health Issues. (June 17, 2016) Web:  The Star. https://www.thestar.com/news/world/2016/06/17/transgender-health-issues-topic-of-medical-journal-report.html . Retrieved June 18, 2016.