Trans youth not at elevated risk of suicide

[IcakethereforeIam]

Published in the BMJ. A very slight elevation seems linked to mental health issues rather than being trans

https://unherd.com/newsroom/new-study-trans-youth-not-at-elevated-risk-of-suicide/

The tras will be relieved to learn this, I imagine 🤔

I’d really like one of our resident scientists in the know about studies to read the original study paperwork and analyse these results.

Not because I doubt them, but because we apply that rigour to anything posted by the TRAs and I’d love to see a post about how well built this study is and how all the variables have been well considered and accounted for!

It's this study. You'll recognise Prof Kaltiala's name from the upcoming conference.

Ruuska S, Tuisku K, Holttinen T, et alAll-cause and suicide mortalities among adolescents and young adults who contacted specialised gender identity services in Finland in 1996–2019: a register studyBMJ Ment Health 2024;27:e300940.

https://mentalhealth.bmj.com/content/27/1/e300940.full

https://can-sg.org/can-sg-conference/

Quick scamper, more later, indicates a robust cohort study with a thoughtfully selected comparator group for the analysis.

Four male and four female controls matched for age and municipality of birth were extracted from the Population Information System for each gender-referred individual. The gender-referred individual’s index date was assigned to all controls. [My emphasis.]

Sensible variables and corrections. E.g., the number of "psychiatric treatment contacts" for the referred young people and those in the comparator.

When only registered sex and year of birth were controlled for, the HR for suicide mortality greatly increased in the gender-referred group. However, when the number of specialist-level psychiatric treatment contacts was added to the model, the difference between cases and controls levelled out. Death by suicide was significantly predicted by a high number of psychiatric treatment contacts, and borderline significantly predicted by male sex and earlier birth year.

More later but it's looking methodologically sound.

I love mumsnet. Thanks @RethinkingLife

Thank you rethinking!!

This really is great news.

'Finnish nationwide cohort of all <23 year-old gender-referred adolescents in 1996–2019 (n=2083) and 16 643 matched controls.'
...
Findings Of the 55 deaths in the study population, 20 (36%) were suicides. In bivariate analyses, all-cause mortality did not statistically significantly differ between gender-referred adolescents and controls (0.5% vs 0.3%); however, the proportion of suicides was higher in the gender-referred group (0.3% vs 0.1%). The all-cause mortality rate among gender-referred adolescents (controls) was 0.81 per 1000 person-years (0.40 per 1000 person-years), and the suicide mortality rate was 0.51 per 1000 person-years (0.12 per 1000 person-years). However, when specialist-level psychiatric treatment was controlled for, neither all-cause nor suicide mortality differed between the two groups: HR for all-cause mortality among gender-referred adolescents was 1.0 (95% CI 0.5 to 2.0) and for suicide mortality was 1.8 (95% CI 0.6 to 4.8).
Conclusions Clinical gender dysphoria does not appear to be predictive of all-cause nor suicide mortality when psychiatric treatment history is accounted for.
Clinical implications It is of utmost importance to identify and appropriately treat mental disorders in adolescents experiencing gender dysphoria to prevent suicide.'

That's so sad. Anyone against treating mental disorders in trans identifying children is evil.

Agree cake. So pleased to see rigorous research emerging despite everything that challenges this. I only hope this will help stop the dreadful extension of the ban on conversion therapy to trans people and that children (and adults) will have their mental health issues taken seriously. We need to end the assumption that gender medication or surgery sorts everything out instead of adding more problems

Apologies to those who've seen these before but for those new to this, a clinical psychologist explains the damage that socially transitioning children does to their psychological development. The first includes some commentary about how the misuse of suicide as a threat can frighten parents into making very damaging decisions about socially transitioning primary aged children.

They're sad to read but very informative about child and adolescent development - something sadly lacking in the narrative normally heard from adult transactivist groups.

https://www.transgendertrend.com/childhood-social-transition/

https://www.transgendertrend.com/teenager-says-theyre-transgender/

I worked in health care in the UK for 31 years (as a doctor). Most of this time was in general practice, though I also worked in sexual health and did a few months in one of the largest paediatric hospitals in the country.

So I have met a huge number of people over the years, of all ages, from a wide variety of backgrounds and with virtually every illness and worry, physical or mental, that you could think of. And I've had access to their medical records and been in a position to ask some pretty searching questions of them when appropriate.

In all that time I met 4 trans adults, at various stages in their "journeys", from questioning through to completion of surgical procedures. I never met a single child saying they were trans. Not one.

I also met a number of people of both sexes who had a variety of disorders of sexual development - everything from very obvious external differences from the physical normal range, through to chromosomal issues that you wouldn't know unless you had their medical records. How many were trans? None. Not one.

In all that time too, I met a number of children who were clearly upset/disturbed/depressed (etc). How many were allegedly trans? None. Not one.

I also met a small number of children who had self harmed. How many were trans? None. Not one.

I'm aware that the world is changing rapidly and one of the changes is that it is now acceptable, nay Stunning and Brave, to be trans, and therefore it's quite possible that some of the people I refer to above may have been trans but not been able to express that. I'm also aware that far more young people are seeking help with MH issues than used to be the case. So I can believe that statistics nowadays may genuinely be different from 30, 20, even 10 years ago.

What I CAN'T believe is that there is an enormous underswell of trans people of all ages, especially youngsters, who are suicidal through not being believed/treated as trans. If that were the case, I think there would have been far more
examples of self-harm for unspoken causes in the past -- and there just weren't.

(Haven't read the BMJ paper yet but I've wanted to say the above for a while!)

As the article says,

The same assertion that invalidating trans youth makes them kill themselves is also behind the rhetorical question routinely used to browbeat parents into consenting to social and medical transition for their gender-confused offspring: “Would you rather have a live daughter or a dead son?”

So what I'm asking is this. In the past it was very much more difficult to express a trans identity, never mind have it validated. So why is there an INCREASE in self harm figures (as the TWAs assure us is the case) now, when it's much EASIER to validate being trans?

Simple facts.

Sadly I don't think the other side of the debate will give Prof Kaltiala's research much credence as they seem to have dismissed her as a transphobe with an agenda.

They are currently incensed that she has is on the advisory board for The Cass Review.

If research is showing that there is no elevated risk then that is fantastic. These children need proper, robust mental health care, that addresses the actual issues.

I think Professor Kaltiala is very admirable. I honestly think the whole world would be a better place if it were easier for people to say. "I've been doing this, but I've learned new information and realised it's probably wrong. So I'm going to stop." She was involved in gender treatment on children, and she changed course, based on the evidence. I'm very pleased to see that there's a live stream for the conference and have signed up - I'd really like to hear her speak.

Thank you so much for this. I've had similar questions, albeit cruder than yours. Like, where is the body count? Horrifically, suicide is an easily counted data point, despite the 'why' being very complicated and multi-layered. Why don't we have higher death by suicide rates from 50, 100 years ago when being trans was almost unheard of, especially not in women and children?

I review for a number of journals, including those in the 'BMJ family' but not this journal.

For every review I do, BMJ normally asks for (pretty much mandates) open review which means the authors know who the reviewers are and all the review comments are published. (This is best practice.)

I can't find the reviewers or their comments for this one. I don't know if this journal is an outlier or if I'm looking with my eyes closed.

I like the relative simplicity of the comparators (age, current sex, # of psychiatric appointments prior to inclusion in the cohort/data) but it would have been helpful to see if the reviewers were content with this or had tried to argue for additional or even fewer.

I mention this because I've previously found it inappropriate when studies compared a group of young people with dysphoria with a history of mental perturbation or distress with a general population rather than a group with a comparable history of mental distress but no reported dysphoria.

At the other end of possible analysis, I don't know what granularity of data is available, but I wondered if any reviewers had requested additional stratified analyses. (The authors comment about limitations like this:
Despite the large amounts of data, deaths were rare in our sample, limiting the possibility of more fine-tuned analyses. Moreover, because the register authorities do not allow researchers to track changes in the registered sex, we were not able to run analyses stratified by birth sex, which is a limitation, particularly given the known sex differences in suicide mortality. However, owing to data security and privacy issues, cell frequencies below a certain limit must not be reported. This would have prevented further stratification anyway. )

It's possible some people are criticising the authors for stressing that some differences are not statistically significant and also have high degrees of uncertainty associated with them. However, there are no Rapid Responses as yet… afaict without access to the data, the authors are reporting the data and analysis in a reasonable fashion.

The uncertainty (as in confidence intervals) etc. fall as they do because, thankfully, the absolute rate of suicide is very low.

I hope Prof. Kaltiala discusses this at the upcoming event. It would be interesting to know what concerns anyone who objects to the findings would raise.

In this study, all-cause mortality was predicted through psychiatric treatment, with a higher risk associated with increased treatment needs and the male sex. Psychiatric disorders are associated with increased burdens of somatic illnesses30 and suicide.22 Our findings concord with these past pieces of evidence and show that the first observed difference between the gender-referred group and matched controls in suicide mortality levelled out when psychiatric treatment was considered. In fact, the novel contribution of this study is showing that suicide mortality associates with increased psychiatric needs; this is an important finding if we consider the failure of previous studies on mortality among patients with GD to account for psychiatric morbidities. In light of our findings, experiencing GD significant enough to seek GR appears to not be associated with increased suicide mortality, but suicides appear to be explained by psychiatric morbidities.
…
Most importantly, when psychiatric treatment needs, sex, birth year and differences in follow-up times were accounted for, the suicide mortality of both those who proceeded and did not proceed to GR did not statistically significantly differ from that of controls. This does not support the claims5 6 that GR is necessary in order to prevent suicide. GR has also not been shown to reduce even suicidal ideation7 8, and suicidal ideation is not equal to actual suicide risk.29 To the best of our knowledge, the impact of GR on suicide mortality among gender-referred adolescents has not been reported in earlier studies. In an earlier study by Dhejne et al,11 even when psychiatric morbidity was controlled for, participants diagnosed as transsexual in adulthood who had undergone both hormonal and surgical GR displayed increased suicide mortality compared with matched population controls. Nonetheless, these authors focused on patients treated before 2002. More recent cohorts, particularly adolescents, may differ from those in earlier decades, and stress related to gender identity itself may be lower presently because of decreasing prejudice.

I hope we can open up genuine understanding around how autism presents in females and how toxic masculinity is expressed in our culture. Internalised homophobia, especially in young gay males and young children who don't identify with sex class stereotypes is powerful too in forming beliefs about self.

No, it needs saying.

This is why people say there's no such thing as trans. Because it manifests more as a symptom of something else. The concept is being used as a tool to swell numbers. It's political.

For instance, the story of the girl who was raped repeatedly by her father and wanted to transition, because denying or removing her sex organs was a solution to that.

Or the boy who was gay and felt totally unable to express himself in a feminine way due to family criticism and wanted to transition because of that.

Sexual trauma and homophobia were the issues. But adult trans men would like that to be called 'trans' to justify their adult decisions.

It's like saying the problem is headaches, all these people with headaches, headaches are the issue, when that could be a result of a brain haemorrhage or a hangover.

Stephanie Davis Arai of Transgender Trend, who gets thousands of emails a week about children, has said she has yet to see a single one who wasn't either gay, the victim of sexual trauma, or autistic.

Indeed, on here, you will occasionally get an adult male saying it's all about gender dysphoria. I've asked, several times, what that was a symptom of. Where did it come from? What caused them to have it?

No one answered me. In fact, the very question seemed confusing. Like it was an end in itself, as an explanation. Not a symptom.

I don't know if it will form part of the study for which Emily Simonoff is a Chief Investigator but she has a research background in autism amongst other conditions relevant to child and adolescent psychiatry.

https://www.kcl.ac.uk/people/professor-emily-simonoff

Professor Emily Simonoff has been confirmed as Chief Investigator and will now lead on developing the detailed proposal for the planned research on puberty suppressing hormones in early onset gender dysphoria. Emily is Professor of Child and Adolescent Psychiatry at the Institute of Psychiatry, Psychology and Neuroscience, King’s College London, where she is also currently Head of the Department of Child and Adolescent Psychiatry and Director of the King’s Maudsley Partnership for Children and Young People. She has extensive research experience and is also academic lead for the Child and Adolescent Mental Health Services Clinical Academic Group at the South London and Maudsley NHS Foundation Trust. The research is being developed through the National Research Collaboration Programme, a joint partnership between the National Institute for Health and Care Research (NIHR) and NHS England.

https://www.england.nhs.uk/commissioning/spec-services/npc-crg/gender-dysphoria-clinical-programme/implementing-advice-from-the-cass-review/cyp-gender-dysphoria-research-oversight-board/

I review for a number of journals, including those in the 'BMJ family' but not this journal.

For every review I do, BMJ normally asks for (pretty much mandates) open review which means the authors know who the reviewers are and all the review comments are published. (This is best practice.)

I can't find the reviewers or their comments for this one. I don't know if this journal is an outlier or if I'm looking with my eyes closed.

Good point, @RethinkingLife - the peer review model for BMJ Mental Health is single anonymised About BMJ Mental Health

(I wonder why it has a different policy? I wish open peer review would be come standard practice as opposed to best practice. Having one's name attached to comments helps keep the process civil. I remember reading some very nasty comments as a very junior researcher. The substance of the criticism was reasonable, and the paper much improved as a result, but there was no need for the bile!)

Can I just check I’ve understood the up thread analysis correctly in lay terms?

The data shows that if you compare patients referred to gender services to those that are not, then it appears that there are more suicides in patients referred to gender services. (0.3% v 0.1%). However, if you compare patients referred to gender services to patients with the same mental health issues but who were not referred to gender services then there is no difference in suicide rate. The implication being that it is the mental health issues at the root of the problem?

Have I got that right?

Broadly, yes.

The following does not discount my agreement.

A substantial assumption is that the number of previous psychiatric appointments is a good rule of thumb for equivalent severity of mental health conditions. So, nobody can assert with certainty that they're the same mental health issues but it seems reasonable to accept that they are comparable in severity and the need for specialist treatment.

But, if you accept that premise, those groups are as reasonably similar as you're going to get. The authors refer to good standardisation of the criteria for referral to a particular tier of such specialised psychiatric services in Finland. Like everyone, I'd be curious about further sub-groups for analysis but

• as the authors explain in their discussion, some of those data aren't available in the register
• a deeper and more specific level of data analysis might run the risk of inadvertently identifying people from the pseudonymised data.

It's been raised here and elsewhere but I should think lots of parents and professionals are concerned about whether there are greater vulnerabilities for children who are living with autism or similar. I know nothing about looked after children in Finland and wonder if there is the same heightened risk for them as is reported in England (I don't know much about other systems in the UK).

For me, the uplifting takeaway from this publication is that the absolute risk of suicide is very low among children and young people. The risk is higher for those CYP who are living with substantial degrees of mental distress or illness: notably, the absolute number remains low.

Thank you Rethinking.

That is pretty much what several UK clinicians wrote several years ago. I believe one was Marcus Evans. I also wonder if I have read Will Malone (SEGM and from the USA) say this too.

What wonderful news

An important caveat is that what is true in Finland may not be true in other countries. E.g. maybe Finnish trans people get bullied less, and maybe trans people who get bullied more are more likely to attempt suicide.