Alarming but false

The "transition or suicide" story is about politics, not evidence

Photo by Nikolas Gannon on Unsplash

“Gender-affirming” hormonal and surgical interventions do not reduce the risk of suicide for transgender-identifying adolescents, according to an unusually comprehensive and rigorous study.

The landmark research from Finland, an international leader in the shift away from medicalised gender change, found that suicide risk in a large group of adolescents was predicted by the psychiatric problems that often accompany gender distress, not by the gender distress itself.

Dramatic claims of the risk of attempted suicide among trans-identifying youth are typically based on low-quality anonymous online self-report surveys with no follow-up checks, potential exaggeration driven by a constant “transition or suicide” narrative, and “convenience samples” unlikely to be representative.

The new Finnish study vindicates that country’s 2020 adoption of a more cautious treatment policy which first targets psychiatric, social and educational problems among gender-distressed youth before any assumption of a stable trans identity justifying “experimental” affirmation with hormones or surgery.

“It is of utmost importance to identify and appropriately treat mental disorders in adolescents experiencing gender dysphoria to prevent suicide; in addition, health policies need to ensure that accurate information is provided to professionals along these lines,” the researchers say in their BMJ Mental Health paper.

The research team includes the psychiatrist Riittakerttu Kaltiala, from Tampere University Faculty of Medicine, who helped pioneer paediatric gender medicine in Finland, but became concerned when she and her colleagues did not see the good outcomes promised by the internationally imitated “Dutch protocol” of puberty blockers followed by cross-sex hormones and surgery.

Clinical psychologist Erica Anderson, a gender clinician and former president of the US Professional Association for Transgender Health, told GCN she believed that other scientific reviews yet to be published would also “raise questions about the assumption that gender-affirming medicines for youth are protective and prevent suicide.”

“If more evidence is accumulated of this type, one of the most frequent justifications for gender-affirming medicines for minors—that such medicines are lifesaving—can no longer be defended.” 

Although Dr Anderson herself practises the gender-affirming model, she has been raising concerns about the weak evidence base and sub-standard clinical practices in paediatric gender medicine.

“Gender-affirming care is medical care. It is mental health care. It is, in some cases, suicide prevention care.”—Dr Rachel Levine, US Assistant Secretary of Health, who is a trans woman and paediatrician appointed by Democratic President Joe Biden, tweet, 13 June 2023

“There’s no epidemic of trans athletes dominating college sports. There IS an epidemic of young trans people dying from suicide as society questions their every civil right.”—Gender-affirming psychiatrist Jack Turban, tweet, 21 January 2021

Video: An alarming claim from endocrinologist Norman Spack, who was involved in founding America’s first specialised children’s hospital gender clinic in Boston in 2007

Under duress

The “transition or suicide” narrative has been used by gender-affirming clinicians, trans rights activists and uncritical journalists to suggest that puberty blockers, cross-sex hormones and surgery such as double mastectomy are “lifesaving.”

Parents hesitant about these poorly evidenced medical interventions have reportedly been asked by clinicians, “Do you want a live son or a dead daughter?”

The suicide narrative also figures in the practice of schools keeping a child’s social transition secret from parents, in the shutting down of debate about the efficacy and safety of hormonal and surgical interventions, and in the promotion of ill-defined bans on “conversion therapy” and “hate speech.”

Chart: Trend over time for the Google search terms “trans suicide” and “trans kids”; 100 on the vertical axis represents peak popularity

“[The] politically potent ‘affirm or suicide’ narrative has been marshalled at nearly every opportunity in public debates over paediatric gender medicine… By invoking the suicide trope, individual activists, organisations like the ACLU, and Democratic politicians are violating well-recognised, research-based guidelines on how to talk responsibly about suicide.”—Leor Sapir, comment article, City Journal, 17 March 2023

“When communicating about suicide it’s important to remember that suicide is a complex issue and is often not preceded by a single event or condition.”—Mindframe, media advice

“[The] language we use to talk about suicide, how we frame the issue, the content that gets shared on the web and social media can affect what happens next—specifically, whether it contributes to more deaths or prevents them.”—Johns Hopkins Bloomberg School of Public Health, media advice

Quality research

The new Finnish research from Professor Kaltiala and her colleagues allows unusually confident conclusions in a field plagued by low-quality activist studies because it—

• used comprehensive data from national health registers, minimising the problem of unknown outcomes for former patients lost to follow-up;

• tracked suicide as well as total mortality among 2,083 gender-distressed adolescents with a median age of 19 seen by nationally centralised gender clinics from 1996 to 2019, with a median follow-up time of almost six years;

• compared their outcomes with 16,643 counterparts from the general population matched for age, sex and municipality of birth;

• compared outcomes for adolescents who were given hormones or surgery with those who were not;

• isolated statistically the effect of co-morbid psychiatric problems on total mortality and suicide among adolescents with clinically significant gender distress.

Oxford University sociologist Michael Biggs, one of very few researchers to have researched actual suicides linked to a youth gender clinic, said the Finnish investigation was “most comprehensive study ever published on suicide by young transgender people who seek medical interventions.”

He told GCN that the Finnish paper “shows again that the risk of death by suicide for young trans-people is thankfully low in absolute terms. This confirms the results of my own analysis of British data from the Tavistock clinic, with superior Finnish data.”

“Although the rate of suicide [in the Finnish study] is just over four times higher among trans young people than their peers, this is explained by their more serious psychiatric problems. When these psychiatric problems are taken into account, there is no evidence that transgender people have a higher rate of suicide.”

In the 2,083-strong “gender-referred” group¹ for the Finnish study, there were seven suicides, giving a rate of 0.3 per cent as opposed to a rate of 0.1 per cent in the group of 16,643 matched controls from the general population.

“Suicide mortality first appeared to be much higher among gender-referred participants; however, the association was fully explained by psychiatric treatment history,” the Finnish researchers said.

“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 [gender dysphoria] to account for psychiatric morbidities.

“In light of our findings, experiencing [gender dysphoria] significant enough to seek [hormonal or surgical interventions] appears to not be associated with increased suicide mortality, but suicides appear to be explained by psychiatric morbidities.

“The suicide mortality of both those who proceeded and did not proceed to [these medical interventions] did not statistically significantly differ from that of controls.

“This does not support the claims that [medicalised affirmation] is necessary in order to prevent suicide.

“The risk of suicide related to transgender identity and/or [gender dysphoria] per se may have been overestimated.

“[Medicalised affirmation] has also not been shown [in other studies] to reduce even suicidal ideation, and suicidal ideation is not equal to actual suicide risk.

“To the best of our knowledge, the impact of [these hormonal or surgical interventions] on suicide mortality among gender-referred adolescents has not been reported in earlier studies.”

“This conclusion from the Finnish data is consistent with findings from a multi-country study of suicidality, a related concept. While suicidality in [gender-dysphoric] youth is elevated, it is similar to that of youth presenting with other mental health diagnoses.

“These findings [from Finland] underscore the fact that most youth presenting with [gender dysphoria] have a high rate of co-occurring psychiatric diagnoses, which predate the onset of [gender dysphoria] by months to years.

“[The latest from Finland supports] the direction by the Finnish, English and Swedish health authorities that psychotherapy (rather than medical gender transition) should be prioritised for most youth presenting with gender-related distress.”—Society for Evidence-based Gender Medicine, Twitter thread, 18 February 2024

Back to basics

Dr Anderson, who is based in California, said the conclusion by the Finnish study that gender-affirming care did not reduce suicide risk was “a startling conclusion in the current debate.”

She said the leading Finnish researcher, Prof Kaltiala, was “in a unique position as the head of gender youth care for Finland and a doctor devoted to evidence-based care for gender-questioning youth. She is smart, compassionate and rigorously honest.”

Dr Anderson highlighted the need for an immediate response to young people with severe psychiatric distress and a high risk of suicide.

“It is not enough to pivot to a focus upon gender dysphoria, if present [in the patient], and offer hormones as a treatment for such symptoms and distress,” she told GCN.

“Basic mental health practice dictates evaluation for suicide risk factors and treatment of suicidality.

“In my opinion, this should be the priority and happen first. Beliefs by some that gender affirmation will cure the patient of suicidality must now be questioned, as I have been doing for some time.

“If gender-affirming medicines could not provide sufficient relief to the adolescents so treated and reduce their suicidality, should such patients have received hormones at all? What treatment should these patients have received?”

“[The paediatric gender centre’s] website said, ‘Left untreated, gender dysphoria has any number of consequences, from self-harm to suicide. But when you take away the gender dysphoria by allowing a child to be who he or she is, we’re noticing that [risk of harm] goes away. The studies we have show these kids often wind up functioning psychosocially as well as or better than their peers.’

“There are no reliable studies showing this. Indeed, the experiences of many of the centre’s patients prove how false these assertions are.”—Gender clinic whistleblower Jamie Reed, article, The Free Press, 9 February 2023

Try psychiatry, not affirmation

In an earlier study using the country’s health registers, Finnish researchers noted that the surge in gender-distressed patients of recent years and the treatment response had not led to a decline in co-morbid psychiatric disorders.

“Both before and after contacting [gender clinics, these adult and minor patients] present with many more common psychiatric needs than do their matched population controls, even when medical [gender-reassignment] interventions are carried out,” the researchers said.

They said the rise in younger people with psychiatric problems going to gender clinics coincided with the crisis in youth mental health across the Western world linked to more social media use.

Although social media could ease stigma and offer support, the researchers said it might also “result in adolescent and emerging adult females—who present particularly frequently with identity confusion—seeking for a solution to their distress through [medicalised gender change, thereby overshadowing] the need for psychiatric treatment.”

1. These were patients diagnosed with “gender identity disorder”, the term that predated gender dysphoria and gender incongruence.