Science AMA Series: I'm Cecilia Dhejne a fellow of the European Committee of Sexual Medicine, from the Karolinska University Hospital in Sweden. I'm here to talk about transgender health, suicide rates, and my often misinterpreted study. Ask me anything!

Abstract

Hi reddit!

I am a MD, board certified psychiatrist, fellow of the European Committee of Sexual medicine and clinical sexologist (NACS), and a member of the World Professional Association for Transgender Health (WPATH). I founded the Stockholm Gender Team and have worked with transgender health for nearly 30 years. As a medical adviser to the Swedish National Board of Health and Welfare, I specifically focused on improving transgender health and legal rights for transgender people. In 2016, the transgender organisation, ‘Free Personality Expression Sweden’ honoured me with their yearly Trans Hero award for improving transgender health care in Sweden.

In March 2017, I presented my thesis “On Gender Dysphoria” at the Karolinska Institutet, Stockholm, Sweden. I have published peer reviewed articles on psychiatric health, epidemiology, the background to gender dysphoria, and transgender men’s experience of fertility preservation. My upcoming project aims to describe the outcome of our treatment program for people with a non-binary gender identity.

Researchers are happy when their findings are recognized and have an impact. However, once your study is published, you lose control of how the results are used. The paper by me and co-workers named “Long-term follow-up of transsexual persons undergoing sex reassignment surgery: cohort study in Sweden.“ have had an impact both in the scientific world and outside this community. The findings have been used to argue that gender-affirming treatment should be stopped since it could be dangerous (Levine, 2016). However, the results have also been used to show the vulnerability of transgender people and that better transgender health care is needed (Arcelus & Bouman, 2015; Zeluf et al., 2016). Despite the paper clearly stating that the study was not designed to evaluate whether or not gender-affirming is beneficial, it has been interpreted as such. I was very happy to be interviewed by Cristan Williams Transadvocate, giving me the opportunity to clarify some of the misinterpretations of the findings.

I'll be back around 1 pm EST to answer your questions, AMA!

Thank you for doing this AMA! As a researcher, how did you respond (professionally and personally) to your work being presented in such a misleading fashion? It seems like an impossible task to correct every single news article, blog, or online comment misinterpreting the results of your study. During the four previous AMAs on transgender health this week, it's been incorrectly cited as evidence against transitioning well over a hundred times. What actions do you recommend a researcher taking if they find their own work being so heavily distorted?

shiruken

Thank you for your question and I am happy I was invited to AMA.

I am aware of some of the misinterpretation of the study in Plos One. Some are as you say difficult to keep track since they are not published in scientific journals. I am grateful to friends all over the world who notify me of publications outside the scientific world. I do answer some of them but I can’t answer all.

I have no good recommendation what to do. I have said many times that the study is not design to evaluate the outcome of medical transition. It DOES NOT say that medical transition causes people to commit suicide. However it does say that people who have transition are more vulnerable and that we need to improve care. I am happy about that it has also been seen that way and in those cases help to secure more resources to transgender health care.

On a personal level I can get both angry and sad of the misinterpretations and also sometimes astonished that some researcher don’t seem to understand some basics about research methology.


What in your opinion are the most important pieces of information that members of the general public should be aware of when it comes to people with trans/gender diverse identities and the connections between individuals with these identities and mental health?

NicolasGuacamole

What in your opinion is are the most important pieces of information that members of the general public should be aware of when it comes to people with trans/gender diverse identities and the connections between individuals with these identities and mental health?

Dear Nicolas, thank you for your question. From my point of you these are some of the things I found important.

1 Being trans/gender diverse is not by it selves a mental health problem, but being trans/gender diverse increases the risk of other factors which contributes to less good mental health. For example being exposed to childhood maltreatment, discrimination in work situations, being victims of hate crimes and sexual abuse, having problem to access health care etc..

2 People with trans/gender diverse identities are a very heterogeneous group, as a group they share their trans/gender diverse identity but on other aspects each individual is different. As a group they are at some bigger risk of having less good mental health but many also have a good mental health.


I know one of the points that I have seen brought up on a regular basis is people who want to claim that there is substantial regret among people who transistion. What has your research on long term follow up found with regards to regret transitioning? Is there any? If there is, are there any common threads that might explain it (is it people who regret the actual transition, or is the regret based on the changes in how society perceives /accepts them, or is it something else)?

Thank you for coming on here to try to clear up any misconceptions.

kerovon

Thank you for asking. I have done study regarding people who applied to legally change back to the sex they were assigned at birth. Between 1960-2010 681 individuals were granted a new legal gender in Sweden. 15 (2.2%) of those applied for reversal to the gender they assigned at birth. During the studied period we saw a significant decline and 11/15 of the regret applications were made of before 2000. The numbers are similar to other studies from Germany. We couldn’t study the reason for that they wanted to retransition. There could be many reasons one is that it was the wrong treatment but there are many others as you mention. Never the less I don’t find the numbers alarming if compared to other medical care they are infact good.


My upcoming project aims to describe the outcome of our treatment program for people with a non-binary gender identity.

Dear Cecilia,

I was wondering if you could clarify what a "non binary gender identity" is, and what kind of treatment do you offer them. If someone is feeling neither neither man nor woman, do you give them any HRT? Which one and on which basis?

lucaxx85

Thank you for your question. A gender identity is some ones perception of being female, male some other gender, or no none of the above. There is no universal definition of a non binary gender identity I think different people mean different things with that identity. In clinical praxis I always ask everyone for their gender identity, what that gender identity means for them and if that identity gives them any feeling of gender incongruence. And if so do they have any body dysphoria which they need help with in order to feel more gender congruent. Everyone who seeks gender-affirming treatment undergo a diagnostic evaluation and if you are diagnosed with Gender Dysphoria and are fully aware of how hormone replacement treatment affects your body but also what it does not do and if we don’t found a medical reasons for not prescribing hormones will receive treatment. We use the same hormones (antitestosterone, GnRH analogues, estrogen, and testosterone) as for binary people sometimes in lower doses.


I have two related questions that bother me about the foundation of transgenderism. I know many will think these read like "trolling" but they are absolutely sincere. Also, I'm going to refer to some social gender constructs that will seem somewhat... "narrow minded" - I want to be clear I am NOT expressing my own opinions about "what is normal" but rather referring to the existing social constructs in the Western world.

1) How do you define "gender identity" in a way that doesn't reflect social norms of gender behavior? As I understand it, the standard trappings of "gender" are mostly social constructs. In the US, it's "wearing dresses," "playing with dolls," makeup, etc - all the usual suspects in gender stereotyping.

Within this social framework, someone born XY can cross-dress, play with dolls, love romance novels, and be homosexual yet they're not TG. Can an XY prefer jeans, carpentry, watching football, and love women yet be TG?

(again - PLEASE note that I am talking in terms of what large swaths of US society consider "normal" for men and women, not my own beliefs)

2) Building on that - if someone feels the need to have their right leg amputated because it "feels wrong" we treat them for body dysmorphic disorder. As far as I know it's unethical to go ahead and remove the leg.

But if an XY wants their "plumbing reworked" to have indoor plumbing instead of an outhouse, then they have gender dysphoria. They will get counseling and support, but eventually may be able to get surgery to realize their inner feelings.

How are these two situations differentiated clinically?

(Final note: These are not attacks or dismissals. I sincerely want to understand the answers to the questions I've asked.)

DonLaFontainesGhost

Gender identity denotes someone perceptions of what gender they belong do, female, male or some other gender. I agree with you that what someone puts into the concept of having one gender identity is partly based on social contruct which differ in countries, cultures and time periods. However regardless of that most people also have an inner feeling of what gender they belong to. One of the differences of people seeks leg amputation is that gender-affirming treatment has been done since 1960. Several studies have shown that the treatment reduces gender dysphoria, and improves mental health (Murad et al 2010) and that there are few regrets to the procedure (Dhejne et al 2014). So even if it is difficult to understand especially if one is not gender dysphoric the treamtent works. Some people might still have problem even after treatment but this is mostly caused by other things and at least they don’t suffer from gender dysphoria any more.


Thank you for taking the time to do this AMA.

What do you think is the best current resource for people looking into the neurobiology behind being trans? In your opinion, to what degree do physical brain differences have to do with transgender identities? Is saying that someone has "a female brain in a male body" (or vice versa) accurate?

chaucer345

I don’t think we have a female or a male brain. The differences we can see in some measures between cisgender males and females are on a group level. We don’t know how our brain gives us the perception of being male, female or some other gender. Do know where to look we need to understand more about how the brain gives us our gender perception. I don't find the expression a female/male brain in a vice versa body is accurate. It is difficult for cisgender people to understand how it is to be transgender or gender dysphoric and the expression is way to explain but we need other expressions.


Do you have anything you'd like to say personally, to those who misuse your study?

I'll make sure to post your message whenever I see someone doing it.

ProbablyBelievesIt

The study is a population-based matched cohort study in Sweden covering the period 1973-2003. By using Swedish national registers we identified 324 individuals who had undergone change of legal sex and underwent gender-affirming genital surgery. The latter was at the time of the study a prerequisite for change of legal gender. We think we catch almost everyone at the period that underwent the procedure during the time period.

191 were assigned males at birth and 133 were assigned females at birth. For each case we had two times ten controls matched for age and sex and sex assigned at birth and final sex. Non of the controls had a gender dysphoria diagnosis in the registers.

The outcome measures were mortality, cause of death, psychiatric inward care any diagnoses, psychiatric inward care for suicide attempts, psychiatric inward care for drug or alcohol abuse and any crime and violent crime. The outcomes were adjusted for psychiatric morbidity prior to change of legal sex and gender-affirming genital operation and immigrant status.

For combined transgender females and males and for the whole period 1973-2003 we saw an increased risk of being dead ( in suicide and cardio vascular diseases) and of being hospitalized for any psychiatric morbidity and for suicide attempts. We saw a positive time trend regarding mortality, suicide attempts and any crime and violent crime. For the last period (1989-2003) the transgender group did not have any elevated risk of being dead or being hospitalized for suicide attempts or committing any crime or violent crime. They had the same risk as the controls. However the elevated risk for being hospitalized for psychiatric morbidity still remained. The elevated risk in the transgender group could be caused of many things which we were unable to control for. We were able to control for psychiatric morbidity and immigrant status but there are more variables which could explain increased mortality suicidality and psychiatric morbidity.

Eg minority stress, childhood maltreatment childhood sexual abuse all common risk factors for suicidality and psychiatric morbidity. Indeed some studies have also showed that minority stress (Bockting et al 2013; Bauer et al 2015, childhood maltreatment (Simon et al 2011) and sexual abuse (Bandini et al 2011) is more common in the transgender group.

The study was not designed to answer the question if gender-affirming surgery causes mortality suicide or criminality so it could not be used to say that gender-affirming surgery causes death. The study does not say that we should not treat transgender persons since they anyway commit suicide on the opposite it say that we need to improve health care for transgender people and that we need to reduce risk in both cardio vascular dead and suicide. Some people interpret that suicide or suicide is a sign of regret to gender-affirming treatment. The study does not say that. To my knowledge there is no study that had showed that suicide attempts in the transgender group is due to that they regret transition. However there are some studies showing an association with suicidality and minority stress (Bauer et al 2015; Bockting et al 2013; Marchall et al 2015).


Dr. Dhejne thank you for the AMA!

I am interested in your work with trans people with non-binary identities. While I would first like to state I am in no way attempting to invalidate their existence, I am curious if you have found whether they remain strong over time or if some non-binary people at some point change their identity to a binary one either through self exploration or by social pressure. In my personal experience I have seen many people who once identified as non-binary identify as a binary trans person as their transition progressed. I also remember Julia Serrano eluding to this phenomenon in her book Whipping Girl but have never found much evidence on the topic.

In the same topic of non-binary people, do you notice any significant difference in those AMAB v AFAB who identify as non-binary? Do you notice a significant difference between NB v binary-trans people seeking a medical transition?

Thank you for you work and advocacy for trans people!

liv-to-love-yourself

Thank you for your question and nice words. So far we have not analyses the data of the people who applied for partial treatment due to a non binary gender identity or other reasons. So I could only answer from my clinical perspective of treating this group. I found them as a group very similar to binary trans people. We do see that quite many help seeking non binary people after a while transition to a gender binary position or have the need for more gender-affirming treatment regardless of how they identify their gender identity. But we also have many who stay non-binary.


Hi Dr. Dhejne,

Thanks for being here! In the abstract in "On Gender Dysphoria" you mention that:

Gender dysphoric transgender women demonstrated a cerebral activation pattern that corresponded predominately to that of cisgender females, but also some cisgender male characteristics.

This is really interesting. Have you ever come across any data that demonstrates cisgender females having patterns that correspond with cisgender male characteristics? Or vice-versa?

Yopassthehotsauce

Thank you for your question. There is a study made in a similar way but using MRI instead of PET from the Netherland by Burke et al 2014. They showed that gender dysphoric adolescent girls and boys activated their brain in line with their experienced gender when smelling steroids compounds. There are more studies please see the sumamry chapter of the thesis.


Do you have any resources you can recommend for helping loved ones through the emotionally turbulent transition process?

My partner recently started transitioning from male to female. She has been on hormone replacement therapy for six months and the emotional mood swings are taking their toll. Lots of crying late into the night, and her natural anxieties seem to have tripled in intensity. Luckily we have a great support group in our immediate family and friends, but the level of depression I'm seeing worries me.

siha_tu-fira

Thank you for your question and the care of your partner. Ask her what she needs from you and or others how you can support her. She should also check with the endocrinologist if her blood values are okey. Sometimes mood changes are caused by to much estrogen or t to Little, high prolactine, or to low testosterone.


How does availability of care for transgender individuals vary across Europe? How does it compare to the United States?

shiruken

The availability to care differs, and some countries don’t follow the Standards of care by WPATH but others do. The main difference compared to the US is that transgender health care in many countries is a part of tax paid national health care system. The advantage with that is that a lot of care is included and doesn’t cost more than any other health care. However the system is under served with long waiting lists in many countries.


Are there any other physical or medical signs that a person is a different gender? For instance, different levels of hormones when blood is taken or different findings in brain imaging. Or is the determination of trans completely reliant on thay person's gut feeling that they are the opposite gender?

gremalkinn

Thank you for you question. There are at present time no signs of gender incongruence or gender dysphoria in blood samples or in different methods of brain imaging. Someones gender identity could only be personaly defind


A lot of people think that LGBT and, in general, non-traditional gender roles and non-traditional sexual views are caused by childhood sexual abuse or bad childhoods sexual encounters. I've never understood this view, but at the same time, a lot of people are still under 16 when they realize their sexual and gender preferences.

  1. Do more of them have negative or abusive sexual encounters at an early age?

  2. Do you have any evidence that disputes the narrative that abuse leads to non conformist identities?

  3. If there's not an association, then how do we discuss and change peoples' minds?

  4. If there IS an association, how can people who are conflicted come to terms with their identity?

Qubeye

Thank you for your qustions.

There are some studies who has been looking at if transgender people have had a history of childhood sexual abuse (Bandini et al., 2011 2013; Gehring & Knudsson 2005. As far as I know only one study used Controls which you need to do if you are going to say it is more common compare dto cisgender people. Kersting et al. (2003) showed that transgender people compared to psyhciatric inpatients reported more emotional abuse and neglect but had less experience of childhood sexual abuse. However this is one study and we need to do more studies if we should find out how it is.My personal view is that childhood sexual abuse don’t contribute to that someone is transgender but could affects that person’s life regardless of if someone is cis or transgender.


One thing the public seems caught up in is the idea of transgendered athletes. What are your views on transgendered people in sport in terms of their rights?

ShrimShrim

I can't answer this question since it is out of my area of expertise


If im a gp w suspicion that the child/adolescent is struggling w gender but the parent seems ignorant/in denial, how should I approach the issue?

starbombed

Thanks for the question. This is not so easy. Depends on how old the child is. Do you see the child alone or with the parents?

Is it possible to ask the child if she/he feels happy by being a boy or girl? What the child think about his/hers body? Or use a meta perspective there could be many reason why someone is not feeling well, is depressed anxious or whatever and then give som example like beeing bullied, not having a friend, not being happy about the body etc.. could any of this be true for you? Or otherwise work with the parents what they think is the problem and then add that it could also maybe be.... what would they think of that?


What age is the earliest we should be considering gender reassignment? Before, or always after puberty? Have you come across patients with regrets about their surgery?

Wildkarrde_

I think we should follow Standards of Care from WPATH regarding treatment of young people. That means that you start with puberty suppression just after puberty have started.

I have come across people who regretted surgery. However some of them actually never wanted the surgery. Before 2013 in Sweden you were more or less obliged to have genital surgery if you wanted or needed to change legal gender. Some of this people to regret the surgery.

But otherwise almost no one. I think the question arises due to that cisgender people are not gender dysphoric and they have a hard time to imagine how it is, so they think that if they were suppose to have genital surgery they would regret it.


I apologize if this has already been asked. It seems that all of the people who I have personally met that are trans have a history of childhood sexual abuse. How common is this factor and does it play a significant role in making a person trans or is my experience just a coincidence?

gremalkinn

There are some studies who has been looking at if transgender people have had a history of childhood sexual abuse (Bandini et al., 2011 2013; Gehring & Knudsson 2005. As far as I know only one study used controls. Kersting et al. (2003) showed that transgender people compared to psyhciatric inpatients reported more emotional abuse and neglect but had less experience of childhood sexual abuse. My personal view is that childhood sexual abuse don’t contribute to that someone is transgender but could affects that person’s life regardless of if someone is cis or transgender.


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