Tag Archives: suicide

Where to Call if you Need Help

This is not a political blog, but I think we all need a reminder to take care of ourselves right now. Reach out for help – there are people who want to help you.

And to parents who read my blog, please tell your kids you love them and will fight for them.

Sources of Help:

Trans Lifeline for trans people:

  • US number: 1-877-565-8860
  • Canadian number: 1-877-330-6366
  • and their website.

The Trevor Lifeline for LGBTQ youth (US) – 1-866-488-7386 and their website.

National Suicide Prevention Lifeline (US): 1-800-273-TALK (8255) and their website.

The International Association for Suicide Prevention – their website has an interactive map with phone numbers and locations of crisis centers.

From Maria Shriver’s blog, Powered by Inspiration.

Two Years After My Suicide Attempt, I’m Still Living and Sharing

“Waking up two years ago gave me opportunities, some of which seem obvious but some of which I’m still discovering. I have the opportunity to continue the life I began and do the things I want to do. I have the opportunity to offer help to people who would have helped me if only I had shared what was going on.”

Read more here.

Finally, some helpful tips from the website Recommendations for Reporting on Suicide:

Suicide Warning Signs

  • Talking about wanting to die
  • Looking for a way to kill oneself
  • Talking about feeling hopeless or
    having no purpose
  • Talking about feeling trapped or
    in unbearable pain
  • Talking about being a burden
    to others
  • Increasing the use of alcohol or drugs
  • Acting anxious, agitated or recklessly
  • Sleeping too little or too much
  • Withdrawing or feeling isolated
  • Showing rage or talking about seeking revenge
  • Displaying extreme mood swings

The more of these signs a person shows, the greater the risk. Warning signs are associated with suicide but may not be what causes a suicide.

What to Do

If someone you know exhibits warning signs of suicide:

  • Do not leave the person alone
  • Remove any firearms, alcohol, drugs or sharp objects that could be used in a suicide attempt
  • Call the U.S. National Suicide Prevention Lifeline at 800-273-TALK (8255)
  • Take the person to an emergency room or seek help from a medical or mental health professional.
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Suicide is not a Footnote

I am fed up with studies that treat suicide like a footnote.

You are not talking about “patients” or “participants” or “transsexuals.” You are talking about people.

If someone commits suicide during the study, I want to read about it in the abstract, not buried in the methods section. So somebody died and didn’t participate in your study – that is not the important story.

Why did they commit suicide? When did they commit suicide – before or after medical treatment? What medical and therapeutic treatments were they getting? Were there any underlying mental health issues that weren’t being treated? Did they need more support during and after transition? Were they properly diagnosed? Did they have depression? Were they trauma survivors?

You don’t get to ignore their death in your conclusions. The person’s death is part of your results. Suicide needs to be reported in your results and it needs to be discussed.

Most of all, you need to talk about what we can do to reduce the number of suicides and suicide attempts among transgender people.

 

To my readers, if you or someone you love is thinking about suicide:

Sources of Help and Information:

Trans Lifeline for trans people:

  • US number: 1-877-565-8860
  • Canadian number: 1-877-330-6366
  • and their website.

The Trevor Lifeline for LGBTQ youth (US) – 1-866-488-7386 and their website.

National Suicide Prevention Lifeline (US): 1-800-273-TALK (8255) and their website.

The International Association for Suicide Prevention – their website has an interactive map with phone numbers and locations of crisis centers.

What to Do

If someone you know exhibits warning signs of suicide:

  • Do not leave the person alone
  • Remove any firearms, alcohol, drugs or sharp objects that could be used in a suicide attempt
  • Call the U.S. National Suicide Prevention Lifeline at 800-273-TALK (8255)
  • Take the person to an emergency room or seek help from a medical or mental health professional

Two Years After My Suicide Attempt, I’m Still Living and Sharing

“Waking up two years ago gave me opportunities, some of which seem obvious but some of which I’m still discovering. I have the opportunity to continue the life I began and do the things I want to do. I have the opportunity to offer help to people who would have helped me if only I had shared what was going on.”

Read more here.

From Maria Shriver’s blog, Powered by Inspiration.

Effects of different steps in gender reassignment therapy on psychopathology: a prospective study of persons with a gender identity disorder

This study found that hormone therapy reduced symptoms of psychological distress, although surgery had no further effect.

However, this conclusion is undercut by the fact that one person committed suicide during follow-up,* treatment did not reduce the prevalence of suicide attempts, and 17% of the people surveyed after treatment reported suicidal thoughts.

There are also areas where the methodology of the study could be improved.

Finally, the data on the percentages of suicide attempts is confusing. See the end of this review for details on the data.

Summary of the results:

After treatment, patients reported fewer symptoms of anxiety, depression, interpersonal sensitivity, and hostility.

Transition did not reduce the percentage of suicide attempts.

One patient committed suicide during follow-up.*

Transition did not affect patients’ psychosocial well-being, i.e. employment, relationships, number of sexual contacts, drug use, and suicide attempts.

Over 90% of patients said that they were happier and felt better about their body after treatment, but 17% reported that they had suicidal thoughts.

The improvement in psychological symptoms happens after hormone therapy. Surgery did not cause a significant change in psychopathology, although patients reported slightly more symptoms after surgery than after hormone therapy.

When asked, 57.9% of patients said that they experienced the most improvement after hormone therapy, 31.6% experienced the most improvement after surgery, and 10.5% experienced improvement just from being diagnosed.

After treatment, the average scores of psychopathology were similar to the general population.

After hormone therapy, none of the average subscale scores were different from the general population. However, after surgery, the group’s average scores for sleeping problems (p=0.033) and psychoticism (p=0.051) were higher than the general population.

These results raise some important questions.

What can we do to reduce suicide, suicide attempts, and suicidal thoughts in transgender people who have transitioned?

Why didn’t the percentage of suicide attempts go down when people were reporting fewer symptoms of depression?

Why didn’t surgery improve the mental well-being of the patients?

There were also a couple of important methodological questions that the authors did not discuss.

Combining the results of different treatments

As often happens, the study lumped together trans men (born female) and trans women (born male). The treatments for trans women and trans men involve different medications and surgeries. It is possible that androgens and estrogens have different effects on mood. Similarly, it might be that some surgeries are more beneficial to mental health than others or that some surgeries are more stressful than others.

The participants in the study were 46 trans women and 11 trans men. The authors do not discuss whether they differed in their mental health symptoms or social well-being. Nor do they give information on the gender of the people who completed the questionnaires at follow-up.

The study does not specify exactly what medications and dosages were used for the hormone therapy. They do not say exactly what surgeries the patients got.

Missing Data

As with many longitudinal studies, they did not have follow-up data on all of the participants due to incomplete questionnaires. In addition, one participant did not complete a questionnaire at the beginning of the study.

Thus, 56 people completed a questionnaire about their mental health before treatment, but only 47 people completed the questionnaire after hormone treatment. The authors then compared the average scores on the baseline questionnaires to the averages on the questionnaires after hormones.

It is possible that this would lead to a bias in the data. For example if depressed people were less likely to complete follow-up questionnaires, the average for the follow-up questionnaires would show fewer symptoms of depression than the average for the initial questionnaires.

The authors do not discuss whether the people who did not complete the questionnaires after hormone therapy were significantly different from those who did.

Leaving suicide out of the results

The person who committed suicide was not included in the study; if they had been it might have distorted the data. Presumably their responses at baseline would have increased the average score for symptoms of depression, but without a follow-up questionnaire for them, symptoms of depression would appear to go down. Leaving them out makes the results clear – symptoms of depression went down among everyone else.

At the same time, without data on the person who committed suicide during follow-up, it is not fully accurate to say that symptoms of depression went down after treatment. For at least one person it doesn’t make sense to talk about symptoms of depression going down.

Suicide during follow-up is part of the results of this study. It is relevant to the question of whether or not people felt better after transition. When someone commits suicide during a study, this needs to be part of the discussion. When did they commit suicide? Were they depressed before transition? Did they regret the surgery? Did they say they were depressed during or after transition?

Not talking about the suicide is disrespectful to the person who died. It leads to possibly false conclusions about the effects of transition. And it stops us from being able to figure out what we can do to prevent future suicides – do we need to give people more therapy before medical treatments? should some people not get surgery? do we need to give people more therapy after surgery?

Back to the questions raised by the study

What can we do to reduce suicide, suicide attempts, and suicidal thoughts in transgender people who have transitioned?

Clearly, medical transition is not enough. It does not prevent suicide, suicide attempts, or suicidal thoughts. It does not even reduce the prevalence of suicide attempts.

As far as I know, this is the only study that has followed a group of people with gender dysphoria during treatment and collected data on suicide attempts.

We need more research to figure out how to prevent suicide and suicide attempts among transgender people after transition. It might also help if we knew more about what was going on in this study.

When exactly were the suicide attempts – after hormones or after surgery? When exactly did the person commit suicide?  Does this reflect regret related to the surgery itself or something else?

Were there any gender differences in the suicide attempts?

Were there any differences in the specific treatments given to the people who attempted suicide? Were there any problems in the outcomes of the treatments?

Did the same people attempt suicide before and after transition?

Did the people who attempted suicide say they were depressed? Had they been diagnosed with mental health issues? Were they getting counseling?

Do we know of things that went wrong in the lives of the people who attempted suicide?

Do some people need more counseling and evaluation before transition? Should we adapt the hormonal doses or surgeries for different people? Do we need to give additional support after transition? Are there alternatives to transition that would better help some people deal with gender dysphoria?

At this point all we know is that we can not rely on medical transition to prevent or reduce suicide attempts among transgender people.

We need to know more.

Why didn’t the percentage of suicide attempts go down when people were reporting fewer symptoms of depression?

The results of this study are somewhat confusing. People reported that their symptoms of depression and psychological distress went down after transition. In addition, the vast majority of people who had transitioned said that they felt better – they were happier (93%), less anxious (81%), more self-confident (79%), and their body-related experience improved (98%). Only 2 people said they were more anxious and 1 less self-confident. Only 2 said that their overall mood was similar.

So why did 7 people (17.6%) report that they had suicidal thoughts? Why were there 4 suicide attempts?

Were the people who had suicidal thoughts so unhappy to start with that an improvement in their mood still left them suicidal? Perhaps they had even more suicidal thoughts before transition – but the prevalence of suicide attempts was not affected by transition.

It’s possible that the group’s average scores for depression are in the normal range while a few individuals are miserable. On the other hand, the group has an above average number of suicide attempts and suicidal thoughts. According to an Emory University website “It is estimated that 3.7% of the U.S. population (8.3 million people) had thoughts of suicide in the past year, with 1.0% of the population (2.3 million people) developing a suicide plan and 0.5% (1 million people) attempting suicide.” In this study, 17.6% of the group reported suicidal thoughts at the moment of follow-up. The suicide attempt percentage was 9.8% at follow-up.

We are looking at a group of people with elevated levels of suicidal thoughts and suicide attempts – how does that fit with questionnaires that find a normal level of symptoms of depression?

Are we seeing accurate reports of how people feel? Are people minimizing their problems when they fill out questionnaires after treatment?

The authors of the study do not discuss the apparent contradiction between suicide attempts and suicidal thoughts one the one hand and an improved mood on the other.

The authors do point out that the percentage of suicide attempts at the beginning of the study was lower than in other studies of transgender people. It may be that the participants in this study had fewer problems than most transgender people; for one thing they are a group that is able to access medical care. However, that does not answer the question of why for this particular group of people transition did not change the prevalence of suicide attempts.

We need more research into what is going on here. We need to be able to identify people who may attempt suicide or feel suicidal after transition so we can help them.

Why didn’t surgery improve the mental well-being of the patients?

We don’t know and we need more research to answer this question. However, here are a few possibilities:

Possibility #1 – Return to regular life

In their discussion, the authors suggest that there might be an initial euphoria after beginning hormones that wears off later on. In addition, after surgery, people might be “again confronted with stigma and other burdens.”

In other words, the improvement after hormone therapy is higher than the improvement will be in the end. There is still an improvement later on, but the initial level of euphoria isn’t going to last. If this is true, it would be important information for people who are transitioning so that they don’t have false expectations of what life will be like after transition is complete.

Possibility #2 – Surgery is not the best treatment for everyone

The authors also suggest that further studies should look at exploring the idea that some patients might want hormones without surgery.

It may be that surgery is not the best treatment for everyone with gender dysphoria. Perhaps some people would have been better off with just hormone therapy.

Previous studies have found that about 3% of people who have had genital surgery regret it, so we would expect one or two people out of 50 to regret their surgery. Perhaps they are depressed and this affects the group average.

Possiblity #3 – Effects of surgery

It is also possible that some people had post-surgical depression and that this affected the results.

Perhaps some people were still recovering from surgery and did not feel well (the study included people 1 to 12 months after surgery). In particular, this might lead to the increase in sleeping problems found in the study.

Perhaps some people were dealing with complications of surgery.

Perhaps the hormonal changes after surgery affected people’s moods.

Possibility #4 – People were already happy

On the other hand, perhaps by the time people get surgery, they are already happy due to counseling, hormones, and social transition.

Perhaps if people had been forced to stop with hormone therapy alone, they would have become unhappy.  As the authors point out, it may have made a difference that they knew they were going to be able to get surgery.

Possibility #5 – Surgery doesn’t affect mental health

It may simply be that surgery does not improve mental health. At this point, we do not have proof that it does.

In the end, we just don’t know.

Further studies are needed to determine if surgery is helpful and who should get it. Perhaps the authors of this study can use the data they already have to address this question.

 

* Data on this patient was not included in the study.

Original Source:

Effects of different steps in gender reassignment therapy on psychopathology: a prospective study of persons with a gender identity disorder by Gunter Heylens, Charlotte Verroken, Sanne De Cock, Guy T’Sjoen, Griet De Cuypere in J Sex Med 2014 Jan 28;11(1):119-26. Epub 2013 Dec 28.

 

Questions about the data on suicide attempts:

The authors talk about the prevalence of suicide attempts before and after transition, but they don’t talk about the time periods they are looking at. The authors say that the prevalence of suicide attempts was unchanged, but they don’t explain when the suicide attempts took place before treatment. It makes a big difference if they are comparing three years before transition to three years afterward or if they are comparing a lifetime before transition to the average 3 year follow-up period – a follow-up that took place 1-12 months after surgery.

In addition, the actual data on suicide attempts is confusing. In Table 3, the authors list the prevalence of suicide attempts as 9.4% at presentation and 9.3% at follow-up. However, in their discussion they say the suicide attempt percentages were 10.9% initially and 9.8% at follow-up.

Looking at Table 3,  there were 5 attempts in a group of 54 people which would give a percentage of 9.26%, a number that doesn’t match either of the ones given by the authors. In addition, there were 4 attempts in a group of 42 people which would give 9.52%, another number that doesn’t match.

The percentage they gave at baseline in Table 3 seems to be 5 out of 53 people, while the percentage at follow-up seems to be 4 out of 43. Perhaps one of the 54 people didn’t answer the question on suicide attempts in the first set of questionnaires. But where does the additional person come from in the second set of questionnaires? If they are including the person who committed suicide in the suicide attempts, wouldn’t the number of people used to calculate the percentage before treatment be 54 or 55, not 53?

None of this explains why they would list different numbers in their discussion. Perhaps there were some suicide attempts by the same person that were included in one set of numbers but not the others? The table talks about the prevalence of suicide attempts while the discussion talks about the percentage.

It would have been helpful if they had clarified this.

 

 

Male-to-Female Transsexualism: Technique, Results and 3-Year Follow-Up in 50 Patients – Study Review

This is a 2010 study of the functional and cosmetic outcomes of the surgical techniques used at a German clinic. They followed 50 trans women who had surgery between May 2001 and April 2008. The surgeries were all performed by the same surgeon who had extensive surgical experience.

Before surgery, all the patients had completed a two year “real life” test and had been recommended for surgery by two independent psychiatrists. They had been on hormones for at least one year, although they stopped taking hormones a month before the surgery.

The patients were sent a questionnaire to follow-up on sexual function and patient satisfaction with the surgery. All 50 patients completed the questionnaire; the mean follow-up time was 3 years.

Outcomes of Surgery

Regrets:

One person regretted the surgery and became clinically depressed. They attempted suicide twice and had not fully recovered two years later.

The patient was 24 years old and the authors suggest that the ideal age for surgery is 30 years old. They also recommend thorough evaluation and good counseling before surgery.

This is consistent with other studies that found a regret rate after surgery of 3-4%. In a group of 50 people getting the surgery, you would expect one or two people to wish that they had not had the surgery.

The patient regretted the surgery 3 days after the operation.

Complications:

6% had bleeding after surgery

4% required operative revision due to the bleeding (two of the three who had bleeding)

10% had shrinkage of the vagina which could be corrected by a second surgical intervention

4% had a minor bulge in the anterior vaginal wall which could be easily fixed with simple excision

There were no post-operative rectocele (bulge of the rectum into the vagina) or urethrovesical fistulae.

The authors of the study say that the incidence of surgical complications was comparable to the data in the literature.

The 6% of patients with bleeding that they report is better than the 10% reported by a United Kingdom clinic in this review.

Their rate of complications is considerably better than this 2001 study at a different German hospital which reported that “Major complications during, immediately and some time after surgery occurred in nine of the 66 patients (14%), including severe wound infections in six, a rectal lesion in three, necrosis of the glans in three and necrosis of the distal urethra in one. Minor complications, e.g. meatal stenosis in seven patients, occurred in 24 (36%) of patients.”

They do not report any problems with narrowing of the urethra, which is also an improvement over the 3-4% reported by the clinic in the Untied Kingdom.

They do not report any problems with pulmonary embolisms or fistualae between the rectum and vagina. These are problems that are relatively rare and you might not expect to see them in a group of only 50 people; the review from the United Kingdom reported a rate of 2 in 1000 pulmonary embolisms with 1 death. They also reported a rate of 6 in 800 rectal fistulae.

Minor complications:

6% subcuntaneous hematoma that did not require any further therapy (i.e. they had a ruptured blood vessel causing a lump or bruise under the skin)

General:

Mean operative time – 190 (160–220) minutes or 3.16 (2,66- 3.66) hours

Mean depth of the vagina – 10 (6–14) cm or 3.93 (2.36-5.51) inches

Median hospital stay – 10 (6–14) days

In comparison, the United Kingdom clinic reported an operative time of 120-150 minutes, while the 2001 German study reported a mean time of 6.3 hours with a range of 4-9 hours.

Satisfaction with results at follow-up

Appearance:

10% of the patients were dissatisfied with the appearance of their labia

90% were satisfied with the appearance of their genitals

We need more research on how to construct labia that are satisfactory for all trans women.

Depth of Vagina:

20% were dissatisfied with the depth of their vagina

80% were satisfied with the depth of their vagina

4% were still dissatisfied with their vagina after a second operation

Of the ten women who were dissatisfied with the depth of their vagina, eight had a new operation to augment the vagina. Of the women who had the second operation, two were still dissatisfied (25%). Perhaps the secondary operation could be improved.

We need to know more – why were 20% dissatisfied with the depth of their vagina? What can be done to ensure that all trans women have vaginas that are deep enough?

How deep were the vaginas at follow-up? Were there some women whose vaginas were not deep who were satisfied anyway?

Sexual Pleasure:

5% of the trans women having regular sexual intercourse experienced pain during intercourse; 84% of the trans women were having regular sexual intercourse

70% of the trans women reported achieving clitoral orgasm

The authors are not clear here, but it looks like 30% of the trans women who had this surgery are unable to achieve orgasm. This is a serious problem; they should have addressed it more fully.

Were some of the women not attempting orgasm? Did everyone answer the question?

At one point the authors say, “84% reported having regular sexual intercourse, of whom 35 had clitoral orgasm” – that would change the numbers to 35 out of 42 women which would be better (although it would still leave 17% of the sexually active women not having orgasms). On the other hand, they also say, “Of the 50 patients, 35 (70%) reported achieving clitoral orgasm.”

As it stands, it looks like a large percentage of trans women are not having orgasms after surgery. That would be a problem and worthy of more discussion in the results. The ability to orgasm is an important, vital aspect of the outcome of these surgeries.

In addition, doctors and surgeons need to address the problem of pain during intercourse. Is there something trans women can do themselves to reduce the pain? Can the surgeries be improved in this area?

From their Discussion and Conclusions:

“The incidence of surgical complications was comparable to the literature data. The most common complication (10%) in the follow-up was shrinkage of the neovagina. In all cases a second surgical correction was necessary to definitively solve the problem. In all patients vaginopexy to the sacrospinous ligament was carried out, reducing the rate of neovaginal prolapse as described in the literature.

After 3 years, 49 patients were satisfied and did not regret or had doubts about having undergone sexual reassignment surgery. The only exception was a 24-year old patient who, 3 days after the operation, regretted his decision. After that, he developed a strong depression which needed psychological therapy. Two years after surgery, the patient had still not recovered completely and had attempted suicide twice.

We agree with Rehman and Melman that the best age to undergo sexual reassignment surgery is 30 years, an age that enables patients to adjust socially and sexually, increasing the possibility to develop attractiveness and allowing the patients to mature in dealing with new life stresses. Moreover, before undergoing such surgery, it is our opinion that all patients at all ages need deep and intensive psychological examination and must be informed about all the functional and cosmetic risks associated with this operation and, above all, about the impossibility of regretting the decision and returning to their natural gender.

With improvements in surgical technique over the years, male-to-female gender-transforming surgery can assure satisfying cosmetic and functional results, with a reduced intra- and postoperative morbidity. Nevertheless the experience of the surgeon and the center remains a central important aspect for obtaining optimal results.”

The full article includes graphic pictures of surgery as well as details of their technique; you can get it at the link below.

Original Source:

Male-to-Female Transsexualism: Technique, Results and 3-Year Follow-Up in 50 Patients by Wagner S, Greco F, Hoda MR, Inferrera A, Lupo A, Hamza A, Fornara P in Urol Int. 2010;84(3):330-3.

Review of Clinical Management of Youth with Gender Dysphoria in Vancouver – Part I – Demographics

This article is a report on health care provided to youth with gender dysphoria at a clinic in British Colombia, Canada. I’m going to focus on just the demographics in this post and do another post later.

QUICK OVERVIEW

The clinic saw a dramatic increase in the number of their teenage patients from 2006-2011. This is similar to other clinics serving teenagers with gender dysphoria.

Most of their patients were trans men (born female). This is similar to the current situation at other clinics for teenagers, but different from the past at other clinics. It is also different from most European clinics for adults.

Their patients had other psychiatric diagnoses including mood disorders, anxiety disorders, and eating disorders. The patients in this study had more psychiatric problems than teenagers studied at a clinic in the Netherlands.

7% of their patients had an autism spectrum disorder. This is similar to the results of a Dutch study of children and teens with gender dsyphoria.

Suicide attempts are a serious problem among their patients. 12% of their patients had attempted suicide before coming to the clinic; 5% attempted suicide after their first visit to the clinic. The decrease is encouraging, but clearly we need to do more to help patients during and after transition.

Some of their patients had to be hospitalized for psychiatric problems. 12% of their patients had been hospitalized before coming to the clinic, but only 1% were hospitalized after the first visit.  Again, we need to be sure to provide support during and after transition.

THE INCREASE IN TEENAGE PATIENTS

The clinic has seen a fairly dramatic increase in the number of teenage patients from 2006-2011. They went from fewer than 5 cases/year before 2006 to nearly 30 cases in 2011.

0

Number of new patients with gender dysphoria seen in 1998-2011. MtF, black bars; FtM, hatched rectangles.

This parallels what has happened at a similar clinic in Toronto, Canada and a clinic in the Netherlands.

Unlike the other two studies, the majority of the patients at this clinic were always trans men (born female). In fact, before 2006 almost all of the patients were trans men. After 2006, the number of trans women patients (born male) began to increase. However, trans men still made up 54% of all the patients they saw between January 1998-December 2011.

This is different from the pattern found in the clinics in Toronto and Amsterdam. In those two clinics the patients were mostly trans women before 2006, but after 2006 they were mostly trans men.

It’s hard to know what these numbers mean because we don’t know how common gender dysphoria is among teenagers.

“The prevalence of adolescent-onset gender dysphoria is not known, and there are limited accurate assessments of prevalence of transgenderism in adults in North America. However, the prevalence of adults seeking hormonal or surgical treatment for gender dysphoria is reported to be 1:11 900 to 1:30 400 in the Netherlands.”

Does this increase reflect an increase in the number of teenagers with gender dysphoria? If so, why are the numbers increasing?

Alternatively, is this increase due to people with gender dsyphoria seeking physical transition at a younger age?

Statistics on most European clinics have shown many more trans women transitioning than trans men (the pattern is reversed in Japan and Poland). Now the statistics on Canadian and Dutch teenagers show more trans men transitioning than trans women.

Are there more trans men than in the past? If so, why?

Or are trans men transitioning at a younger age than trans women? But then why did the other two clinics treat more teenage trans women than teenage trans men in the past?

BASIC DEMOGRAPHICS OF THE PATIENTS IN THIS STUDY

The clinic at British Colombia Children’s Hospital saw 84 youth with a diagnosis of gender dysphoria from January, 1998 to December, 2011.

45 of the patients were trans men, 37 were trans women, and 2 were males who weren’t sure of their gender identity.

Two of the trans women had disorders of sex development – one had Klinefelter syndrome (XXY chromosomes) and one had mild partial androgen insensitivity syndrome (i.e. her body made androgens, but they didn’t fully affect her).

The median age at the first visit was 16.8, the range in ages was from 11.4 to 22.5.

At the first clinic visit, most patients were in school grades 8-10 (32%) or grades 11-12 (48%); 12% were in grades 5-7, and the remaining 8% were in college/university or no longer attending school.*

PSYCHIATRIC COMORBIDITIES

Diagnoses made by a mental health professional:**

35% of the patients had a mood disorder (20 trans men, 7 trans women and probably the two males with uncertain gender identity)

24% had an anxiety disorder (15 trans men, 4 trans women and probably one male with an uncertain gender identity)

10% had ADHD (2 trans men, 6 trans women)

7% had an autism spectrum disorder (2 trans men, 4 trans women)

5% had an eating disorder (2 trans men, 2 trans women)

7% of their patients had a substance abuse problem (2 trans men, 4 trans women)

26% of their patients had two or more mental health diagnoses (12 trans men, 9 trans women) and probably one male with an uncertain gender identity.

Suicide attempts:

10 of the teenagers attempted suicide before coming to the clinic (12%). 6 of them were trans men and 2 were trans women. Perhaps the other two were the two males who weren’t sure of their gender identity.

4 of the patients attempted suicide after the first visit to the clinic (5%). Three of them were trans men and one was a trans woman.

Psychiatric hospitalizations:

12% of the patients had been hospitalized for a psychiatric condition before coming to the clinic – seven trans men and three trans women.

One trans man was hospitalized for a psychiatric condition after the first visit to the clinic (1%).

Conditions requiring hospitalization included posttraumatic stress disorder, depression, substance abuse, behavioral issues, psychosis, and anxiety.

Mood, puberty blockers, and hormones:

One trans woman and one trans man discontinued the use of a puberty blocker after they developed emotional lability (7% of the patients who took the puberty blocker). The trans man also had mood swings.***

One trans man had significant mood swings as a side effect of testosterone treatment. (3% of the patients who took testosterone.)

Two trans men temporarily stopped testosterone treatment due to psychiatric conditions – one was depressed and one had an eating disorder. (5% of the patients who took testosterone.)

One trans man temporarily stopped testosterone treatment due to distress over hair loss. (3% of the patients who took testosterone.)

Gender differences:

Trans men were significantly more likely to have depression or anxiety disorders than trans women. 44% of trans men had mood disorders compared to 19% of trans women. 33% of trans men had anxiety disorders compared to 11% of trans women.

There were no significant gender differences in other mental health issues.

27% of trans men had two or more psychiatric diagnoses compared to 24% of trans women. This seems surprising given that trans men were more likely to have mood and anxiety disorders.

The most important issue is the number of suicide attempts.

Why were there four suicide attempts after the first visit to the clinic?

Were the suicide attempts related to the two patients who developed emotional lability on blockers? or the trans man who developed mood swings after taking testosterone?

Were they related to the trans man who stopped taking hormones due to depression? Was he the same person as the trans man who developed mood swings on testosterone?

What about the trans man who stopped his hormones due to an eating disorder?

When were the suicide attempts? Were they before the patients got blockers or hormones? Did they happen after stopping hormones for any reason? Or were the patients already on hormones or blockers?

Could they have been prevented by more therapeutic support before treatment? during treatment?

Is there a way to identify which patients are at risk for suicide attempts during or after treatment?

It is encouraging to see that there were fewer suicide attempts after the first visit to the clinic than before, but it is not enough. We need to do more.

We also need more data on the decrease in the number of suicide attempts after coming to the clinic. Was it statistically significant? Was the time period before the first visit to the clinic equal to the time period after the first visit to the clinic?

Psychiatric comorbidities comparison

Compared to a clinic in the Netherlands, these patients were more likely to have mood disorders (35% vs. 12%), but about as likely to have anxiety disorders (24% vs 21%).

5% of the Vancouver patients had an eating disorder while none of the patients in the Dutch study did.

7% of the patients in this study had a substance abuse problem while only 1% of the patients in the Dutch study did.

26% of the patients in this study had two or more psychiatric diagnoses. In comparison, only 15% of the teenagers in the Dutch study had two or more psychiatric disorders.

Finally, the Dutch study found that trans women were at higher risk for having a mood disorder or social phobia while this study found that trans men were at higher risk for mood and anxiety disorders.

Why is the psychiatric comorbidity higher in the Vancouver patients?

The authors of the report suggest that it might be because the average age of their group was higher than the average age in the Dutch study – 16.6 year vs 14.6 years. It might simply be that older teenagers have had more time to develop mental health issues.

They also suggest that there could be differences in diagnostic criteria. Both groups seem to have been using DSM-IV diagnoses, but the Vancouver data was based on clinic notes while the Dutch data was based on interviewing parents. It may be that parents underestimate their children’s problems. For example, they might not realize that their teenager has a substance abuse problem or an eating disorder.

In addition, the Vancouver study includes all 84 patients their clinic saw between 1998-2011. In contrast the Dutch group invited 166 parents to participate in their study, but only 105 parents did so. It is possible that the 61 parents who did not participate had children with more problems, although the authors suggest that the inconvenience of travelling to the center was the main issue.

Finally, the Dutch group has 17 teenagers who were referred to the clinic but dropped out after just one session, “mostly because it had become evident that gender dysphoria was not the main problem.” These patients might have had more psychological comorbidity than others.

It is hard to compare this to the Vancouver clinic, however, because the Vancouver clinic’s focus is on endocrine care. 93% of the patients they saw had already been diagnosed with gender dysphoria by a mental health professional. Were there teenagers in Canada who discovered that gender dysphoria was not the main problem and did not go on to the clinic? If so we would expect the two clinics to have similar rates or psychological comorbidity. If not, we might expect a higher rate of comorbidity in Canada.

A final possibility is that the Canadian teenagers with gender dysphoria simply have more psychological problems than Dutch teenagers with gender dysphoria. Perhaps they experience more bullying and violence. Perhaps they had less supportive parents.

As usual, we need more studies. Why are the numbers of teenagers at clinics for gender dysphoria increasing? What is the prevalence of gender dysphoria among teenagers? How common are psychological comorbidities? Are trans men or trans women more at risk for depression and anxiety? What can we do to prevent suicide attempts after treatment begins? How can we better support patients with gender dysphoria during and after transition?

Original Source:

Clinical Management of Youth with Gender Dysphoria in Vancouver by Khatchadourian K, Amed S, Metzger DL in J Pediatr. 2014 Apr;164(4):906-1.

 

*This would suggest that 48% of the students were 16-17 years old, 32% were 13-15, 12% were 11-12, and 8% were 18-22.5.

** The table indicates that these were diagnoses made by a psychiatrist or psychologist. There were other diagnoses the authors didn’t include in the table: 1 patient with trichotillomania, 2 with borderline personality disorder, 1 with psychosis not otherwise specified, 1 with adjustment disorder, 2 with tic disorders, and 1 with oppositional-defiant disorder. I am not sure why these diagnoses weren’t included; perhaps they weren’t made by mental health professionals.

***The blockers being used were gonadotropin-releasing hormone analog or GnRHa.

Characteristics of children and adolescents with gender dysphoria referred to the Hamburg Gender Identity Clinic – Brief Review

This article is in German, so I have only seen the abstract.

Demographic data on trans kids and teens is generally lacking, but there seems to be an increase in diagnoses of gender dysphoria.

“Given the increasing demand for counselling in gender dysphoria in childhood in Germany, there is a definite need for empirical data on characteristics and developmental trajectories of this clinical group.”

This study looked at the patients at one clinic and found that there were significant differences between the girls and boys with gender dysphoria. They suggest that the two groups will need “different awareness and individual treatment approaches.”

Between 2006 and 2010, the Hamburg Gender Identity Clinic saw 45 “gender variant” children and teens. 40 of these patients were diagnosed with gender identity disorder (88.9%).

Differences reported between girls and boys with gender dysphoria:

The girls were older than the boys on average.

A higher percentage of the girls were referred to the clinic at the beginning of adolescence (over 12 years old), although more girls reported an early onset of gender dysphoria.

More of the girls talked about their “(same-sex) sexual orientation during adolescence and wishes for gender confirming medical interventions.”

More of the girls reported self-mutilation in the past or present.

More of the girls reported suicidal thoughts and/or attempts.

The referral rate of girls with gender identity disorder was higher than the rate for boys. They give the ratio 1:1.5. (I am not sure what this means; this is a translation of an abstract.)

Original Source:

“Characteristics of children and adolescents with gender dysphoria referred to the Hamburg Gender Identity Clinic” by Becker I, Gjergji-Lama V, Romer G, Möller B. in Prax Kinderpsychol Kinderpsychiatr. 2014;63(6):486-509.

The Science Behind Suicide Contagion – New York Times Article

Reposting this for the holidays. There have been more trans teenagers and adults who committed suicide since I wrote this article. We need to do anything we can to stop this.

“When Marilyn Monroe died in August 1962, with the cause listed as probable suicide, the nation reacted. In the months afterward, there was extensive news coverage, widespread sorrow and a spate of suicides. According to one study, the suicide rate in the United States jumped by 12 percent compared with the same months in the previous year.

Mental illness is not a communicable disease, but there’s a strong body of evidence that suicide is still contagious. Publicity surrounding a suicide has been repeatedly and definitively linked to a subsequent increase in suicide, especially among young people. Analysis suggests that at least 5 percent of youth suicides are influenced by contagion.”

Read more: The Science Behind Suicide Contagion, The New York Times, August 2014.

I am posting this link because last Sunday a transgender teenager committed suicide after posting a suicide note on Tumblr.

This came about a month and a half after another widely discussed case of a transgender teenager who committed suicide after posting a suicide note on Tumblr.

Two days ago another transgender teen posted on Instagram that they were going to commit suicide. They made multiple references to the first two teenagers – they wondered what selfie people would use to talk about them and would they get a hash tag? It is not clear what happened to the third teenager, although they posted a suicide note that was later taken down.

I believe some of my readers are parents of teens. Hug them, love them, compliment them. Talk to them about this issue.

Sources of Help and Information:

Trans Lifeline for trans people:

  • US number: 1-877-565-8860
  • Canadian number: 1-877-330-6366
  • and their website.

The Trevor Lifeline for LGBTQ youth (US) – 1-866-488-7386 and their website.

National Suicide Prevention Lifeline (US): 1-800-273-TALK (8255) and their website.

The International Association for Suicide Prevention – their website has an interactive map with phone numbers and locations of crisis centers.

From Maria Shriver’s blog, Powered by Inspiration.

Two Years After My Suicide Attempt, I’m Still Living and Sharing

“Waking up two years ago gave me opportunities, some of which seem obvious but some of which I’m still discovering. I have the opportunity to continue the life I began and do the things I want to do. I have the opportunity to offer help to people who would have helped me if only I had shared what was going on.”

Read more here.

Finally, some helpful tips from the website Recommendations for Reporting on Suicide:

Suicide Warning Signs

  • Talking about wanting to die
  • Looking for a way to kill oneself
  • Talking about feeling hopeless or
    having no purpose
  • Talking about feeling trapped or
    in unbearable pain
  • Talking about being a burden
    to others
  • Increasing the use of alcohol or drugs
  • Acting anxious, agitated or recklessly
  • Sleeping too little or too much
  • Withdrawing or feeling isolated
  • Showing rage or talking about seeking revenge
  • Displaying extreme mood swings

The more of these signs a person shows, the greater the risk. Warning signs are associated with suicide but may not be what causes a suicide.

What to Do

If someone you know exhibits warning signs of suicide:

  • Do not leave the person alone
  • Remove any firearms, alcohol, drugs or sharp objects that could be used in a suicide attempt
  • Call the U.S. National Suicide Prevention Lifeline at 800-273-TALK (8255)
  • Take the person to an emergency room or seek help from a medical or mental health professional