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Long-Term Follow-Up of Individuals Undergoing Sex-Reassignment Surgery: Somatic Morbidity and Cause of Death

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Introduction: Studies of mortality and somatic well-being after sex-reassignment surgery (SRS) of transsexual individuals are equivocal. Accordingly, the present study investigated mortality and somatic morbidity using a sample of transsexual individuals who comprised 98% (n = 104) of all surgically reassigned transsexual individuals in Denmark. Aims: To investigate somatic morbidity before and after SRS and cause of death and its relation to somatic morbidity after SRS in Danish individuals who underwent SRS from 1978 through 2010. Methods: Somatic morbidity and mortality in 104 sex-reassigned individuals were identified retrospectively by data from the Danish National Health Register and the Cause of Death Register. Main Outcome Measures: Somatic morbidity and cause of death. Results: Overall, 19.2% of the sample were registered with somatic morbidity before SRS and 23.1% after SRS (P = not significant). In total, 8.6% had somatic morbidity before and after SRS. The most common diagnostic category was cardiovascular disease, affecting 18 individuals, 9 before and 14 after SRS, and 5 of those 14 who were affected after SRS had cardiovascular disease before and after SRS. Ten individuals died after SRS at an average age of 53.5 ± 7.9 years (male to female) and 53.5 ± 7.3 years (female to male). Conclusion: Of 98% of all Danish transsexuals who officially underwent SRS from 1978 through 2010, one in three had somatic morbidity and approximately 1 in 10 had died. No significant differences in somatic morbidity or mortality were found between male-to-female and female-to-male individuals. Despite the young average age at death and the relatively larger number of individuals with somatic morbidity, the present study design does not allow for determination of casual relations between, for example, specific types of hormonal or surgical treatment received and somatic morbidity and mortality.
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BASIC SCIENCE
Long-Term Follow-Up of Individuals Undergoing Sex-Reassignment
Surgery: Somatic Morbidity and Cause of Death
Rikke Kildevæld Simonsen, MA,
1
Gert Martin Hald, PhD,
2
Ellids Kristensen, MD, FECSM,
3
and
Annamaria Giraldi, PhD, MD, FECSM
3
ABSTRACT
Introduction: Studies of mortality and somatic well-being after sex-reassignment surgery (SRS) of transsexual
individuals are equivocal. Accordingly, the present study investigated mortality and somatic morbidity using
a sample of transsexual individuals who comprised 98% (n ¼104) of all surgically reassigned transsexual
individuals in Denmark.
Aims: To investigate somatic morbidity before and after SRS and cause of death and its relation to somatic
morbidity after SRS in Danish individuals who underwent SRS from 1978 through 2010.
Methods: Somatic morbidity and mortality in 104 sex-reassigned individuals were identied retrospectively by
data from the Danish National Health Register and the Cause of Death Register.
Main Outcome Measures: Somatic morbidity and cause of death.
Results: Overall, 19.2% of the sample were registered with somatic morbidity before SRS and 23.1% after SRS
(P¼not signicant). In total, 8.6% had somatic morbidity before and after SRS. The most common diagnostic
category was cardiovascular disease, affecting 18 individuals, 9 before and 14 after SRS, and 5 of those 14 who
were affected after SRS had cardiovascular disease before and after SRS. Ten individuals died after SRS at an
average age of 53.5 ±7.9 years (male to female) and 53.5 ±7.3 years (female to male).
Conclusion: Of 98% of all Danish transsexuals who ofcially underwent SRS from 1978 through 2010, one in
three had somatic morbidity and approximately 1 in 10 had died. No signicant differences in somatic morbidity
or mortality were found between male-to-female and female-to-male individuals. Despite the young average age
at death and the relatively larger number of individuals with somatic morbidity, the present study design does not
allow for determination of casual relations between, for example, specic types of hormonal or surgical treatment
received and somatic morbidity and mortality.
Sex Med 2016;4:e60ee68. Copyright 2016, International Society for Sexual Medicine. Published by Elsevier Inc.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Key Words: Follow-Up; Gender Identity Disorder; Somatic Morbidity; Sex-Reassignment Surgery;
Transsexualism
INTRODUCTION
Transsexualism refers to a condition in which the core char-
acteristic is an individuals experience of profound incongruence
between assigned sex at birth and the experienced gender.
1
According to the International Statistical Classication of
Diseases and Related Health Problems, 10th Edition (ICD-10),
2
the diagnostic criteria of transsexualism are (i) the desire to live
and be accepted as the opposite sex, (ii) usually a sense of
discomfort with or inappropriateness of ones anatomic sex, and
(iii) a wish to have surgery and/or hormonal treatment (HT) to
make the body as congruent as possible with the preferred sex.
To develop characteristics of the opposite sex, treatment with
cross-sex hormones (HT), castration, and genital reconstructive
surgery (sex-reassignment surgery [SRS]) might be conducted.
The parent category of transsexualism in the ICD-10 is gender
identity disorder (GID).
2
In Denmark, individuals with GID are
referred to the Gender Identity Unit, University of Copenhagen
(GIUUC) under ICD-8
3
code 302.39 and 1993 ICD-10
2
codes
DF64.0 to DF64.9 by a general practitioner or psychiatrist.
Assessment, in accordance with Danish Health Authority
Received November 25, 2015. Accepted January 13, 2016.
1
Department of Sexology, University Hospital of Copenhagen, Copenhagen,
Denmark;
2
Department of Public Health, University of Copenhagen, Copenhagen,
Denmark;
3
Sexological Clinic, Psychiatric Center Copenhagen, Copenhagen, Denmark
Copyright ª2016, International Society for Sexual Medicine. Published by
Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
http://dx.doi.org/10.1016/j.esxm.2016.01.001
e60 Sex Med 2016;4:e60ee68
guidelines,
4
includes blood sample analyses for chromosomal and
hormonal abnormalities, screening for psychiatric and somatic
morbidities, psychological testing, and sessions with a psychol-
ogist or psychiatrist.
If SRS is desired by the individual diagnosed with trans-
sexualism, an observational period of at least 1 year 6 months (in
the study period, 2 years), including 1 year of HT and living in
the gender role as the opposite sex, is obligatory before applying
for SRS to the Danish Health Authority. The Danish legal
criteria for SRS and castration are an ICD-10 diagnosis of
transsexualism (F64.0), persistent wish for and understanding of
the consequences of castration, and a minimum age of 18 years
(during the study period, ie,1978e2010, the minimum age was
21 years).
5
All treatment is paid for by the public Danish medical
system. Treatment with cross-sex hormones and genital recon-
structive surgery has existed for more than 60 years, but ndings
on mortality and somatic well-being after SRS in long-term
follow-up studies are equivocal.
6
For possible somatic conse-
quences of HT, the following outcomes have been studied the
most: cardiovascular disease (CVD), bone growth, and hormone-
sensitive cancer malignancies.
A review and meta-analysis of 16 studies, including 1,471 male-
to-female (MtF) and 651 female-to-male (FtM) individuals, found
no overall signicant effect of HT on CVD.
7
However, the type of
HT (ethinyl estradiol) and the manner in which HT (oral estro-
gens) was administered in MtF patients were signicantly associ-
ated with CVD.
8,9
Further, in a Swedish study, increased CVD
mortality in FtM and MtF individuals at least 10 years after HT
was found,
6
indicating a possible delay of adverse somatic conse-
quences from HT on cardiovascular pathology.
10
Studies of muscle and musculoskeletal diseases, bone growth,
and bone deciencies overall did not show an increased risk
of osteoporosis in FtM individuals.
11e16
However, in MtF in-
dividuals, lower bone mass density, possibly from androgen
deprivation, was found after treatment compared with before
treatment with HT.
17e19
However, because of increased bone
density before treatment and no loss of bone density from
menopause, MtF individuals maintain a lower risk of osteopo-
rosis than assigned women.
20
In cancer studies involving transsexuals receptive of SRS and/
or HT, the focus has been on breast cancer, although the overall
number of studies in relation to this issue is limited. The
conclusions emerging from these studies suggest that for MtF
individuals
20e23
the risk of breast cancer is lower than the
expected risk of breast cancer in assigned women but similar to
that expected in assigned men. For FtM individuals, male sex
hormones might have an antiproliferative effect on breast cancer
cell lines.
24,25
Thus, few cases of breast cancer in FtM individuals
have been reported,
26,27
indicating FtM individuals have similar
risk as expected for male breast cancer.
Concerning cancer malignancies, a Belgian study, in which the
average time of HT was 6 years (FtM) or 7 years (MtF), found
no increase in cancer malignancies among included transsexuals
compared with controls randomly selected from the popula-
tion.
28
In contrast, a Swedish study found borderline signicant
risk of death from neoplasms compared with controls.
6
Lifestyle
habits such as smoking and avoidance of the health care system
were suggested as possible mediating mechanisms.
When studying increased and decreased risks of cancer in trans-
sexuals receiving HT, it is important to note that HT has been used
for 60 years in some transsexual individuals. Accordingly, the
duration of exposure to HT might not be long enough for tumors to
manifest and the number of individuals exposed is small.
29
Further,
it has been suggested that inconsistency in reporting cancer incidents
among transsexuals might lead to an underreporting of cancer in this
cohort,
21,30
likely affecting prevalence and incidence rates.
Studies of mortality in transsexuals have suggested an increased
mortality risk compared with controls.
6,10
For example, a Swedish
study of 324 MtF and FtM individuals after SRS (follow-up ¼
11.4 years) found that the all-cause mortality rate was three times
higher in this cohort compared with controls.
6
Similarly, in a
Dutch long-term follow-up study of 966 MtF and 365 FtM in-
dividuals (follow-up ¼18.5 years), a 51% higher mortality rate was
found in MtF subjects compared with the general population.
10
For FtM subjects, no increased mortality was found compared
with the general population. A Dutch study of 1,109 individuals
receiving HT found no increased mortality overall, but in MtF
subjects 25 to 39 years old, mortality was signicantly increased
because of suicide, acquired immune deciency syndrome, CVD,
drug abuse, and unknown causes.
31
The only Danish study on
transsexualism conducted thus far, which included 37 individuals,
reported three deaths of 29 reassigned MtF individuals and no
deaths of 8 FtM individuals studied from 1956 through 1978.
32
Somatic morbidity after alcohol abuse has not been investi-
gated previously, although studies of substance abuse in in-
dividuals with transsexualism have been conducted. A Belgian
study (N ¼35) conducted at the University Hospital of Gent
found alcohol and drug abuse in 50% of MtF and 61.5% of FtM
individuals.
33
A Spanish study (N ¼230) of individuals with
complaints of GID seen at the Hospital Clinic (Barcelona, Spain)
found current alcohol- and substance-related disorders in 11%
MtF and 1.4% of FtM subjects.
34
A Swiss study found that 45%
of 31 GID individuals diagnosed by the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition, Text Revision
35
had
lifetime substance abuse (MtF ¼50%, FtM ¼36.4%).
36
A
Swedish study of 233 individuals found substance abuse in
18.2% of FtM and 11.9% MtF individuals.
37
However, in a
different Swedish study of 324 MtF and FtM transsexual in-
dividuals, no signicant risk of being hospitalized for substance
abuse was found compared with the general Swedish popula-
tion.
6
Lung diseases related to or caused by smoking have not
been investigated previously in persons with transsexualism,
although lesbian, gay, bisexual, and transgender persons have a
higher incidence of smoking.
38,39
Accordingly, this was included
as an outcome in the present study.
Sex Med 2016;4:e60ee68
Transsexualism: Somatic Morbidity and Mortality e61
For many of the studies that have focused on somatic
morbidity and mortality, including those reviewed earlier, the
following methodologic shortcomings apply: small sample,
recruitment and diagnostic biases and inconsistencies (eg, place
of participant recruitment and differences in diagnostic criteria),
heterogeneity of treatment regimens, and varied duration of
follow-up periods.
6
The aim of the present study was to (re)investigate somatic
morbidity and mortality using registry data in a cohort including
98% of all Danish individuals referred to a public GID clinic in
Denmark who underwent SRS from 1978 through 2010 after a
diagnosis of transsexualism.
AIMS
The specic aims of the study were to investigate (i) somatic
morbidity before and after SRS and (ii) cause of death and its
relation to somatic morbidity.
METHODS
Procedure
The study was approved by the Danish Data Protection
Agency and the Danish Health Authority. Permission was ob-
tained from the Civil Law Board to identify names and social
security numbers of individuals who underwent SRS from 1978
through 2010 and who were treated at the GIUUC.
National Registers
The Danish National Health Register (LPR) was used to draw
data on somatic morbidity. The LPR contains diagnoses and
dates of onset and end of treatment of all somatic episodes at
hospitals from 1977 (inpatients) and from 1995 (outpatients). In
the LPR, diagnoses are coded according to the ICD-8
(1969e1993) or ICD-10 (1994e).
2,3
Data from the LPR from
1977 to January 2013 were included in the study.
The Cause of Death Register has recorded all deaths and
causes of death in Denmark since 1970. Death events occurring
up to April 2014 were included in the study.
Study Population
Included in the study were 104 individuals (56 MtF and 48
FtM) diagnosed with transsexualism according to the ICD-8
3
or
ICD-10
2
at the GIUUC. All participants underwent castration
with permission from the Danish Health Authority from 1978
through 2010. Verication that an individual had undergone
SRS was accomplished using social security numbers (ie, Danish
Cause of Death Register numbers); numbers ending in even
numbers indicate female-assigned sex and those ending with odd
numbers indicate male-assigned sex. Accordingly, changes in this
number from even to odd or vice versa indicate the ofcial
change of assigned sex (ie, successful completion of SRS).
Baseline data (Table 1) were obtained from medical records.
Sociodemographic data (Table 2) were obtained from medical
records and are further described by Simonsen et al.
40
Because of the lack of a specic code for SRS, the date of start of
follow-up was dened as the date of permission to undergo SRS.
Measures
Baseline data (Table 1) were obtained from medical records
based on interviews performed by specialized psychiatrists, psy-
chologists, and medical doctors at the GIUUC during the
treatment period.
Using the LPR and death registers, we obtained information
pertaining to somatic morbidity before and after permission to
undergo SRS and time and cause of death after obtaining this
permission. More specically, somatic diagnoses given to the pa-
tient from 1977 to January 2013 were investigated. Accordingly,
each individual could present with different diagnoses, but mul-
tiple contacts with the somatic care system with the same diagnosis
only had one outcome before SRS and one outcome after SRS. In
addition, data on time and cause of death after permission to un-
dergo SRS were drawn from the death registers until April 2014.
For each diagnosis, specically chronic heart disease (ICD-10
diagnoses F400e490), chronic lung disease (ICD-10 diagnoses
J40e47, ICD-8 diagnoses 490e493), cancer (ICD-10 diagnoses
C00eC97.9, D00eD10.9, ICD-8 diagnoses 140e209), alcohol-
related liver morbidity (ICD-10 K70e77, ICD-8 303e304), or
muscle and musculoskeletal diseases (ICD-10 M80e85, ICD-8
720e729), individuals were stratied by diagnostic group mem-
bership (ie, had received the diagnosis or had not received the
diagnosis) and assigned sex (ie, MtF or FtM).
Mortality was determined by the cause-of-death certicate.
Hence, each individual was dead or alive. For death, data related
to cause of death were drawn from the death certicate.
Statistics
Statistical analyses were conducted in SPSS 19.0 (SPSS, Inc,
Chicago, IL, USA). Clinical variables were analyzed using
descriptive statistics. Means and SDs were calculated for
Table 1. Baseline Data
Variables
Male to female
(n ¼56)
Female to male
(n ¼48)
Mean age at referral (y),
mean (SD)
30.3 (9.8) 27.0 (8.7)
Mean age at permission
for SRS (y), mean (SD)
37.1 (9.7) 32.6 (8.0)
Mean age at initiating
cross-sex hormones
(y), mean (SD)
32.0 (9.9) 29.8 (8.4)
Mean length of follow-up
(y), mean (SD)
16.38 (7.1) 10.21 (6.1)
SRS ¼sex-reassignment surgery.
Sex Med 2016;4:e60ee68
e62 Simonsen et al
continuous variables. Frequencies and percentages were gener-
ated for nominal and categorical variables. Between-group dif-
ferences were analyzed using c
2
test, t-test, and Fisher exact test.
No missing values were found for somatic outcome variables
because they were obtained from the register data, where values
are present (affected) or absent (unaffected).
RESULTS
Baseline data related to age at referral, permission for SRS,
cross-sex hormonal initiation, and years of follow-up after SRS
are presented in Table 1.
To investigate the rst study aim concerning somatic
morbidity before and after SRS, the total number of included
individuals who received a somatic diagnosis was identied
(Table 3). As presented in Table 3, 20 FtM and MtF individuals
(19.2%) before SRS and 24 FtM and MtF individuals (23.1%)
after SRS had somatic morbidity, with no signicant difference.
Nine individuals (eight MtF and one FtM) had somatic
morbidity before and after SRS, resulting in 35 individuals
(33.7%) overall who had somatic morbidity. Table 4 lists the
specic diagnoses of somatic morbidity.
As presented in Table 4, 25 somatic diagnoses were reported
before SRS and 27 diagnoses after SRS from a total of 20 in-
dividuals before SRS and 24 individuals after SRS. Nine of the
24 individuals had somatic morbidity before and after SRS. The
most common diagnostic category was CVD, affecting a total of
18 individuals, 9 before and 14 after (23 diagnoses) SRS, and 5
of the 14 individuals had CVD before and after SRS. The second
most common diagnostic category was muscle and musculo-
skeletal diseases, with 12 diagnoses, six before and six after SRS,
affecting a total of 11 individuals, with only one individual
having muscle and musculoskeletal disease before and after SRS.
To investigate differences in somatic morbidity between MtF
and FtM individuals, c
2
test, Fisher exact, and t-test were used.
Across diagnostic categories, no signicant differences in somatic
morbidity between MtF and FtM individuals were found. When
comparing somatic diagnoses using c
2
test, no signicant dif-
ferences between the number of somatic diagnoses given before
and after SRS were found.
Concerning the second study aim, cause of death and its
relation to somatic morbidity was investigated from after SRS
until April 2014. Ten individuals (9.6%; six MtF [10.7%] and
four FtM [8.3%]) died from after SRS to April 2014. Mean age
at death was 53.5 ±7.9 years (median ¼55.5) for MtF in-
dividuals and 53.5 ±7.3 years (median ¼52.5) for FtM in-
dividuals (P>.05 by t-test). Somatic morbidity (ie, ofcial cause
of death) included two suicides (19 and 26 years after SRS,
respectively), heart disease (n ¼2), cancer (n ¼1), ulcer (n ¼1),
and smoking- and alcohol-related diseases (n ¼4).
Because the results might be inuenced by changes in clinical
procedures and guidelines over time and the cultural acceptance
of transsexualism, data were checked for systematic differences in
permission to undergo SRS from the rst 16 years (1978e1994)
to the next 16 years (1994e2010). Signicantly (P<.05) more
individuals with transsexualism received permission to undergo
SRS from 1995 through 2010 (28 individuals in 1978e1994
and 76 individuals in 1995e2010).
DISCUSSION
We report the rst nationwide register-based SRS follow-up
study in Denmark of 98% of individuals who ofcially under-
went SRS from 1978 through 2010.
For the rst study aim (ie, investigation of somatic morbidity
before and after SRS), we found that 19.2% of the cohort had a
somatic diagnosis before and 23.1% after SRS. This difference
Table 2. Sociodemographics by Male to Female and Female
to Male*
Male to female
(n ¼58)
Female to male
(n ¼50)
Primary and secondary education (y), n (%)
11 40 (69.0) 38 (76.0)
12e13 (completion of
high school)
16 (27.6) 12 (24.0)
Missing information 2 (3.4) 0
Education beyond primary and secondary school at time of
referral, n (%)
None 29 (50.0) 30 (60.0)
3 y or apprenticeship 21 (36.2) 8 (16.0)
4 y 5 (8.6) 10 (20.0)
Unknown 3 (5.2) 2 (4.0)
Education beyond primary and secondary school when permission
for SRS was granted, n (%)
None 25 (43.1) 25 (50.0)
3 y or apprenticeship 21 (36.2) 13 (26.0)
4 y 8 (13.8) 10 (20.0)
Unknown 4 (6.9) 2 (4.0)
Employment at time of referral, n (%)
Employed 36 (62.1) 31 (62.0)
Unemployed
Sickness or
unemployment
benets
12 (20.7) 7 (14.0)
Social welfare or pension 10 (17.3) 12 (24.0)
Employment when permission for SRS was granted, n (%)
Employed 32 (55.2) 27 (54.0)
Unemployed
Sickness or
unemployment
benets
5 (8.6) 11 (22.0)
Social welfare or pension 20 (34.5) 11 (22.0)
Unknown 1 (1.7) 1 (2.0)
From Simonsen et al.
40
SRS ¼sex-reassignment surgery.
*The c
2
and Fisher exact tests were conducted but showed no signicance
(P<0.05).
Sex Med 2016;4:e60ee68
Transsexualism: Somatic Morbidity and Mortality e63
was found not to be statically signicant. Further, no signicant
difference in somatic morbidity between FtM and MtF cohorts
was found. For the second study aim (ie, investigation of mor-
tality), no signicant difference in mortality between MtF and
FtM cohorts was found. Average age at death was 53.5 years, and
10 individuals died after SRS.
For somatic morbidity, CVD was found in 6 MtF individuals
(10.7%) and 12 FtM individuals (25.0%). In comparison, 4.4%
of assigned men and 3.6% of assigned women older than 35
years in the general Danish population were found to have
CVD.
41
In the present study, CVD might have been due to
long-term follow-up after HT (16.3 years for MtF cohort, 10.8
years for FtM cohort) as reported by other studies,
6,10
or the
observed prevalence of CVD might be explained by a correlation
between depression and anxiety and CVD as suggested by pre-
vious research.
42,43
Socioeconomic status and CVD are
related,
44,45
and the present study group was characterized not
only by anxiety and depression
46
but also by social marginali-
zation
47
and difculties in school, education, and employment.
40
Hence, these factors could be important underlying mediating
and/or moderating mechanisms driving or affecting prevalence
rates of CVD in transsexuals, although the design of this study
did not enable us to explore this further.
Muscle and musculoskeletal morbidity was found in 11 in-
dividuals (10.5%). From 1997 through 2002, 13.9% of the
general Danish population was diagnosed with muscle and
Table 3. Individuals with Somatic Morbidity Before and After SRS*
Diagnosis, n (%)
Before SRS After SRS Before and after SRS
Male to female
(n ¼56)
Female to male
(n ¼48)
Male to female
(n ¼56)
Female to male
(n ¼48)
Male to female
(n ¼56)
Female to male
(n ¼48)
Cancer 0 3 2 1 0 1
CVD54 68 50
Musculoskeletal 3 3 3 3 1 0
Lung 2 1 3 1 2 0
Alcoholic liver 1 3 0 0 0 0
Individuals with somatic diagnosis
Yes 8 (14.3) 12 (25.0) 12 (21.4) 12 (25.0) 8 (14.3) 1 (2.1)
No 48 (85.7) 36 (75.0) 44 (78.6) 36 (75.0) 48 (85.7) 47 (97.9)
CVD ¼cardiovascular disease; SRS ¼sex-reassignment surgery.
*The c
2
and Fisher exact tests were conducted but showed no signicance (P<0.05).
Table 4. Number of Somatic Diagnoses*
Diagnosis, n (%)
Before SRS After SRS
Male to female
(n ¼56)
Female to male
(n ¼48)
Male to female
(n ¼56)
Female to male
(n ¼48)
Alcohol related
Yes 1 (1.8) 3 (6.2) 0 0
No 55 (98.2) 45 (93.8) 56 (100.0) 48 (100.0)
Cancer
Yes 0 3 (6.3) 2 (3.8) 1 (2.0)
No 56 (100.0) 45 (93.8) 55 (98.2) 47 (97.9)
Heart
Yes 5 (8.9) 4 (8.3) 6 (10.7) 8 (16.7)
No 51 (91.1) 44 (91.7) 50 (89.3) 40 (83.3)
Lung
Yes 2 (1.8) 1 (2.1) 3 (5.4) 1 (2.1)
No 54 (96.4) 47 (97.9) 53 (94.6) 47 (97.9)
Musculoskeletal
Yes 3 (5.4) 3 (6.3) 3 (5.4) 3 (6.3)
No 53 (94.6) 45 (93.8) 53 (94.6) 45 (93.7)
Positive somatic diagnosis 11 14 14 13
SRS ¼sex-reassignment surgery.
*The c
2
and Fisher exact tests were conducted but showed no signicance (P<0.05).
Sex Med 2016;4:e60ee68
e64 Simonsen et al
musculoskeletal disease by hospital care.
48
Smoking and excessive
alcohol consumption have been linked to low bone mass and
increased fracture risk in MtF and FtM individuals,
49,50
and such
lifestyle issues might characterize the present cohort.
6,46,51,52
However, given the limited number of individuals presenting
with skeletal morbidity in this study, more comparable studies
are needed to conrm the possible increased risk of skeletal
morbidity in this cohort.
Concerning cancer malignancies, ve individuals (6.2% of
FtM and 3.6% of MtF) were found to have a diagnosis of cancer
compared with 2.4% of assigned women and 1.56% of assigned
men older than 15 years in the Danish general population.
53
Previous studies involving transsexual individuals have found
hormone-sensitive tumors.
16,20,54
Further, in the present study,
two deaths were caused by cancer and by leukemia and lung
cancer, respectively. However, as in the present study, small
samples and the sample design preclude causal inferences
regarding relations between treatment of SRS individuals and
cancer or cancer-related deaths.
In Denmark, alcohol-related diseases cause 5% of the total
number of deaths,
55
with more alcohol and substance abuse in
sexual minority groups.
51,52,56e58
Four individuals had a diag-
nosis of alcohol-related diseases before SRS with none after SRS.
Further, in the present cohort, two individuals died of the effects
of alcohol abuse after SRS. In a previous study on psychiatric
morbidity of the present cohort, four diagnoses indicative of
alcohol abuse after SRS were found.
46
Alcohol-related diseases
are often the consequence of long-lasting alcohol abuse. There-
fore, the actual number of individuals in the present cohort with
alcohol abuse could be larger.
Four individuals had a diagnosis indicative of chronic lung
disease (3.8%). In comparison, 1.3% of individuals older than
35 years in the in the general Danish population had a diagnosis
of severe chronic lung disease.
59
Lung diseases have, to our
knowledge, not been investigated previously in individuals with
transsexualism, and therefore we lack and call for comparable
studies in which to situate our ndings.
Somatic morbidity in the present study group could be due to
long-term HT and/or, as suggested by numerous previous studies,
inuenced by poor mental health, low economic status, social
exclusion,
60
harassment, negative experiences with school
61
and
the employment system,
34,37,62
and discrimination in the health
care system.
46,63,64
Thus, previous studies of the present group
have found that 50% of the cohort did not complete further ed-
ucation beyond primary and secondary school. Also, at the time of
SRS, only 55% were employed
40
and 25% presented with psy-
chiatric morbidity before and after SRS.
46
For the second study aim (ie, cause of death and its relation to
somatic morbidity), the study found that 9.6% of the cohort had
died at an average age of 53.5 years, with the main cause of death
related to smoking and alcohol abuse. The life expectancy of
assigned women and men in Denmark is 81.9 and 78.0 years,
respectively. Previous studies of mortality in transsexual in-
dividuals in countries comparable to Denmark
6,10
have found an
increased risk of death in transsexual individuals. The present
study had a lack of statistical power, and further long-term
studies are needed to draw rm conclusions about trans-
sexualism and increased risk of death.
Two individuals in the study group committed suicide 19 and
26 years after SRS, respectively. A Swedish study of SRS in-
dividuals (N ¼324) found signicantly increased mortality from
suicide and signicantly higher risk for suicide attempts compared
with the general Swedish population.
6
A Dutch study (N ¼1,109)
of SRS and non-SRS individuals found a high incidence of
attempted suicide and completed suicide in the study cohort
compared with the general Dutch population.
31
An Italian study of
163 SRS MtF individuals found that four had attempted suicide
before SRS and one had attempted suicide 12 to 18 months after
SRS.
65
A Danish study reported death from suicide in 3 of 29 SRS
MtF individuals (follow-up ¼6 years).
32
Many explanations can
be considered for suicide and attempted suicide. One might be
regret for undergoing SRS,
32
but in the present study suicide
occurred more than 19 years after SRS and therefore does not seem
to be an immediate consequence of SRS. Because reasons for sui-
cide attempts and manifest suicide often are multifactorial and
because of the low incidence in the present study, further research
is needed to contextualize these results further.
Limitations
The strength of this study is the unique cohort studied. Thus,
on a national basis and over a 30-year period, 98% of all SRS
individuals were included. This provides a unique opportunity to
assess differences between MtF and FtM individuals on variables
for somatic morbidity and mortality. The cohort included only
individuals who received permission to undergo SRS during a
period with strict criteria for obtaining permission to undergo
SRS. Accordingly, the group is highly selected and might not
reect transsexuals per se in Denmark. Although we had a very
large cohort for this type of study, some of our statistics had small
cell sizes, limited numbers, and thus low statistical power,
increasing the chances for type II errors. Because most somatic
care in Denmark is provided by general practitioners, an un-
derestimation of the prevalence of somatic morbidity in the study
is plausible. Thus, somatic morbidity as presented in this study
might be substantially higher.
CONCLUSION
Using a sample comprised of 98% of all individuals who
underwent SRS in Denmark from 1978 through 2010, this
study found somatic morbidity in 19.1% of the study group
before and 23.2% after SRS. Mortality rates were 9.6%, with an
average age at death of 53.5 years. No signicant differences in
somatic morbidity or mortality were found between MtF and
FtM individuals. No rm conclusions can be drawn from the
Sex Med 2016;4:e60ee68
Transsexualism: Somatic Morbidity and Mortality e65
present study, because the present study design does not allow
for determination of causal relations between HT or SRS and
somatic morbidity or mortality. One can speculate as to whether
the increased risk of psychiatric problems and lifestyle issues in
sexual minority groups inuenced the risk of mortality and CVD
in the present study. The ndings underline the importance of
supporting individuals with transsexualism to contact and be
treated in the public health care system and to pay more atten-
tion to lifestyle issues in general.
Corresponding Author: Rikke Kildevæld Simonsen, Depart-
ment of Sexology, University Hospital of Copenhagen, Bleg-
damsvej 9, Copenhagen 2100, Denmark. Tel: þ45-3864-7150;
Fax: þ45-3864-7164; E-mail: rikke.kildevaeld@regionh.dk
Conict of Interest: The authors report no conicts of interest.
Funding: None.
STATEMENT OF AUTHORSHIP
Category 1
(a) Conception and Design
Rikke Kildevæld Simonsen
(b) Acquisition of Data
Rikke Kildevæld Simonsen
(c) Analysis and Interpretation of Data
Rikke Kildevæld Simonsen; Gert Martin Hald
Category 2
(a) Drafting the Article
Rikke Kildevæld Simonsen; Gert Martin Hald; Ellids Kristensen;
Annamaria Giraldi
(b) Revising It for Intellectual Content
Rikke Kildevæld Simonsen; Gert Martin Hald; Annamaria Giraldi
Category 3
(a) Final Approval of the Completed Article
Rikke Kildevæld Simonsen; Gert Martin Hald; Ellids Kristensen;
Annamaria Giraldi
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e68 Simonsen et al
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IntroductionLimited evidence suggests that transgender individuals smoke at significantly higher rates than the general population. We aimed to determine whether structural or everyday discrimination experiences predict smoking behavior among transgender individuals when sociodemographic, health, and gender-specific factors were controlled.Methods Data from the National Transgender Discrimination Survey (N=4,781), a cross-sectional online and paper survey distributed to organizations serving the transgender community, were analyzed in order to determine the association between current smoking and discrimination experiences and other potential predictors. Logistic regression models were used to establish factors that predict smoking.ResultsParticipants reported experiencing both structural (78.9%) and everyday (64.3%) discrimination. Multivariate analyses showed that participants who reported attending some college, graduating college, or having a graduate degree were less likely to smoke compared to those with a high school degree or less. Uninsured participants were more likely to report smoking compared to those with private insurance. Those who used alcohol or drugs for coping were also more likely to smoke. Participants whose IDs and records listed their preferred gender were less likely to smoke (OR=0.84); those who had experienced structural discrimination were more like to report smoking (OR=1.65).Conclusions Further research is needed in order to explore the relationship between smoking and legal transition among transgender individuals. Strategies to prevent smoking and encourage cessation among this vulnerable population are also needed. In addition, comprehensive collection of gender identity data in the context of national surveys, tobacco-related research, and clinical settings is sorely needed.
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Introduction: Male-to-female (MtF) and female-to-male (FtM) individuals with transsexualism (International Classification of Diseases-10) may differ in core clinical and sociodemographic variables such as age, sexual orientation, marriage and parenthood, school, educational level, and employment. Assessing and understanding the implication of such differences may be a key to developing appropriate and effective treatment and intervention strategies for this group. However, research in the area remains sparse and is often on small populations, making the generalization of results from current studies on individuals diagnosed with transsexualism difficult. Aims: (i) To describe and assess key sociodemographic and treatment-related differences between MtF and FtM individuals in a Danish population of individuals diagnosed with transsexualism; (ii) to assess possible implications of such difference, if any, for clinical treatment initiatives for individuals diagnosed with transsexualism. Methods: Follow-up of 108 individuals who had permission to undergo sex reassignment surgery (SRS, meaning castration and genital plastic surgery) over a 30-year period from 1978 to 2008 through the Gender Identity Unit in Copenhagen, Denmark. The individuals were identified through Social Security numbers. Clinical and sociodemographic data from medical records were collected. Results: The sex ratio was 1.16:1 (MtF : FtM). Mean age at first referral was 26.9 (standard deviation [SD] 8.8) years for FtM and 30.2 (SD 9.7) for MtF individuals. Compared with MtF, FtM had a significantly lower onset age (before 12 years of age) and lower age when permission for SRS was granted. Further, FtM individuals were significantly more often gynephilic (sexually attracted to females) during research period and less likely to start self-initiated hormonal sex reassignment (SR) (treatment with cross-sex hormones). The MtF and FtM groups did not differ in years of school, educational level, employment, or engagement in marriage and cohabitation. Conclusions: As approximately half of MtF started cross-sex hormonal SR without attending a gender unit, future treatment needs to focus on this group of MtF individuals in order to accommodate the medical risks of self-initiated hormonal treatment.Earlier intervention with adolescents appears necessary since three-quarters of FtM individuals before age 12 had problems with their assigned sex. For both MtF and FtM, we found problems in areas of school, education, and employment and recommend further help in these core areas.
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Gender dysphoria (GD) is characterized by discomfort with the assigned or birth gender and the urge to live as a member of the desired sex. The goal of medical and surgical treatment is to improve the well-being and quality of life of transpeople. The acquisition of phenotypic features of the desired gender requires the use of cross-sex hormonal therapy (CHT). Adult transmen are treated with testosterone to induce virilization. In adolescents with severe and persistent GD, consideration can be given to arresting puberty at Tanner Stage II and if dysphoria persists CHT is generally started after 16 years of age. Currently available short and long-term safety studies suggest that CHT is reasonably safe in transmen. Monitoring of transmen should be more frequent during the first year of cross-sex hormone administration reducing to once or twice per year thereafter. Long-term monitoring after sex reassignment surgery (SRS) includes annual check-ups as are carried out for natal hypodonadal men. In elderly transmen special attention should be paid to hematocrit in particular. Screening for breast and cervical cancer should be continued in transmen not undergoing SRS. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.
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Cross-sex hormone treatment of transsexual people may be associated with the induction and growth stimulation of hormone-related malignancies. We report here five cases of breast cancer, three in female-to-male (FtoM) transsexual subjects and two in male-to-female (MtoF) transsexual subjects. In the general population the incidence of breast cancer increases with age and with duration of exposure to sex hormones. This pattern was not recognised in these five transsexual subjects. Tumours occurred at a relatively young age (respectively, 48, 41, 41, 52 and 46 years old) and mostly after a relatively short span of time of cross-sex hormone treatment (9, 9-10 but in one after 30 years). Occurrence of breast cancer was rare. As has been reported earlier, breast tumours may occur in residual mammary tissue after breast ablation in FtoM transsexual people. For adequate treatment and decisions on further cross-sex hormone treatment it is important to have information on the staging and histology of the breast tumour (type, grade and receptor status), with an upcoming role for the androgen receptor status, especially in FtoM transsexual subjects with breast cancer who receive testosterone administration. This information should be taken into account when considering further cross-sex hormone treatment. © 2015 Blackwell Verlag GmbH.