In a world first, researchers have found that transgender people in Denmark have a significantly higher risk of suicide than other groups, with the analysis of health and legal records from nearly 7m people over the past four decades being the first to analyse national suicide data for this group.
Transgender people in the country had 7.7 times the rate of suicide attempts and 3.5 times the rate of suicide deaths compared with the rest of the population, according to the records analysed in the study, though suicide rates in all groups decreased over time. And transgender people in Denmark died – by suicide or other causes – at younger ages than others.
“This is a huge problem that needs to be looked at,” said Dr Morten Frisch, a sexual health epidemiologist at Statens Serum Institut in Copenhagen and a co-author.
The New York Times reports that the findings, published in the Journal of the American Medical Association, come as various laws have been enacted in the US targeting sexuality and gender identity, restricting drag performances, bathroom use for transgender people and gender-related medical care.
Studies of LGBTQ people in the US have shown they have high rates of suicidal thoughts and attempts, putting them at increased risk of death by suicide. But with scant data on actual deaths, suicide risk has become a matter of heated speculation and debate.
Some have argued that suicides among transgender people are rare, while some LGBTQ advocates have declared that the new laws could lead more young transgender people to commit suicide.
“This offers a stark rebuttal to some of those political arguments suggesting suicide risk in these groups are exaggerated,” said Ann Haas, an emeritus professor at the City University of New York who has studied suicide risks among LGBTQ people for two decades.
The United States, like most countries, does not have information about the sexual orientation or gender identity of people who die violent deaths because this information is not recorded on death certificates. A few death investigators are trying to collect such data by interviewing the friends and family of the deceased, though progress has been slow.
Denmark, however, has a centralised data repository for all of its citizens, enabling researchers to conduct massive and rigorously controlled studies.
The authors of the new report identified nearly 3 800 transgender people in Denmark by pulling data from two sources: hospital records and applications for legal gender changes. Among that group, nearly 43% had a psychiatric diagnosis, compared with 7% percent of the non-transgender group.
The study identified 92 suicide attempts and 12 suicide deaths in the transgender group between 1980 and 2021, a rate considerably higher than what was found in the non-transgender group. The researchers said there were most likely other suicides that were not captured in the data because no records indicated the person’s gender identity.
The study also found the rate of other, non-suicide deaths in the transgender group was nearly double the rate of the non-transgender group.
The US and Denmark have comparable suicide rates – 14 per 100 000 people in the entire population – suggesting that the study’s findings may apply in the United States as well, researchers said.
“Trans people face widespread poverty; widespread discrimination; they’re more likely to experience homelessness; they’re also over-represented in the prison system, and foster care system,” said Gillian Branstetter, a communications strategist at the American Civil Liberties Union who focuses on transgender rights. “That material lack has very real consequences on their lives, up to and including early deaths.”
But the researchers cautioned against drawing overly broad conclusions about the calculated rates. For one thing, the raw number of suicides and attempts among transgender people was small.
Based on their search tools, the researchers found that approximately .06% of the Danish population was transgender.
In contrast, the Williams Institute at the University of California-Los Angeles has estimated, using survey data, that the number of people who self-identify as transgender in the US is 10 times higher than that.
That might mean that a lot of transgender people in Denmark, and especially the increasing number of younger people who identify as trans or non-binary, were not captured in the data, and perhaps that the true suicide rate is different from what was reported, the researchers said.
“These surveys tend to include much broader spectrums of trans individuals, and we cannot be as certain that our results are as problematic in the broader group,” Frisch said.
Study details
Transgender Identity and Suicide Attempts and Mortality in Denmark
Annette Erlangsen, Anna Lund Jacobsen, Anne Ranning, et al.
Published in the Journal of the American Medical Association on 27 June 2023
Key Points
Question Do transgender individuals have higher rates of suicide attempt and mortality than non-transgender individuals?
Findings In this nationwide cohort study of 6 657 456 Danish-born individuals, transgender individuals identified through hospital and administrative registers had significantly higher rates of suicide attempt (adjusted incidence rate ratio [aIRR], 7.7), suicide mortality (aIRR, 3.5), suicide-unrelated mortality (aIRR, 1.9), and all-cause mortality (aIRR, 2.0) compared with non-transgender individuals.
Meaning This Danish population-based cohort study spanning more than four decades found that transgender individuals had higher rates of suicide attempt and mortality compared with non-transgender individuals.
Abstract
Importance
Prior studies have suggested that transgender individuals may be a high-risk group with respect to suicide attempt and mortality, but large-scale, population-based investigations are lacking.
Objective
To examine in a national setting whether transgender individuals have higher rates of suicide attempt and mortality than non-transgender individuals.
Design, Setting, and Participants
Nationwide, register-based, retrospective cohort study on all 6 657 456 Danish-born individuals aged 15 years or older who lived in Denmark between January 1, 1980, and December 31, 2021.
Exposure
Transgender identity was determined through national hospital records and administrative records of legal change of gender.
Main Outcomes and Measures
Suicide attempts, suicide deaths, non-suicidal deaths, and deaths by any cause during 1980 through 2021 were identified in national hospitalisation and causes of death registers. Adjusted incidence rate ratios (aIRRs) with 95% CIs controlling for calendar period, sex assigned at birth, and age were calculated.
Results
The 6 657 456 study participants (50.0% assigned male sex at birth) were followed up during 171 023 873 person-years. Overall, 3759 individuals (0.06%; 52.5% assigned male sex at birth) were identified as transgender at a median age of 22 years (IQR, 18-31 years) and followed up during 21 404 person-years, during which 92 suicide attempts, 12 suicides, and 245 suicide-unrelated deaths occurred. Standardised suicide attempt rates per 100 000 person-years were 498 for transgender vs 71 for non-transgender individuals (aIRR, 7.7; 95% CI, 5.9-10.2). Standardised suicide mortality rates per 100 000 person-years were 75 for transgender vs 21 for non-transgender individuals (aIRR, 3.5; 95% CI, 2.0-6.3). Standardised suicide-unrelated mortality rates per 100 000 person-years were 2380 for transgender vs 1310 for non-transgender individuals (aIRR, 1.9; 95% CI, 1.6-2.2), and standardized all-cause mortality rates per 100 000 person-years were 2559 for transgender vs 1331 for non-transgender individuals (aIRR, 2.0; 95% CI, 1.7-2.4). Despite declining rates of suicide attempts and mortality during the 42 years covered, aIRRs remained significantly elevated in recent calendar periods up to and including 2021 for suicide attempts (aIRR, 6.6; 95% CI, 4.5-9.5), suicide mortality (aIRR, 2.8; 95% CI, 1.3-5.9), suicide-unrelated mortality (aIRR, 1.7; 95% CI, 1.5-2.1), and all-cause mortality (aIRR, 1.7; 95% CI, 1.4-2.1).
Conclusions and Relevance
In this Danish population-based, retrospective cohort study, results suggest that transgender individuals had significantly higher rates of suicide attempt, suicide mortality, suicide-unrelated mortality, and all-cause mortality compared with the non-transgender population.
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