Transgenderism: A Scientific Analysis

Transgenderism: A Scientific Analysis

by Dr. Sadiq Muhammad

Contents

  1. Disorder or Dysphoria?
  2. Transgender, Transexual, Transvestite…Confused?
  3. Are Trans-people “Born that Way”?
  4. Blocking Puberty in Children
  5. Suicidality and Transgenderism
  6. The Real Cause of Gender Dysphoria
  7. Sex Change Regret
  8. High Transgender Suicide not caused by Transphobia
  9. Conclusion

Summary

  • There is not such thing as a “trans-brain” or being “born trans”. 
  • Transgender individuals are many times more likely than cisgendered individuals of having suffered sexual assault at all ages of their youth, from childhood to teenage years and on to early adulthood. Such assault ranges from unwanted sexual touching to rape. Such negative experiences have a proven causal association with gender dysphoria (as detailed in the article “What Causes Homosexuality?”).
  • Children with gender-dysphoria from the ages of 5-12 are likely to be cis-gendered 10 years later, if left alone.
  • Suicidality in transgender individuals is poorly explained by social stigma or transphobia. This includes offensive behaviour or physical violence.
  • Suicidality in transgender individuals remains high (19 times higher) after gender reassignment surgery. It is difficult to claim gender-reassignment surgery as a success for transgender individuals, when such high levels of attempted and successful suicide continue even afterwards.
  • Gender reassignment surgery shows improved trends in quality of life (QoL) for 1 year after surgery, which are reversed to pre-surgical levels after 3 years. By 5 years post surgery, the QoL of transexuals is worse than it was before surgery.
  • Anecdotal evidence highlights a significant proportion of individuals who wish to de-transition after going through gender re-assignment surgery. The exact proportions of such individuals require further study, but may, if significant enough, further undermine the mantra that gender-reassignment surgery is the only treatment for gender dysphoria. 

Disorder or Dysphoria? 

Transgenderism is unease and distress that arises from the feeling that one is trapped in the wrong gender and that one’s internal gender is different to one’s external, physical sex. It is the result of a discordance between one’s internal view of oneself and the external reality, witnessed by others.

In the United States, latest large-scale surveys place the percentage of transgender individual at 0.6% of the population1. Transgenderism was classified as a mental health illness in the Diagnostic and Statistical Manual (DSM) until very recently, the official term being “Gender Identity Disorder”. This was replaced in DSM V by the term “Gender Dysphoria”, meaning “gender unease or dissatisfaction”. The purpose of re-classifying transgenderism as a product of a dysphoria, rather than as a disorder, is to promote a shift in the language surrounding transgenderism, from a pathological condition, to one which is a natural variation of human experience, and not a psychological illness per say. This was accepted by the American Psychiatric Association (APA). A subcommittee member, Jack Drescher, explained to the Advocate2:

“We know there is a whole community of people out there who are not seeking medical attention and live between the two binary categories. We wanted to send the message that the therapist’s job isn’t to pathologize.”

This is a confused statement, because the criteria for diagnosing “gender dysphoria” is, according to the DSM V3:

  1. “Incongruence between one’s experienced/expressed gender and assigned gender,”
  2. “Clinically significant distress or impairment in social, occupational, or other important areas of functioning.”

This fits precisely with the meaning of  a “pathology”; that a condition should cause distress and thus impairment of the individual’s normal functioning. Therefore, the shift in language from “disorder” to “dysphoria” in fact does nothing to eliminate the pathologising aspect of transgenderism, rather, it simply makes the diagnosis more palatable to the lay-public who will not know what “dysphoria” necessarily means. It is important in this definition, to understand what “gender dysphoria” is not. It is not a boy who doesn’t like traditionally male roles or activities, nor does it refer to a girl who does not enjoy traditionally female roles and activities. These operate within the normal spectrum of gender-identity. To be classified as gender dysphoric, the feeling of incongruence between the physical and psychological sex must be such as to impair one’s normal social, occupational or “other important areas of functioning”. Thus, the term should not be used as a catch-all for all those who do not conform fully to traditional gender roles.

As for whether “gender-dysphoria” (transgenderism) causes significant impairment of an individual’s healthy functioning, a quick glance at some statistics should give a clear answer:

  • 48% of transpeople under the age of 26 said they had attempted suicide before, 30% having attempted in the past year in the UK, with 59% having considered committing suicide.4
  • In the US, the attempted suicide rate reach 41% among transpeople.5
  • HIV infection rates are approximately four times higher (2.64%) than the general population (0.6%).5 Interestingly, this is driven principally by the male-to-female (MTF) individuals (4.28%) rather than female-to-male (FTM) individuals, whose HIV infection rates were lower than the national average (0.51%).
  • Psychiatric disorders in general are significantly higher in the transgender population. Among young transgender women (16-29 years old) for example, rates of psychiatric disorders or substance abuse was found to between 1.7-3.6 times higher than the general population.6

We can see therefore that transgenderism is associated with a significant impairment of normal, healthy functioning both at the physical and psychological level, and poses a very significant risk to one’s life, through suicide. When we further consider that a large number of transgender individuals also undergo life-changing hormonal therapy and/or surgery, resulting in infertility and/or removal and reconstruction of genitalia, we can understand further than transgenderism is not simply an “alternative” manifestation of one’s gender identity. It entails a large psychological and physical burden, and as such, cannot but be classified as interfering with one’s normal healthy functioning, and therefore as pathological.

Trans-activists would say that the above co-morbidities and indeed mortality associated with transgenderism, is not due to transgenderism in and of itself, but is due to the social rejection, stigma and often violence that trans-individuals suffer. Indeed, trans-activists have structured their arguments for normalisation and full acceptance as a non-psychological condition, on the following basis:

  1. Transgenderism, like homosexuality, is something a person is born with. It is not something that they develop after birth.
  2. Transgender individuals have extremely high rates of suicide and self-harm, and this is due to the rejection of their “true”, inner gender by the wider community.
  3. In light of the above points, transgender individuals must be accepted in society for the gender they inwardly feel, so as to prevent feelings of rejection and the development of severe mental health problems.

By attributing the physical and psychological harm associated with transgenderism to social rejection of trans-individuals rather than the gender dysphoria itself, trans-activists have sought to shrug off the “pathological” label.

If the activists are correct then we should forthwith push for the normalisation of transgenderism in society. If however, the physical and psychological harm is due to the transgenderism itself, then the very opposite is true; by promoting transgenderism in society, we may be promoting gender dysphoria itself, and the very serious mental and physical health problems that are associated with it.

The stakes are high.

Transgender, Transexual, Transvestite…Confused?

The Transgender pride flag, first made public in 2000 by Monica Helms in Phoenix, Arizona.

Teasing apart these definitions is important because understanding what transgenderism or “gender dysphoria” is, is as much about understanding what it is not. Here are the definitions:

Transgender: We have already discussed this above. It relates to someone who experiences unease and distress on account of feeling that they are in the wrong biological sex.

Transexual: Someone who has transitioned surgically from their sex at birth to their target sex, when they had transgender feelings. As will be discussed, many transexuals (individuals who have undergone gender reassignment surgery) continue to suffer from gender dysphoria, and thus, from transgender feelings. A person can thus be transgender and transexual simultaneously.

Transvestite/Cross-dresser: These relate to individuals who consider themselves as the sex and gender of their birth, but who enjoy dressing up as women. Cross-dressing is the preferred term; transvestism is regarded as offensive by many cross-dressing individuals. If transvestism is accompanied by erotic emotions and is accompanied by psychological distress, it is classified as “travestic fetishism” and has a place in the DSM V.

Book cover of DSM-5, Copyright owned by the American Psychiatric Association

From the above we can see that transexualism is seen as the means of resolving transgender feelings and emotions for many transgender individuals. Supporting transexualism is often what is meant by supporting transgenderism. This highlights the interrelationship between gender and sex that lies at the core of the transgender struggle. Trans-people, whether they suffer from “gender-identity disorder” or “gender-dysphoria” have a problem related to their gender, and not their sex. The distinction is important, and gets to the heart of whether trans-people are “born that way”. The APA define the two in the following manner:

Sex is assigned at birth, refers to one’s biological status as either male or female, and is associated primarily with physical attributes such as chromosomes, hormone prevalence, and external and internal anatomy. Gender refers to the socially constructed roles, behaviors, activities, and attributes that a given society considers appropriate for boys and men or girls and women. These influence the ways that people act, interact, and feel about themselves. While aspects of biological sex are similar across different cultures, aspects of gender may differ.7

Thus, transgender individuals may seek to resolve the discordance between their physical sex and their psychological sex (known as gender), by changing their external sex through transexualism.

For the vast majority of individuals, the terms “gender” and “sex” are interchangeable because both are in consonance with one another. Further, we must take exception with the above definition of gender, as gender is not wholly “socially constructed”. Gender is, in itself, rooted in a recognition of one’s sex, and the recognition of one’s differences from members of the opposite sex. It is out of this biological difference that the psycho-social differences in “behaviors, activities, and attributes” of the different genders, arise.

Indeed, in the article “What Causes Homosexuality” we probed the origins of sexual orientation  and found it deeply related to gender identity. That is, gender identity is determined largely in childhood, pre-pubertally, and sexual orientation develops during puberty in consonance with the psychological gender-identity developed. That is, a male psychological state will predispose to an attraction to females, whether one is male or female by sex; a female psychological state will predispose to an attraction to males, whether one is male or female by sex. This is discussed further in other articles.

This interplay between gender and sex is seen clearly when looking at the case of intersex individuals who had often been raised in the gender opposite to their genetic profile (eg: genetic males raised as females due to partial androgen insensitivity syndrome), who yet showed high rates of conformity to the gender of raising, and high rates of heterosexuality8. Cases of homosexuality were invariably related to individuals whose gender-identity had been perturbed through multiple genital surgeries, and whose gender was therefore perceived by themselves to be artificial rather than natural9.

It is not surprising then that transgender individuals are many times more likely to be non-heterosexual. While rates of homosexuality and bisexuality among the non-transgender UK population stand at around 1% and 1.5% respectively10, the rates for the transgender population stand at 23% for homosexuality, 25% bisexual, and 23% queer (sexually confused/ambiguous). Non-heterosexual individuals therefore make up around 77% of the transgender community in the US 5.

From the above analysis, we can see then that transgenderism is not a disorder of one’s sex, but of one’s gender, and through that, sexual orientation is also affected. While sexual orientation is affected, trans-people are usually reproductively healthy, and are able to father or bear children even after sex-change treatments (depending on the nature of the treatment, as some treatments cause infertility).

Attempts at representing trans-people as being “born that way” therefore do not claim that transgender people are biologically different as regards their reproductive or genital characteristics; they are not intersex. Rather, the focus is on the argument that trans-people have “brain differences” that align them more closely with the opposite sex than their sex of birth. Just as in the case with homosexuality, these “differences” are minor, accounted for by confounding factors, and cannot be said with any certainty to have preceded or caused the transgender emotions and feelings; behaving and conforming to opposite-sex behaviours through transgenderism could quite easily have also moulded the brain to adopt opposite-gender features.

Claiming the transgender individuals are “born that way” is the basis of the argument stated above for the normalisation of transgenderism in society. To know whether transgender individuals are born that way is key, as with homosexuality, to the argument that only through normalisation can we limit the psychological harm they face. To this question then, we now turn our attention.

Are Trans-people “Born that Way”?

There has been considerably less research into the biological origins of transgenderism than there has been regarding homosexuality. The reason is simple: the prevalence of the myth that gay people are “born that way” has meant that there is less need for transgender studies to seek to provide an academic basis for their similar claim. Trans-activists have thus benefited from the widespread acceptance of false claims that homosexuality has an innate, inherited, biological cause.

It should be noted that this discussion regarding whether transgender people are “born that way” does not refer to intersex individuals, who do have a biological basis for transgender feelings, not least because they are biologically ambiguous between both sexes. As such, there can be no argument that they do not have a biological cause for feeling like they are the wrong sex. Our discussion is limited to those individuals who – to all intents and purposes – have the normal biological functioning of their own sex (male or female) and have been raised in accordance with their apparent biological sex.

Could it be that intersexuality is a wider spectrum that previously thought, and that individuals may possess normal biological functioning from a reproductive standpoint, but may yet have brains that are biologically hard-wired like those of the opposite gender, rendering them “trapped” in the wrong sex?

The best way to assess whether a person is biologically programmed for a condition or trait is to see what the identical-non identical twin concordance difference is in a random population sample. When we looked at homosexuality, the difference was a mere 5-6%, which places homosexuality as less genetically/developmentally driven that conditions such as Parkinson’s disease (9% difference), which is acknowledged by health professionals to have no genetic component. As regards transgenderism, there has been no serious large-scale studies looking at identical-non identical twin concordance differences. The highest level of evidence in this category have been case studies.

Identical twin Studies

Unfortunately there have been no randomised controlled trials looking at twin concordance for transexualism. The only evidence we have regarding identical-non identical twin concordance differences is from reviews of case-report literature, conducted via surveys, with very low numbers.

Heylens et al11 found that of 23 identical twins, 9 were concordant for transexualism. In comparison, none of the 21 dizygotic twins reviewed were concordant for transexualism. Similarly, in a study combining past reports of case-reports and a survey performed by Milton Diamond12, 32% of 64 identical twins were found to have transitioned to transexualism, while only 2.6% of 38 non-identical twins were found to have undergone sex-reassignment surgery. From the apparent results therefore, there seems to be some significant, though not deterministic, genetic component. However, on careful reflection of the case reports of the concordant twins, as well as the methods used by Milton Diamond in his survey, we find severe confounding factors emerge,  undermining the conclusions of the papers entirely:

Firstly, if it was purely genetically caused, one should expect to see 100% of identical twins as concordant for transexualism. We see only a 33% concordance. This indicates, at best, some genetic influence. Further, if there was a genetic component, one would not expect there to be absolutely no concordance in dizygotic twins. After all, dizygotic twins still possess large amounts of similar genetic information.

This lack of any significant concordance amongst non-identical (dizygotic) twins points to a deeper methodological flaw, relating to the recruitment method utilised by Milton Diamond for his review. Recruitment to the survey study was achieved through advertising for twins on unspecified internet websites, to present themselves for a survey into transexualism in twins. This is a self-selecting method that has also been utilised in the past for studies looking at homosexual twin-concordance. In the case of homosexuality, such studies resulted in highly over-inflated homosexuality concordance rates, prior to large, randomised, population studies demonstrating no significant identical-non identical twin concordance (see: “Are People Born Gay?”). The reason for this is that individuals themselves who have beliefs that transgenderism or transexuality is biologically programmed through genetics or developmental factors, will more likely apply to be involved in such a survey if their identical twin is also transexual, in an attempt to validate their own belief. The corollary to this is also true. That the internet websites by which recruitment was achieved are not specified further renders the results suspect. One would assume that given the very small proportion of the population who are transgender (0.6%) and even fewer who are transexual, the only place to recruit such individuals online would be on messaging boards and transgender/transexual community forums, in which the dominant narrative promoted is that transgenderism is biologically inherent and pre-determined.

Further, the very nature of the studies makes the conclusions extremely weak. Retrospective methods, which are highly prone to recollection bias, whether through Diamond’s survey or through case-reports, can significantly skew the results, especially on matters of such high emotive value. We must have a degree of sympathy with the authors, since it is extraordinarily difficult to achieve sufficient population sample data for transgender individuals in any significant numbers, given their extremely low percentage in the population. However, this was compounded by the poor method of data collection. In the case of Heylens’ review of case reports, the material was collected from internet searches for keywords. This in itself is not a comprehensive manner of data collection. In the case of the survey conducted by Diamond, the problems multiply manifold, since the survey letters sent to each set of siblings were not always completed by both. In his words, “Responses were not always forthcoming from both members of the twin pair. Most often it was the twin that had transitioned that responded for both.” It is unclear whether such responses were included.

In addition, the sample numbers involved in these papers are extremely low, and do not make for extrapolation to questions of causation at a population level. In Heylens’ paper, only a total of 44 twins were looked at; 23 monozygotic (identical) and 21 dizygotic (non-identical). In Diamond’s work, 112 twin sets, 43 of whom were drawn from previous studies.

Another key confounding principle that must be borne in mind is that transexualism is not the same as transgenderism. That concordance for transexuality may be more prevalent among identical twins may simply reflect the fact that identical twins are closer to one another than non-identical twins, and as such, may provide support to one another better, to undergo gender-reassignment surgery. Discordance in transexualism between non-identical twins does not therefore indicate a lack of concordance in transgenderism.

An analysis of the papers’ results rather than simply the methodologies, also reveal serious issues. Diamond’s paper reveals a particularly superficial review of the rearing conditions of the various groups, with only a few basic questions asked relating to attitude of parents towards gendered upbringing, equal treatment between siblings and whether the parents had desired children of a different gender to those they had. No questions were asked in-depth regarding parent-child relationships, history of the family, divorce, death, adoption, abuse etc. Given that the baseline characteristics of the two groups were not randomised, this becomes all the more problematic.

As regards Heylens et al’s work, greater rigour has been shown however, and we have some data regarding these parameters. Heylens’ works shows that the instances of transexual concordance between identical twins was significantly confounded by the up-bringing of the subjects and life-experiences. In all three (out of eight) concordant female identical twins, serious familial issues surrounded the up-bringing of the girls. Two of the three pairs were found to have “had troublesome childhoods, a difficult relationship with their parents (particularly with the mother), cross-gender behaviour since early childhood on”. For the third pair, a history of mental illness was otherwise present and puberty in particular “was very problematic for both of them…they developed anorexia nervosa to put a stop to their female pubertal body development. This problem was never resolved by one of the twin sisters, and her mental state and physical health deteriorated progressively. She died in January 2010 from the consequences of her anorexia.” From the above we can see that psychological issues can be serious confounding factors in the development of transgenderism and later, transexuality.

In summary, we can see that the most comprehensive studies looking at transgenderism between identical twins is fatally flawed in numerous ways, such that we are unable to say that transgenderism has a genetic/heritable basis. The results in fact hint strongly to a relationship between psychological trauma and transgenderism – a theme we will pick up later.

Do Trans-Brains Exist?

A recent trend in neuro-imaging has been to take groups of individuals with behavioural differences, and analyse their brain structure using MRI, to see if any differences in structure correspond to behavioural difference.

The latest attempt to “prove” transgenderism as being something we are born with, is to look at the brains of transgender adults (who have both received hormonal therapy, and those who have not) and compare them with “cig-gender” (i.e: non-transgender) brains of adults as published as an article in Nature by an Italian research team by Spizzirri et al.13 Before we get to the results, we must highlight the same methodological flaw that underpins this approach, as we did with homosexuality. Looking at adult brain structure is not a valid method of determining causation of a behaviour. Yet this is precisely what this group did, and precisely how it has been interpreted by the media.

This is for the simple reason that behaviour itself moulds the shape and structure of the adult brain. Therefore, it should be no surprise that transgender individuals – who may have undergone significant psychological trauma as a result of gender dysphoria – should have slightly different brain structures. Indeed, it would be surprising if this was not the case. The entire basis, for example, of Cognitive Behavioural Therapy, is to externally change one’s words and behaviour so as to change the way one processes and perceives information. The ability of the brain to change its structure as a result of interaction, behaviour and experience, underpins the neurodevelopment of unique identity of each individual, based on the interplay of our unique upbringing – which can never be identical, not even for twins – and our unique set of genes. Indeed, the whole basis for physiotherapy, as an example, after suffering a stroke – is to “re-train” the brain, which literally means, to “re-wire” different parts of the brain to take over the functions of such brain parts as have been rendered dead by the lack of blood during the stroke.14

Despite these established facts, some agenda-driven scientists, still insist on looking at adult brain differences and concluding that the brain differences preceded and caused transgenderism, rather than concluding simply that the brain differences could equally be a consequence of the different experiences transgender individuals have gone through.

In the work by Spizzirri et al, they found that transgender individuals prior to hormonal therapy and after hormonal therapy show statistically-significantly smaller grey-matter volume in a region of their brain known as the “insula” (thought to be responsible for regulating one’s image of oneself), as compared to cis-gender counterparts. This however, is contradicted by the work of Savic and Arver in 201115 who, along with Zubiarre-Elorza et al in 201316, found that the insula was larger in transgendered individuals relative to controls. This finding of alteration in a region of the brain thought to correlate to body-self image is to be expected, given that transgender individuals have a problem with precisely this issue. Whether the brain region difference is causative or whether it is a consequence of their traumatic issues with gender identity, remain entirely unexplored by this paper.

Further, as the authors themselves discuss, the insula is also found to be smaller in individuals who are otherwise cis-gender, but who suffer from depression with melancholic symptoms17, as well as being found to be smaller as patients with depressive psychosis.18 Given that transgenderism has overlap with both depression and psychosis, the result then that the insula of transgender individuals is smaller compared to controls, is entirely unsurprising.

Despite these rather moot results, this paper was reported in one pro-transgender news-outlet with the following headline: “Transgender people are born that way, new study has found“. Such dishonesty sadly, is rampant across scientific journalism when it comes to gender-science. This paper and its accompanying representation in the media has been selected for discussion as it is typical of a so-called “positive result” in brain-differences seen across the literature on transgenderism.

Blocking Puberty in Children

A powerful study by Wallien and Cohen-Kettenis, titled “Psychosexual Outcome in Gender-Dysphoric Children” in 2008 looked at children with gender-dysphoria from the ages of 5 to 12 and followed them up 10 years later, to see to what extent their gender dysphoria persisted. 54 of the 77 children were traceable and of those, 21 (39%) were still gender dysphoric, while 33 (61%) were not. Further, of those children who persisted in gender dysphoria, none were transgender, but all were either homosexual or bisexual. Of those who were no longer gender dysphoric at 10 year follow, all the girls and half the boys were heterosexual, while the other half of the boys were homosexual or bisexual. What this study showed is that gender dysphoria in itself does not mean, by any stretch of the imagination, that a child will grow up to be transgender. The majority in fact will emerge as cis-gendered, heterosexual individuals.

In the UK in 2012, the age limit for receiving puberty-blocking drugs, so as to prevent children from developing into their biologically-determined gender, was dropped from 16 years of age to 10 years of age. One report by the Mail on Sunday showed that of 800 children receiving puberty blocking drugs in a clinic in London and in Leeds, 230 (more than 25%) were under the age of 14.

These hormone replacing drugs are known to cause bone demineralisation in adolescence, by preventing calcium-uptake (at a stage of life where the children is growing) as well as causing diminished fertility later in life. While the effect of hormone-replacing therapy drugs are known in adults, as for example in menopause, the effects of such drugs on the brains of adolescence, is not known. No studies have been conducted on this sensitive issue. Given the fundamental role of hormonal balance on teenage mental health, and the fact that transgendered individuals both before and after surgery have high rates of suicidality, we can only speculate as to the potentially traumatic consequences of such therapies.

What emerges from the above assessment is that as a society, we are giving drugs, the effects of which are known to have harmful effects, to children who suffer from gender dysphoria, and who, if left alone, would likely grow up to be cis-gendered individuals of varying sexual orientations. To understand why such an irrational procedure is being followed, we must look at the argument being made for such therapies.

Suicidality and Transgenderism

“The Suicide” by Edouard Manet is a famous painting depicting the immediate moment after suicide. Manet was among the first 19th century artists to pain modern life.

The underlying premise of current attempts to curb the high rates of suicidality, depression and other mental health issues associated with transgenderism is that these mental health problems are a consequence of gender dysphoria, itself exacerbated by a lack of acceptance in society of one’s chosen gender. This dysphoria, as we have discussed, is due to discordance between the psychological gender experienced as an internal state, and the external biological sex. Because the psychological gender is regarded as unchangeable from birth, the only treatment available to bring the psychological gender and physical sex into alignment, is surgery; to change the physical sex of the individual to match their psychological gender.

If this model of understanding transgenderism was true, we should expect to see normalisation of suicidality, depression and other markers of psychological pathology, after gender-reassignment surgery, or at the very least we should see considerable decrease in such problems. This however, is not the case.

Very few studies have looked at the long-term benefit (or lack thereof) of sex-reassignment surgery. One such study that has, is a population based, prospective, cohort study, conducted in Sweden.19 This superb study aimed to estimate “mortality, morbidity and criminal rate after surgical sex reassignment of transsexual persons” between 1973 and 2003, across the population of Sweden. The results are startling.

The Swedish study began looking at this issue with the knowledge that the long-term effects of sex-change surgery are largely absent from the literature. Anecdotally, improvement in gender dysphoria is experienced with sex-change surgery in the immediate period of months to a few years. However, the long-term effects of sex-change surgery had not been explored, and those studies that had looked at the issue over a period of a few years, yielded contradictory results.

The Swedish study took its cohort from the National Registry of Sweden, a database of 13.8 million unique individuals. By utilising this database, in conjunction with others, such as the Hospital Discharge Register, the Total Population Register, the Medical Birth Register, the Cause of Death Register, the National Censuses of 1960-1990 and the Crime Register, they were able to track individuals who had undergone sex-change surgery between 1973-2003, in terms of their medical diagnoses, their death rate and cause of death, and criminal convictions. To be included in the study, the individual must have had a diagnosis of gender dysphoria without a diagnosis of any concomitant psychiatric condition. This is important, for reasons shortly elaborated upon. For each individual who met the inclusion criteria for study, 10 subjects who had not undergone sex-change were used as the control, matched to sex, birth year, and had to be resident in Sweden at the time of the test subject’s sex-change.

324 transexual persons met the criteria, and were studied over this period of time, 59% of which (N=191) were male-to-female (MTF) transexuals and 41% of which (N=133) were female to male (FTM) transexuals. The study found that transexual persons were 19 times more likely to commit suicide than non-transexual persons (CI 5.8-62.9) and an average of 5 times higher risk of attempting suicide (CI 2.9-8.5). Criminality in MTF transexuals was further 6.6 times higher as compared to female controls, but equivalent to male controls. This shows that MTF transexuals, despite having transitioned surgically to the female sex, still retained characteristically male levels of criminality.

Fig. 1: Risk of various outcomes among sex-reassigned subjects in Sweden (N = 324) compared to population controls matched for birth year and birth sex.

These results are in keeping with the largest prospective Quality of Life study,20 involving questionnaires given to 190 individuals before gender reassignment surgery, as well 1 year, 3 years and 5 years afterwards. This study found non-significant trends of an improvement in the immediate year following surgery in some categories, including “Mental Health” and “Social Functioning”, but notably, showed a worsening in multiple categories at 3 and 5 year follow up as compared to pre-operatively, for a number of criteria from “Mental Health”, “Vitality”, “Bodily Pain”, “Social Functioning”, “Emotional role” and “Physical role” as well as “General Health”. In other words, in most parameters of measurement, the (non-significant) improvement resulting from gender-reassignment surgery was reversed by 3 years, and by 5 years, the individuals were worse off than they were before surgery.

Despite these negative results, the researchers still chose to headline their study with the title: “Quality of life improves early after gender reassignment surgery in transgender women”. The title would have been more accurate as: “Gender-Reassignment Surgery shows no Significant Benefit 1-year on and Worse Outcomes 5-Years on, in Transgender Women”.

0 year1 year3 years5 years
Mean (SD)95 % CIMean (SD)95 % CIMean (SD)95 % CIMean (SD)95 % CI
Mental health66.6 (24.2)62.7–70.670.1 (24.0)65.5–74.667.7 (25.3)61.4–73.966.1 (26.6)58.2–74.1
Vitality58.8 (25.3)54.6–62.961.1 (25.5)56.2–65.959.2 (23.8)53.3–65.057.3 (26.6)49.4–65.3
Bodily pain80.1 (25.3)75.9–84.382.1 (24.4)77.4–86.778.6 (28.0)71.6–85.672.5 (26.5)64.5–80.4
Social functioning73.7 (27.0)69.1–78.277.5 (27.7)72.2–82.873.8 (28.4)66.8–80.869.8 (29.4)60.8–78.9
Role emotional69.5 (39.7)62.9–76.069.1 (41.2)61.3–76.965.1 (41.7)54.8–75.459.7 (44.0)46.5–72.9
Role physical82.5 (30.4)77.5–87.582.9 (32.7)76.7–89.279.3 (33.5)71.1–87.570.9 (42.2)58.3–83.6
Physical functioning91.2 (13.7)89.0–93.492.4 (13.9)89.8–95.089.7 (17.6)85.4–94.191.5 (11.8)88.0–95.1
General health52.0 (10.4)50.3–53.751.9 (12.2)49.6–54.250.0 (12.1)47.0–53.048.1 (12.6)44.2–51.9
Fig 2: Scores on SF-36 for all individuals in the study comparing pre-gender reassignment surgery questionnaire scores to 1, 3 and 5 year scores across a range of parameters.

These two studies tell us that despite undergoing gender-reassignment surgery, psychological problems continue, resulting in many times higher rates of suicide post-surgery. In layman’s terms, gender-reassignment surgery has minimal to no long-term benefit for individuals suffering gender dysphoria.

These results can only be explained one of two ways:

  1. Gender dysphoria is the cause of psychological distress, suicidality, and other mental health issues, but gender-reassignment surgery is ineffective in treating gender dysphoria long term (3 years or more).
  2. Gender dysphoria is not the cause of psychological distress, suicidality, and other mental health issues, but is a manifestation of a deeper underlying issue, one manifestation of which is gender dysphoria. Because gender-reassignment surgery does not treat this underlying cause, the symptoms of psychological distress (eg: high suicidality rates), return.

These are the only two options open to us, in light of the above results. On the face of it, option two seems more likely. The reason for this is that it is difficult to imagine that drastic and radical surgery, involving stripping away genitalia, creating new genitalia, involving the creation or removal of breasts, testicles and other bodily parts, as well as the use of hormones to eliminate or add body hair, should have such minimal impact on gender dysphoria, if indeed gender dysphoria is driven by a mismatch between external sex and internal gender.

It seems more likely that an underlying, deeper cause of the gender dysphoria is at play, one that is not eliminated by surgery, and which persists, on account of the root cause having not been treated. To this then, we now turn our attention.

The Real Cause of Gender Dysphoria

In the articles on “What Causes Homosexuality“, we detail how sexuality is deeply related to gender identity, which precedes sexuality, and out of which sexuality is shaped. We explore how gender identity in itself is intimately related to childhood upbringing, particularly ones relationship with one’s parents and peers. The details of this process can be read in that article, here. A summary of the mechanism of gender development, is however pertinent:

An infant on entering the world has only their biological sex. They do not have a sense of gender. Until the age of approximately 3-5 years of age, children have no sense of gender permanence. In a now classic study by Lipsitz Bem21 in 1989, she showed that children believe, before this age, that changing clothing to the opposite gender actually changes whether you are a boy or a girl. Only after around the age of 5 years of age do children understand that changing one’s hairstyle or clothing does not result in a change in gender.22

The development of one’s sense of gender does not end at age 5, though it has formed a basis by then. The initial formation of gender identity between the ages of 3-5 is on the basis of one’s relationship with one’s parents, principally, or, on the major care-giver, if parents are not present. The result is that the child increasingly matches their physical sex of birth with one of their parents, and imitates that parent’s gendered behaviour, as an expression of their own biological sex. In other words, their observation of parental gendered behaviour gives birth to their own gendered behaviour. At school, children go on use their same-sex peer group as the means of correcting and refining gendered behaviour, so as to solidify their identity as part of their biological sex. This solidification and identification in one’s gender group continues all the way through to late-teens, and into young adulthood.

If there is a disruption in any part of this journey, from imitation of one’s parents to imitation of one’s peers, the individual can develop gender dysphoria. Such “disruption” can take many forms, but classically most often takes the form of parental death, parental divorce, sexual abuse at the hands of parents or older gender role models, rape and/or incest of some form.

Much work has been done showing how gender non-conformity in childhood has its basis in such adverse events. We refer the reader to the article, “What Causes Homosexuality?” for that data. As regards transgenderism directly, minimal research has been conducted on the connection between sexual assault/abuse in youth and later transgenderism. One study that has looked at this, is from the FORGE survey of 2004-5, looking at the history of sexual assault in the older transgender population – aged 50 and above.23

They found that of their 302 respondents, only 44 answered the question directly, “Have you experienced unwanted sexual touch?”. Of those 44 who responded, 64% replied as “yes”. To put this in perspective, it should be noted that the overwhelming majority of respondents had been born male and transitioned to female (MTF), at 88% and that the national US average for sexual assault experienced by cisgender men is 3%. Thus, we can say that transgender people have approximately a 21 times higher risk of sexual assault than their cisgender counterparts. This may very well be an underestimation, given that only 44 of 302 respondents chose to answer this question. Indeed, we must ask why the overwhelming majority of respondents chose to ignore this question. Perhaps because of the difficult, traumatic and painful memories such questions may elicit.

The questionnaire then analysed specifically the nature of such sexual assault, in particular, its frequency, and the age of the victim at the time. Their results were as follows:

 0 – 12 years old: 27%
13 – 15 years old: 22%
16 – 18 years old: 9%
19 – 21 years old: 9%
22 – 40 years old: 14%
41 – 60 years old: 18%
These results show that 67% of sexual assault occurred before the age of 21, with almost 50% of abuse occurring before the age of 15. These statistics give a powerful picture of a history of sexual abuse in the lives of transgender individuals. When we consider that gender-identity develops during childhood, through stable, loving and imitating relationships with parents and peers, it becomes clear that such high levels of abuse must play a very significant role in the aetiology of gender dysphoria.
If the above hypothesis is true, we should see evidence of “sex-change regret”. In other words, individuals who have undergone surgery, imagining it would cure their depression and dysphoria, find that it has only papered-over the problem, and that the root cause of their psychological distress, remains untreated. When, however, they do receive psychological counselling for the sexual abuse or other trauma they may have suffered, resulting in a resolution of the cause of their gender dysphoria, they find that they experience “sex-change regret” and may even wish to de-transition back to the gender of their birth.
This is precisely what we see.

Sex Change Regret

Only anecdotal evidence exists, but there is plenty of it. It is not, further, for want of attempts to carry out studies. James Caspian, a psychotherapist who works with transgender individuals at the University of Bath in the UK, came across multiple examples in his practice of significant rates of sex-change regret (reported as a fifth of individuals in the US and Holland according to one journalist’s research24). He sought funding to carry out a comprehensive study on the matter. He was initially approved, but then it was turned down, on the grounds that it might cause offence and that it would be “politically incorrect” to such an extent that it might affect the reputation of the university25:

When he went back with his preliminary findings that suggested growing numbers of young people, particularly women, were regretting gender reassignment, Bath Spa said his proposal would have to be resubmitted to the ethics committee, which rejected it…

Speaking on what spurred his interest, he said:

He said he was first alerted to the issue of gender reassignment reversal in 2014, when a Belgrade doctor told him he had been asked to carry out an unprecedented seven reversals that year…“I found it very difficult to get people willing to talk openly about the experience of reversing surgery. They said they felt too traumatised to talk about it, which made me think we really need to do the research even more,” he said.

On this issue, Walt Heyer, a man who de-transitioned himself, has done extensive work, as can be seen from his website www.sexchangeregret.com and from his book, Paper Genders. Writing for The Public Discourse, he quotes Dr. Charles Ihlenfeld, a doctor who by 1979 had treated more than 500 individuals for sex-change hormonal therapy:

In his medical opinion, 80 percent of those who want a sex change should not do it. And for the remaining 20 percent, he found that that the sex change would only provide a temporary reprieve, not a lifelong solution.
Other anecdotal evidence can also be seen from interviews and films. In one excellent film, 15 transgender individuals talk of their journey to the opposite gender, and back again.

In his article for The Public Discourse, Walt Heyer writes of how, since opening his website, he regularly receives hundreds of letters from transexual individuals who now regret their gender-reassignment surgery. He cites one letter, typical of the type he receives:

I transitioned to female beginning in my late teens and changed my name in my early 20s, over ten years ago. But it wasn’t right for me; I feel only discontent now in the female role. I was told that my transgender feelings were permanent, immutable, physically deep-seated in my brain and could NEVER change, and that the only way I would ever find peace was to become female. The problem is, I don’t have those feelings anymore. When I began seeing a psychologist a few years ago to help overcome some childhood trauma issues, my depression and anxiety began to wane but so did my transgender feelings. So two years ago I began contemplating going back to my birth gender, and it feels right to do so. I have no doubts–I want to be male!

I did have orchiectomy [the removal of one or both testicles], and that happened before my male puberty had completed, so I have a bit of facial hair which I never bothered to get electrolysis or laser for, and so the one blessing about all this is that with male hormone treatment I can still resume my male puberty where it was interrupted and grow a full beard and deep voice like I would have had if transgender feelings hadn’t intruded upon my childhood. My breasts are difficult to hide though, so I’ll need surgery to get rid of them. And saddest of all, I can never have children, which I pray God will give me the strength to withstand that sadness.

This is in keeping with Walt Heyer’s own description of the journey he went through, starting from the age of five26:

It was then my grandmother, when I was being babysat by her, started dressing me in female clothing. She even made me a purple chiffon evening dress…And when dad found out what grandma had been doing, and dressing me up like a girl, it did change everything. His adopted brother Fred began to sexually molest me. Mom’s discipline got even more severe and I would learn much later in life that on one occasion, her discipline was so tough, she thought she had almost killed me.

Anecdotes can never take the place of hard-facts. We do not know for sure what percentage of individual attempt to de-transition, since the research has not been conducted, for political reasons more than anything else. Nevertheless, these anecdotes point to an underlying mechanism of transgenderism that well explains the real cause of psychological distress in such individuals, and why gender-reassignment surgery shows such poor long-term outcomes.

High Transgender Suicide not caused by Transphobia

In the month of June 2018, the World Health Organisation (WHO) decided to remove gender dysphoria, or transgenderism, from its list of mental health conditions. This was done so as to “decrease stigmatisation” of the condition. It is difficult to understand how this decision was made. After all, removing depression from its classification of mental health conditions may decrease the stigma associated with it. Indeed, the same could be said for any mental health condition. By this criteria, no psychological pathology could be categorised as a mental health condition.

Conference Room of the World Health Organisation (WHO) which recently removed “gender dysphoria” from its list of pathological conditions

The criteria for the definition of a pathology is well known and straightforward in medicine: a condition that causes distress to the extent that it prevents normal functioning. Given what we know about gender dysphoria, we can say with certainty that it most certainly should be categorised as a pathology.

This is not unknown to the eminent scientists at the WHO. And yet, they have totally disregard the norms of medicine, so as to pursue an agenda of normalising transgenderism. They have done this ostensibly because they claim that the high rates of suicidality in people with gender dysphoria are due to social stigmatisation. This claim however, is contrary to the evidence.

In April of 2018, a much-lauded survey of victimisation and suicidality in the Swedish Transgender population was published in the journal LGBT Health27. The study looked at suicidality and victimisation through a self-selected anonymous online survey in 2014 of 796 transgender individuals from 15 to 94 years of age. The scientists who conducted the study concluded that:

Our findings show that suicidality is directly correlated with trans-related victimization. Preventing targeted victimization is, therefore, a key preventive intervention against this elevated suicidality.

Unfortunately for them, their study in itself totally disproves the conclusions that they reached. Their study showed some key results that require emphasis:

  1. Around 5% of the population of Sweden, according to national estimates cited by the study itself, have seriously considered suicide in the past year28. The rate found by this study in 796 transgender individual was around 7-8 times higher, at 37% with attempted suicide rate at 32%.
  2. A trans-individual who had experienced offensive behaviour in the 3 months prior to the survey was 1.58 times more likely to have attempted suicide (95% CI: 1.02–2.46) as compared to a trans-individual who had not experienced such behaviour.
  3. A trans-individual who had experienced any trans-related violence in their life was 1.77 times more likely to have attempted suicide (95% CI: 1.09–2.86) as compared to a trans-individual who had not experienced such violence.
  4. Never having practical support was correlated with a 4 times higher risk of attempted suicide (95% CI: 1.45–11.16).

If the WHO were correct that a stigmatising, transphobic environment is the cause of the higher attempted and actual suicide rate among trans-individuals as compared to the general population, then we should see the 7-times higher rate of attempted suicide reported in this very paper (as well across various surveys in multiple countries) explained by “offensive behaviour” and “lifetime trans-related violence” to significant extent. The opposite is the picture. Taken together, they only account for a 2.8 times higher risk of attempted suicide (1.58 multiplied by 1.77). That leaves trans-individuals who have experienced neither offensive behaviour nor trans-related violence, at around a 4-times higher risk of attempting suicide than the general population.

One might argue that if one has suffered offensive behaviour in the last three months, as well as suffering trans-related violence in one’s life, as well as lacking practical support, the combined effect of all three factors would account for the 7-times higher rate of attempted suicide (1.57 x 1.77 x 4). Notwithstanding this highly tenuous and unlikely line of argumentation, once again, the study does not support this conclusion. Given that 32% of the 796 individuals had attempted suicide in the past 12 months, this would mean that 32% of the individuals in the study should fit the bill for all three of the above factors. The reality however, is that only 1.7% of the study participants fit the bill for all three factors. Therefore, it is impossible to argue that the 32% who had attempted suicide can be explained by a combination of some or all of the above factors, increasing their risk of attempting suicide.

Despite this glaring chasm that remains between what we see and what we would expect to see, if trans-phobia and trans-violence were the cause of the high attempted suicide rate, the authors of the study still argued that reducing victimisation of transgender individuals in society is the best way to reduce their high suicide rate. This is contrary to the facts. It no doubt does play a part, but a minor one. Indeed, even if all offensive behaviour suffered and lifetime trans-related violence was reduced to nil, trans-individuals would still suffer from around 4-times higher rates of attempted suicide, and as per other studies cited earlier, a much higher rate of actual suicide (19 times higher in the case of transexual individuals, as elucidated earlier).

From this, we can only conclude that the driving factor behind suicidality in the transgender community is not social stigmatisation, as per the WHO declaration.

Conclusion

When we consider that gender studies have demonstrated an intimate link between one’s relationship with gender role models and one’s evolving gender identity (see “What Causes Homosexuality?”), it is unsurprising that those who have suffered sexual assault, rape or other traumatic experiences, should develop gender dysphoria. Indeed, it would be surprising if they didn’t. When we see further that gender reassignment surgery neither improves quality of life, nor normalises suicide rates, then we can understand why: Surgery does not deal with the underlying psychological trauma at the heart of gender dysphoria. Gender dysphoria is a product of traumatic early life experiences, which can range from absent parents to sexual assault. Unless those traumas are dealt with through psychotherapy, hormonal and surgical therapies will only ever be superficial solutions.

Transgender individuals are often described as having the “wrong brain” in the “wrong body”. Until now, medical health professionals have sought to reconcile this discordance by assuming the “brain” as fixed and the “body” as malleable, able to change to the brain’s needs. The problem with such thinking is that it totally ignores the fact that the brain is not fixed at birth, but adaptive to a child’s growing circumstances and environment. A newborn baby’s brain at birth is around 30% of its volume at 1 year of age. Such a trajectory of brain development is shaped in response to the stimuli the child receives.

To ignore the role that the environment plays in shaping our gender identity, is to do a disservice to gender-dysphoric individuals. To offer them therapies that harm them in the long term and do little to improve their quality of life or normalise their suicide rate, is to deceive them with what can be described as little more than quackery. We imagine as 21st century medical professionals that we live in an age of evidence-based medicine. However, the manner in which gender-dysphoric individuals have been failed by the medical community reveal that in some respects, we are still deep in the Dark Ages, where superstition and popular beliefs rule the day.

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