TS Mortality, With Side Comment on Suicide Rates

[LeaP]

... with a side comment on suicide rates.

The linked study (2011) is of long-term mortality in 1331 transsexuals receiving cross-sex hormones. Median follow-up time is 18.5 years.

http://www.eje-online.org/content/164/4/635.full.pdf

It presents elevated mortality rates versus the general population. Hopefully it will be an eye-opener for people who like to take simplistic views of statistics. Examples:

Drug abuse is higher in the population and constitutes a significant source of the mortality increase.

Mortality rates vs. the general population were higher in MTF's and about the same as the general population for FTMs - but the FTM cohort started hormone treatment at an earlier age.

Hormone use correlates to greater cardiovascular risk – but that, in turn, is most strongly correlated to the use of ethinyl estradiol.

Cancers are more common among transsexuals - but smoking among the population is also higher.

AIDS is higher in the population and is major component of the increased mortality rate. In younger MTFs there were more deaths from AIDS than any other cause. AIDS was also the largest trigger for suicide.

Suicide is higher – but a significant proportion of those (in addition to those with AIDS) were pre-ops with (actually denied SRS because of) mental stability issues.

***************

The side comment on suicide refers to the number of suicides reported in the study. While there was a significant increase in the death by suicide rate over the general population, the numbers are still lower than published suicide rates would predict. All of the suicides were in the MTF cohort, and none of the suicides were individuals over 64 years old.

If you take the oft-cited 41% attempt rate, you would expect 396 of the MTF cohort to have attempted suicide. 17 actually died by suicide. The grossest possible interpretation of that number would still conclude that the success rate is very low. Given the death rate in the study and applying the published attempt rate, that would be one death out of 23 attempts. (396/17). If you take the number of typical attempts as somewhere between four and seven (that representing different subgroups' attempt rates in the most recent study), the number of attempts would be between roughly 1580 and 1770. The corresponding success rates based on the mortality suicide death numbers would be between 1 out of 93 and 1 out of 163 - neither of which squares with the success rates I've seen quoted (e.g., as high as 15-20% of the population, or a quarter to as much as half the attempts)

There are several possible conclusions:


Both attempt and suicide death data are garbage.

The attempt rates are vastly UNDERSTATED, but the death rate is directionally correct.

The death rate is vastly inflated, but the attempt rates are directionally correct.

Assume for a second that the sorts of suicide success rates implied in the mortality study are directionally correct. If the numbers of deaths in the transsexual population are as high as often reported, applying the mortality study implied rates would require either an incredibly high attempt rate, far in excess of those actually reported (and this was self reporting!), or a much larger transsexual population. Neither is credible.

I believe the truth is implied in the mortality study numbers. That is, the suicide death rate is higher than in the general population (at least among MTFs). That almost certainly means the attempt rate is higher also, though there are no numbers in the mortality study to show that one way or another. But that in any scenario, it is highly likely that the attempt rate is lower than the self-reported rates. Finally, a significant proportion of the suicide are correlated to mental health issues at specific transition points, and to AIDS.

To the degree this is true, concerns over death by suicide in the transsexual population are overhyped. Second, that reported suicide "attempts" in the transsexual population are proportionately less intended to cause death than attempts in the general population. In other words, the attempt rate is more of a "misery index" as I recently termed it. Intense, genuine, heartbreaking misery, to be sure. And finally, that preventing death by suicide in the transsexual population needs to target certain subgroups. Those at highest risk are those with AIDS and those with mental instabilities, particularly when denied SRS.

I am not advocating ignoring suicide threats! No one knows the reality of the death risk in any individual case. But I do get the sense that there is a certain, shall we say, attachment to the high published rates. Whether that is for political consumption, opinion manipulation, a way of pleading for personal attention, or something else, I can't say for sure. But people get really excited about these rates in a very weird way and frankly, the numbers stink.

[Persephone]

Lea,

Thank you so much for attaching the study and for your excellent synopsis and presentation.

Hugs,
Persephone.

[LeaP]

Oh, the numbers continue to just get more interesting if you intersect the published trans suicide rates with the actual CDC general population suicide rates.

The CDC reports approximately 40,000 suicides per year. That's also consistent with other figures I have read. The national suicide rate as of 2007, for example, was 11.26 per 100,000. Applied to the 2012 population that would have predicted just over 35,000 suicides. But by 2007 the rate had been rising for several years

Going back to the CDC figures, on a leveled rate basis, one out of every 25 attempts succeeds. These are annual attempts! How do get to annual attempts in the trans population from the lifetime rates in the NTDS trans suicide survey? Not so easy. Studies indicate that 7 - 13% of attempters eventually kill themselves ... but those studies range over 5 - 37 years follow-up. But let's go ahead and SWAG a number anyway. Pick a percentage in the middle of the range – say 10% – and timeframe – say 20 years – to give half a percent per year. Applying a middle of the road prevalence rate (Lynn Conway's "Goldilocks" rate, so called because it's neither too high nor too low) would mean that roughly 10% of the suicides every year are by trans people. Ask yourself if that is credible.

[Kathryn Martin]

Lea,

Have you read Injustice at every turn and the attempt rates coming from a survey of over 6000 transgender persons in the US. Attempt rate was 32% if family acceptance was present and 51% when it was not. Bad numbers.

[Rogina B]

Acceptance is truly the key cause,and one that can be changed,and is. Discrimination comes from non acceptance and life goes downhill from there. Desperation becomes reality when people slide down that slippery slope into the dark hole. Most can never get out. As they were slipping,they may have picked up HIV and feel they have nothing to live for as they have nothing good to look forward to. As a T activist here in NE Florida,I feel it is crucial to promote acceptance from the mainstream world.Accepted and included people tend to stay away from the slippery slope that most often ends in premature death.

[LeaP]

... a survey of over 6000 transgender persons in the US. Attempt rate was 32% if family acceptance was present and 51% when it was not. Bad numbers.

I'm not sure what you mean by "bad." If you mean bad data, I agree. If you mean bad in the sense of scale that OP challenges, well, that IS the point of the thread.

Yes, I've read it. It's the "published" numbers that I keep referring to. Many of the numbers don't make sense. The simplest cut at the problem is that the numbers of people supposedly attempting suicide can't realistically be reconciled - at any level - to the number of people who actually die from suicide. This is actually made worse by the scope of the NTDS survey, which spans everyone under the entire transgender umbrella.

In short, if the attempt rates are even remotely accurate (understanding, of course, that these are not annual attempt rates/percentages), a lot more deaths by suicide would be occurring annually. Alternatively, the self-reported attempts aren't, in the main, serious attempts at suicide success. (Which doesn't mean they aren't of concern for other reasons.)

But some bits of real perspective can be brought to bear. One that self-reported rates of NTDS survey type are known to be off (inflated) appx. 100%, based on similar surveys. Second, after you adjust for that, the numbers can be further adjusted for self-harm intent vs ideation vs actual attempts to die. Attempt rates and success rates vary WILDLY between subgroups in the general population ... but in known ways. While I expect that trans subgroups would differ at the margins, one can certainly use a conservative adaptation.

No matter how you cut it, though, the numbers are too high. Probably WAY too high. Again, go to the mortality study. Over the DECADES of follow-up (and this was transsexuals, where the rates actually ARE higher, not "transgender"), you would expect to see many times the actual suicide deaths, were rates implied in the NTDS stats used - not 17.

I don't know, and while I'm sure a talented statistician can draw more and better conclusions than me, the focus on what I think is essentially a bogus rate because it is high and dramatic, disturbs me. It is quoted like a badge of honor.

You would think the topic demands a serious study, not simplistic surveys. There aren't any. There is an interesting comment on the GIRES site: "Mortality ... May be higher in the transgender population, where suicidality is a significant risk, with 35% reporting having made at least one suicide attempt. However, we are not aware of any data that indicates high mortality among severely gender dysphoric people from successful suicide attempts." (Echoing my second paragraph, above.)

[Kathryn Martin]

You would think the topic demands a serious study, not simplistic surveys. There aren't any. There is an interesting comment on the GIRES site: "Mortality ... May be higher in the transgender population, where suicidality is a significant risk, with 35% reporting having made at least one suicide attempt. However, we are not aware of any data that indicates high mortality among severely gender dysphoric people from successful suicide attempts." (Echoing my second paragraph, above.)

I don't disagree with you. I think that the numbers extracted from the survey because self reported are always questionable, however, when you were to attempt to actually get to some "real" numbers your would have to interview everyone who would be involved in every bit of allegedly discriminatory behavior to get "real" evidence on the difference between perception and actuality.

It is a little bit the same with the whole bullying issue. Driven to suicide, are few but many contemplate suicide and make some half hearted attempts. The issue asI see it is not so much what the actual rate is but that people are driven to even contemplate taking their own life. And- as you know there are some who make very serious attempts with serious consequences and for some reason it does not work - sometimes three times. I guess shit happens. What is at the heart of this is the curious intersection between suicidal ideation and victimhood. That would be a topic to discuss and it infuses some actuality into the entire conversation around the illusion that is connected with taking your own life. I know I am cryptic but there are limits on how far we can go on a public board.

[LeaP]

One of the intentions of the thread is to drive that sort of discussion, Kathryn. I believe suicide IDEATION is sky-high in the trans community. Attempts and deaths are higher too, based on the sketchy real evidence out there. I just don't believe that they are high as some would have you believe. (And they REALLY, REALLY want you to believe ...)

Perpetuating victimhood is a real phenomenon with many minority communities. Nothing new there at all. It's manifest in a lot of ways - one of which is the psychological investment in the high numbers. Misty recently pointed to another in her "must be desperate to transition" comment. The kind of victimhood we're talking about is less about community victimization than personal (inner) victimization. THAT'S manifest in a lot of ways, but most importantly, in the persistence of the phenomena lumped into GD, at least after the point of realization.

Another topic that deserves mention is "suicide contagion." This term is used by researchers to describe spikes in copycat suicides from suicide reporting. You can't make someone suicidal by talking about a suicide, but you can trigger those who are already suicidal to act. I think there are aspects of suicide discussion in the trans community that are dangerous and, in particular, I wonder if we are subtly encouraging attempts inadventently.

Suicide is a strong theme among trans people. I think that's because there is a special kind of personal negation involved in growing up trans. It needs a better outlet.

[Kathryn Martin]

Suicide is a strong theme among trans people. I think that's because there is a special kind of personal negation involved in growing up trans. It needs a better outlet.

Suicide as a concept is also a justification. The psychological inversion is a real mind twister - if you are a freak, suicide becomes the proof of normality, it underwrites your freakishness by showing a way out of it. It is in this sense often a perceived sign of ones humanity. But always this is fed by a wrong sense of victimhood. Trans-sexed people learn this early on - being a victim is the polar opposite of what they need and want.

[LeaP]

Kathryn, your last response could easily be a dissertation topic. Bravo!

So, suicidality is both:

1) an expression of pain and conflict and,

2) an implicit acknowledgment that one is psychologically aligned with the view that they are abnormal.

Internal victimization underlies many things. You mentioned internalized transphobia recently and I agree. You mentioned agency in relation to this, and I agree with that also.

Loss of agency (or the ability to choose and direct) seems to be a difficult concept for many to understand. There are two types, enforced and self-driven. Enforced loss of agency is irrelevant here, except to say that those with a victimized outlook believe their situation is forced upon them.

Almost all restrictions on choice are self-imposed constraints! If you think about it, that applies to good things and bad, moral and immoral, legal and illegal, etc. If you aren't physically restrained or incompetent, you ARE exercising your agency, whether or not you like or accept that this is so, and whether or not you are doing so consciously. See below for a discussion of accountability, however.

Victimization shows up in this context as acting (making choices) based on reactions to anger and resentment, fear, pain, etc. That's carefully worded. There is nothing wrong with any of these reactions or emotions per se. But driving your life based on them, perpetuating them, is to treat an issue or consideration as an externally enforced constraint. I.e., someone else's fault. People tend to focus on the emotional side of things here, e.g., justifying their anger. What they miss is the subtlety of shifting responsibility for choices as a result. "I'm angry because YOU ... and as a result I HAVE to ..." No. You don't. A rational person reacts then puts that aside, considers things, and not only chooses, but accepts any and all implications arising from the choice. "But, but ... " But nothing! Life isn't fair.

Consider gender dysphoria. People continually confuse GD with its effects. GD is incongruence. Period! It's effects may include "... clinically significant distress or impairment in social, occupational, or other important areas of functioning". These are not GD! They are symptoms of victimization and the result of self-imposed loss of agency, whether called coping behavior or anything else.

There is an ethics point to be made here, however, and that's accountability. The degree of accountability is a judgement against action based on things such as knowledge, reasonability assumptions, and intent. This gets very complex very quickly. My view is that a transsexual becomes fully accountable the moment they realize they are transsexual. Not when they worry about it, obsess over it, think they might be, lock it away in compartmentalized thinking, etc. When they KNOW they are transsexual (more accurately, know when they have an incongruence issue).

But many do not accept their agency even then. Decision that are actually of a nature of "I will not," "I don't want to," and "I can't decide" turn into "I cannot." And the reasons (blame) are all over the place. The way out of the mess is to accept responsibility for your choices, not just those which you now make in the light of day, but the hurtful and ignorant ones you may have made in the past. NOT that these are determinant of future action!

I'm not suggesting that it's easy to get past pain and victimization. It can be excruciating. But being what you are and being what others want you to be are usually mutually exclusive with transsexuality. And no-one is entitled to anything, including acceptance, a pain or conflict-free life, having it all, fair treatment, or anything else. Welcome to reality.

[Rianna Humble]

Consider gender dysphoria. People continually confuse GD with its effects. GD is incongruence. Period! It's effects may include "... clinically significant distress or impairment in social, occupational, or other important areas of functioning". These are not GD!

I cannot let you get away with this one. Gender Dysphoria is not the incongruence itself - it is the outcome of that incongruence.

We were born with the lack of congruity. Over time the distress builds up to a point where it becomes necessary to act, but the distress is the result not the cause.

[becky77]

Suicide as a concept is also a justification. The psychological inversion is a real mind twister - if you are a freak, suicide becomes the proof of normality, it underwrites your freakishness by showing a way out of it. It is in this sense often a perceived sign of ones humanity. But always this is fed by a wrong sense of victimhood. Trans-sexed people learn this early on - being a victim is the polar opposite of what they need and want.
That just sums up my teenage years, I felt like such an isolated freak. However I am not a victim, yeah I felt pretty sorry for myself but even so I never have had that victim mentality. I always tried focuss my attentions on the good things (very few of those at that time, but you endure) even if that is a form of delusion, I guess it's a coping mechanism.
Anyway my point is had my mind set been more negative and victim like, I'm pretty sure I would have been another statistic. Did I think about it? sure I did and confess sometimes still do but i'm sure i'm too much of a surviver to have ever done it, but it only takes one little thing to tip that over the edge.

Have the numbers gone down now that people have greater access through internet?
I mean when I was younger I thought it was only me, the younger generation can learn pretty quickly these days that there is a community out there. That knowledge takes away much of the isolation and uniqueness, I know it would have helped me and probably opened my eyes to transitioning much earlier.

[LeaP]

I cannot let you get away with this one. Gender Dysphoria is not the incongruence itself - it is the outcome of that incongruence.


Interesting phrasing ...

(All emphases below are mine.)

DSM 302.85A provides the diagnostic definition and the criteria are 100% about incongruence.

302.85B is the source of the disparity here. It states: "The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning." Ok, but what kind of distress? (Not where, but what.)

The chapter preface states "Gender Dysphoria as a general descriptive term refers to an individual's affective/cognitive discontent with the assigned gender but is more specifically defined when used as a diagnostic category." Read carefully - even as a descriptive term, it refers to gender discontent.

The criteria are followed by several pages of commentary on diagnostic features, development, risk and prognosis, etc. - all of which are concerned with incongruence ... finally getting to a single paragraph with the header "Functional Consequences of Gender Dysphoria". And this is where such things as mental health issues, relationship problems, school and work problems, etc. are described. But these are the result of GD, not GD itself.

Summary: Part A defines GD as an incongruence condition. Part B adds the distress over gender which must be present for a GD diagnosis. The text describes other issues that may present as a consequence, but which are not part of the diagnostic criteria.

Why is this important? Because the focus on consequential issues leads to short-cutting the diagnostic process which in turn can lead to misdiagnosis. Not just a misdiagnosis of transsexuality, but a complete miss on the diagnosis regarding gender issues manifesting as the result of conditions not rooted in gender identity. I am not referring to non-binary gender conditions here. The DSM itself makes it clear that a Gender Dysphoria diagnosis is appropriate for non-binary gender identities also. However, non identity-related gender issues constitute the majority of gender presentments, according to everything I've ever read.

This is one area in which a gatekeeper process helps in some ways (such as the NHS). The looser therapy process in the US allows for practice spanning from rigorous diagnosis to reading tea leaves. If there ever were a risk of enablement, this is a prime source.

[PaulaQ]

My suicide attempt last year was done simply to ease the intense pain I felt when presenting as a man, and feelings that my situation was hopeless - that I had no path that would ever let me escape the horrible things GD made me feel. I had little emotional support - I was in rural Oklahoma. My wife was not supportive - quite the opposite. Watching her emotionally self-destruct made me feel as if I'd murdered someone - I felt so guilty for what she was going through.

Presenting as a man caused me just incredible emotional pain. I couldn't take it anymore. But my wife couldn't stand to see me, and the rural area I lived in was incredibly transphobic and dangerous. (They liked to tell stories at gatherings about trans women who'd fled the area in the past. It was genuinely an awful place to be for someone with gender issues.)

My therapist was more than 100 miles away. The nearest source of support for anyone LGBT was 70 miles away, in Tulsa.

I felt any attempt I'd make at transition was doomed to fail - that there was no solution to the pain I felt, that I'd feel these horrible things for the remainder of my life.

So at a moment of total despair, I attempted my life. I just wanted the pain to end. I saw no other way out. I was alone, I hurt, I was terrified, and I was tired of fighting. So I just gave up.

[LeaP]

I'm sorry, Paula. It's a very hard thing to find yourself feeling that hopeless and trapped.

[Kathryn Martin]

That just sums up my teenage years, I felt like such an isolated freak. However I am not a victim, yeah I felt pretty sorry for myself but even so I never have had that victim mentality.

Becky I just want to point a finger at you and say: yeah, yes......

You made my point, what transsexed people want and need is to survive and do exactly what I have done and you are in the process of doing. And that means becoming physically congruent to the largest extent possible.

Victimhood in the trans context is a blame game and a zero sum game. It gets us nowhere. Being weird is with all due respect to all of us part of the territory and transsexed people know this instinctively the moment they become conscious of the world below the belt. For most transsexed people it starts the quest to become congruent and for some it takes longer than for others. Yet being weird is not a solution and if it is it is the direct path to the hell of self victimization and victimization at the hands of others which becomes essentially one of the collateral drivers of buying into self victimization.

This is in my view why transsexed people tend to align themselves with gender binary not because they deny the existence of queerness but they need to physically align themselves with who they actually are: that is the source of need for surgery.

[Rianna Humble]

Interesting phrasing ...

(All emphases below are mine.)

DSM 302.85A provides the diagnostic definition and the criteria are 100% about incongruence.

302.85B is the source of the disparity here. It states: "The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning." Ok, but what kind of distress? (Not where, but what.)

The chapter preface states "Gender Dysphoria as a general descriptive term refers to an individual's affective/cognitive discontent with the assigned gender but is more specifically defined when used as a diagnostic category." Read carefully - even as a descriptive term, it refers to gender discontent.

You have just demonstrated that by definition the Dysphoria (or discontent) is not the incongruence itself but the consequential discontentwith the incongruence, which is exactly the opposite of what you claimed before I challenged you.

[LeaP]

"Gender Dysphoria as a general descriptive term" - i.e., in broad usage. The sentence goes on to say that the meaning is more defined when it comes to diagnosis. The sentence is intended to discriminate between its descriptive usage and diagnostic usage. Even so, it limits discontent (or distress) to the topic of GENDER. I.e., it is not depression, not obsession, not borderline personality disorder, or social anxiety. It is specifically distress over lack of congruence, and there are pages and pages of amplifying detail in the full text of the DSM. I suggest you read it. The DSM further, and specifically, distinguishes distress over incongruence from what it terms "Functional Consequences." Consequences are the result of something that already exists. Finally, look again at Part B of the diagnosis: "The condition is associated ..." Which condition? The incongruence described in Part A!

Look, I'm not disputing that distress is a necessary part of the diagnosis. It IS a "dysphoria" diagnosis, after all. "Gender Incongruence" was hotly debated as an alternative. "Gender Dysphoria" essentially represents a political decision among the various factions in the DSM committees. "Gender Dysphoria" is a carefully crafted balance between the older "Gender Identity Disorder" and "Gender Incongruence." It removes the controversial "disorder," but doesn't go so far as to take the diagnosis completely from a pathology, as it keeps language about "clinically significant distress." The language settled on distress ABOUT incongruence, however, and ONLY about incongruence. It's an important point.

[Rianna Humble]

Since you persist in trying to say that I am wrong to say that Gender Dysphoria is not the incongruence but is distress about the incongruence, how do you reconcile


The language settled on distress ABOUT incongruence

with


Consider gender dysphoria. People continually confuse GD with its effects. GD is incongruence. Period! It's effects may include "... clinically significant distress or impairment in social, occupational, or other important areas of functioning". These are not GD!

It seems to me that the person who needs to reread the DSM is the one who can hold forth two such contradictory viewpoints and use them to criticise someone who says what the DSM says that Gender Dysphoria is distress ABOUT incongruence not the incongruence itself

[Zylia]

This part of the DSM-V chapter on GD seems pretty clear about it (and in support of Rianna Humble's POV as far as I know):


Gender dysphoria refers to the distress that may accompany the incongruence between one's experienced or expressed gender and one's assigned gender. Although not all individuals will experience distress as a result of such incongruence, many are distressed if the desired physical interventions by means of hormones and/or surgery are not available. The current term is more descriptive than the previous DSM-IV term gender identity disorder and focuses on dysphoria as the clinical problem, not identity per se.

Cherry picked from page 451.

[Starling]

Let's get back to basics. The Oxford Dictionary of American English defines dysphoria as, “A state of unease or generalized dissatisfaction with life. The opposite of euphoria.” Modifying it with “gender” merely limits its application.

Unless the editors of the DSM deliberately set out to confuse the issue by using the word in a novel way, I believe they intend us to understand GD not as a feeling of incongruence, per se, but one’s reaction to it. It might be theoretically possible to be amused by one’s incongruence. As amused, say, as a caricaturist engaging an especially intriguing subject.

Wouldn’t it be a delight to be so evolved as to know you’re TS, and yet not to bother about it? Wouldn’t it save a lot of trouble? We’re all just waves, anyway, seeking out a good reception area.

:) Lallie

[LeaP]

I obviously created confusion or controversy in citing the B criterion, in particular, in my original comment (the one Rianna responded to). The point I was trying to make, and unsuccessfuly tried to clarify in subsequent responses, is that the GD diagnosis is completely dependent upon incongruence. I.e., that the B criterion (which is necessary to a diagnosis under 302.85) of distress or impairment is also about incongruence. In that sense, and that sense only, is my original statement about GD being about incongruence ("period," etc.) true.

In retrospect, it was a mistake to cite the B criterion without explaining its limited sense in the diagnosis. In short, in trying to make a broader point about inconguence unifying the criteria of the diagnosis, the A criterion defining incongruence and the B criterion describing distress or impairment about incongruence, I generalized the criterion B effects into the non-GD, "consequential" effects. Is is unfortunate that the B criterion itself is not more specific on this point, but the accompanying text provides the clarification.

The DSM-5 Guidebook (a companion volume, also published by the APA) provides the same clarification on this point, stating:

"The diagnosis of gender dysphoria requires discomfort with one's own assigned gender and clinically significant distress or impairment. In adolescents and adults, the disturbance is manifested by symptoms such as stated desire to be of the other gender, frequent passing as the other gender, desire to live as the other gender, and the conviction that the person has the typical feeling and reactions of the other gender." I.e., manifested in the bullets of the A criterion!

This approach isn't limited to the GD diagnosis in the DSM. Many diagnoses have a distress and impairment criterion. The intent is that diagnoses should be made only where there is clinical significance to a given condition. ("The condition" in 302.85B is incongruence, back-referencing the A criterion) Put another way, this is about intensity of the condition. You don't diagnose GD unless the intensity of the incongruence is sufficient to rise to clinical levels, as measured by distress and impairment.

Lest any take this as hinting at definitions of "true transsexuality" on the basis on nominally similar intensity arguments often made elsewhere, the DSM commentary not only does not make any such definition, but mentions non-binary identities.

I apologize for the confusion. I will stand by the gist of my original statement, however, in that GD is all about incongruence ... specifically including the distress/impairment.

[stefan37]

I have no idea if my diagnosis would have risen to the bar of what is being discussed. But the inner urge to feminize myself grew stronger and my anxiety levels were hard to control. I started estrogen and 3 days later my anxiety was gone. First time in an extremely long time. I am in full transition and could not be healthier or happier. Nuff said.

[Cheryl123]

It doesn't surprise me that 40%-50% of transsexuals report that they have attempted suicide. Untreated depression is the leading cause of suicide and most transgender people suffer from it in one degree or another. Drawing conclusions between the published rates of attempted suicides and actual suicides is very difficult. Attempted suicide figures are more accurate because the individuals making the attempt will often admit that they have tried to kill themselves. The term Suicide is a legal description of an unattended death. A death can only be classified as suicide when there is evidence to support the ruling. In the absence of evidence the death is ruled accidental. Many suicides, especially those involving drug overdose, are ruled accidental. The "official" suicide rate is always less han the actual rate. Suicide attempts among transgender teens here is a very large problem that needs much more attention than it gets.

Regarding GID, my medical provider (Kaiser Hawaii) pretty much bi-passes strict diagnosis -- thank goodness. After a short discussion with a psychiatrist, they concurred that I was transgender and suffered from depressions. I got a prescription for estrogen and 2 antidepressants on the same day. I have phone consultations with the psychiatrist regarding transition issues every two weeks and meet with her every two months and have a blood test at that time. Their approach makes like simple for me and I don't know why I avoided seeing them for so long.

[Rose]

Is depression included in those "mental stability issues?"

[LeaP]

The mortality study didn't say.

[Pink Person]

Conversations about suicide with people who might be prone to suicidal ideation make me EXTREMELY nervous. Appeals to rationality seem so utterly weak. I am left just wanting to scream to anyone who might be having suicidal thoughts JUST DON'T DO IT! DON'T DO IT FOR ANY REASON!

Does it help? I hope so. My sympathy for TG and TS people is very strong and deep. I want all of them to know that there is always hope for them no matter what pain they are experiencing.

On the subject of gender dysphoria, it seems to me that it is both a condition and the negative consequences that are associated with the condition. It’s not one or the other.

[LeaP]

Appealing to reason with a suicidal person IS weak. But that's not the point of the thread.

Talking ABOUT suicide rationally is critically important. Every major suicide prevention organization stongly supports this. Not talking about it perpetuates myths and taboos ... not just the ones I bring up here, but myths about its immorality, selfishness, craziness, etc., or the myth that it will lead to people commiting suicide.

[DebbieL]

There had been very few attempts to study mortality rates for transsexuals until starting about 2009.
The study that started this thread seems to be focused on those who have actually been treated for gender dysphoria with hormones - with 86.7 % opting for SRS.
The mortality rate of 12% due to all causes was high compared to the general population, but relatively low compared to those who are self-identified transgender and have not transitioned.
I don't see a statistic for homicide victims in the cause of death list.
The sample is also very small - 966 MtF and 365 FtM transse xuals.

Other studies, including some of those cited on Laura's playground include surveys of nearly 1 million respondents, and the statistics are much more alarming.
Mortality rates aren't tracked because respondents were self selected and were not subjected to follow-up status checks.
What was discovered was that there was a much higher percentage of suicide attempts, number of suicide attempts, number of suicide attempts that should have been fatal (vs plea for help).
There was also a much higer incidence of self-destructive behavior such as drug abuse, alcoholism, AIDs, prostitution, and criminal activities - especially among those who did NOT transition.
Laura's also maintains a suicide hotline for those who are transgender and keeps statistics for those calling with desire, ideation (actual plan), implementation (aquiring means), attempts, and lost contacts (not responding to follow-up support calls). These rates were also rather grim compared to more traditional suicide hot-lines.

Being one of those who attempted suicide multiple times using means that should have been effective, I remember here were several factors that were significantly different.
The adage "be yourself" or "to thine own self be true" was particularly painful - I had tried to discuss my gender dysphoria with parents, doctors, nurses, and mental health professionals, including a psychologist I was seeing daily, mental health workers I had been seeing on a daily basis, and marriage counselors. In each case, there was immediate and clear message that I shouldn't even attempt to have the discussion.

My father at first thought it was just "a phase" and would pass.

My mother talked to her therapist she was seeing when I was 6 years old and told her I wanted to be a girl. Mom was told that the treatment would be daily electro-shock therapy (without anesthesia - this was the early 1960s), and if that didn't work - a lobotomy. She was also warned back in 1961 that the mortality rate for gender dysphoria (not what they called it back then), was extremely high, which is why the treatment was so extreme.

Getting bullied for being a sissy didn't help either. I didn't have the limbic response to fight when threatened, and the boys sensed the weakness and exploited it. It's hard enough to deal with 1 or 2 bullies, but when your are being bullied by 12-15 boys in your class of 30 students at lunch, recess, gym, and on the way home from school, the administration didn't want to deal with the paperwork and legal hassles of dealing with the parents of that many boys - especially since many of them were upper middle class and had good lawyers. I was hospitalized with Asthma induced as a direct result of bullying and many times I would go into the hospital and when I switched into the hospital gowns they would ask me if my parents were abusing me because I had so many bruises. I would explain how the other boys had done this, and often the details were so graphic that even trained medical professionals would cringe. I think they kept me in the hospital longer than necessary several times just to spare me a few more days of the abuse.

My grandfather was a fundamentalist Christian and he did his best to dissuade my interests in being a girl with bible readings of various types. At one point, he even read me the passages from Deuteronomy and Leviticus - maybe even all 8 verses - warning me to give up my desire to be a girl. Thank goodness I didn't have to actually live with him, and my mom was a bit of a rebel.

My father eventually told me that he had taken a personality test in college and was told that he was 75% female. He even admitted that he enjoyed doing "girly things" and admitted proudly that he would rather go to a symphony or ballet than a football game or baseball game. He tried to point out that he had turned out all right and was able to continue living as a man and that I could too. But he also admitted that he understood how much I wanted to be a girl, and was sorry that there was nothing he could do.

The psychologist had even stranger responses. He told me "we know you are a girl inside, that you want to be a girl, and you would be happier as a girl, but it's not something that you can change, so we can't even start to talk about it". It had taken every ounce of courage to tell him what he already knew. To find out that I was condemned to spend the rest of my life as a boy was worse than a death sentence. It was more like being sentenced to life in solitary confinement with thrice daily beatings - without the possibility of parole.

When I was 11 I got Chigellossis - it was fatal. My heart even stopped beating for about 3 minutes because my brain had overheated (fever shot to 107 degrees before they could cover my body with towels soaked in ice cubes). When I came back - I was actually angry that they had brought me back.

When my testacles dropped, I tried various ways to castrate myself - tying them off with rubber bands (I'd read they did that with sheep), I even tried a 2x4 and a large hammer - not something I was willing to repeat a third time.

I started having "periods". I don't know what they really were, but about every 4 weeks I would get constipated, then I'd get cramps that were horrible, then sometimes screaming in pain I would push out the "plug" followed by a reddish brown liquid which I now know was bloody stool. My parents knew about this, especially since I woke them up several times. Eventually, mom could predict when I was going to get constipated and would give me ex-lax. I'd still get the cramps and the bloody bowels, but at least they got to sleep at night. It was only when I was 13 and it came out bright red that my parents were alarmed. My mom asked "is he having his period?" My dad's response surprised me,. It wasn't "don't be silly" or "boys don't have periods", it was "no it would be darker". So they took me to the hospital. Even then knowing this, transition was not an option that was even offered.

When I was told that I would be singing bass in the school choir, at 14 years old, I turned to drugs and booze. I'd go into black-outs on a regular basis. I figured that even though my speaking voice was still higher than most girls' I was condemned to live the rest of my life as a man. I still dressed up and my mother knew I still wanted to be a girl, and I still got beat up, but even then there was no chance of reprive.

In high school, everyone assumed I was gay because I was so effeminate. I even had long flowing curly hair.
Fortunately, I ended up making friends with some gays including a couple of guys on the football team and a few guys who wanted to date them. This resulted in my being under their "protection". Of course then, the fear was that if these boys found out that I was a girl, or wanted to be a girl, I would lose that protection and end up going back to the thrice daily beatings and torture.

We often forget that it wasn't until 2013 that the clinical term was changed from Gender Identity Disorder (inability to accept one's birth gender) to Gender Dysphoria (unhappy with one's gender). In the 1960s, a transexual was suffering from a psychotic dilusion that he was a girl inside and had to literally be "shocked" back into accepting (submitting to) the "reality" of his birth gender. In the 1980s, the term "Gender Identity Disorder" made it legal to treat transexuals by giving hormones and SRS surgeries, but even then, many states could revoke a doctor's license and a doctor could lose his hospital priviledges even for just prescribing hormones, let alone performing SRS.

Treatment quality has also improved. Christine Jorgensen had been castrated and emasculated. Even the vaginoplasty was almost a butcher job. When I saw "Sulka's wedding after reading an article about her SRS in the late 1970s, I was astonished to find that what she had didn't look much like a woman at all. It was hard to imagine how she could achive orgasm, since it didn't appear that she had a ciltorus. In 1986, I saw a video about tthe actress named Shannon, who paid for a very complex and expensive experimental procedure in which they were able to give her that bit of equipment. Her own description in the video was that it was extremely painful, especially when they had to configure the nerves with only light local anesthesia because they hadn't yet learned how to reconnect all those nerves in the right configuration. Today, modern SRS is available in several states, and many doctors have full time practices devoted to meeting the needs of the transsexual and transgender community.

Another important shift was the result of known cases of "cyber bullying". After the suicides of a number of children were investigated by distraught parents who saw threats on their child's cell phones or computers, police began routinely reviewing cell and computer records of children who commited suicide and found that an extraordinarily high percentage of male suicides were investigated and police discovered that the boys were gay, bisexual, or transgendered. Often the "trigger" was rejection by the parents, a romantic interest, or being outed to and rejected by former friends and peers.

Remember that it was only about december of 2013 that the American Psychology Association, American Psychiatry Association, and American Medical Association declared that attempting to force a transsexual patient to accept their birth gender was considered UNETHICAL. Even today, many doctors, for religeous, political, or hospital priviledges reasons are often reluctant to treat transgender and transsexual patients even when they have the therapists letters. My family doctor refused to prescribe hormones and would not refer me to an endochrinologist who would. I finally found out that I could drive or take the train for two hours to Philadelphia to see doctors at the Mazzoni center. Upon examination and interviews, they reconfirmed previous diagnosis that I was a "type 6 transsexual" likely to become self destructive if not assisted in transition.

I was first diagnosed in 1988 by a couples therapist. At that time, my wife told him about my dressing, and then told him "he's really not much of a man at all". After 3 hours of private interviews, he told me and my wife that I was at least 95% female and that if I didn't transition, I would probably become self destructive in some way. He then pointed out that I already had throughout my teens and twenties, and even though I was thirty and had several years clean and sober, forcing me to remain as a boy would probably result in some form of early death. Of course, she wasn't a lesbian, or even bisexual, so we ended up getting divorced about 18 months later. Sadly, as a result of threats to lose all contact with my children, I did abort transition and eventually began new modes of self destruction - overeating and more than doubling my "girl weight", having a heart attack, and a stroke - with a standing DNR living will in place.

My second wife knew about Debbie before we even met, and we talked about it via e-mail and phone, and eventually got together. Her daughter pointed out "well mom, at least you won't have to worry about bruising his male ego when he finds out you're in charge of it". Even at our first date, she took charge and I loved it. When we made love the first time, I offered some "toys" and she was delighted, when I made lesbian love to her she loved that even more, and when she realized how small I was and that I really wasn't all that into intercourse, she realized that I was her lesbian lover. She loved my personality, my sense of humor, and my loving ways, as well as my patience, lack of mean temper, and positive outlook. After 1 year we were engaged (she proposed to me) and a year later we were married.

By then I was also "out". I had a facebook account for Debbie as well as an e-mail account, and Lee had told her family about Debbie. When a few women at church asked if I was gay because I was effeminate, she would tell them about Debbie.

When my dad was about to die, I flew out to be with him. Prior to that he had seen Debbie a few times and said "I just don't want to deal with it. I don't want it thrown in my face". I think he thought it was his fault.
When I got there, the first conversation he had was "If I can't give you anything else, I want you to be yourself, even if that's Debbie". Later he told me that he had been following Debbie's postings on facebook and understood that for me, that was the only way I could truly be true to myself. He told me about how they wanted to shock me and turn me into a vegetable. He even told me that he and mom had known for a long time and were afraid that if they tried to get help for that issue, they might lock me up and do the lobotomy. Even for them it was like a secret they had to keep. He even hinted that I was physically "more female than male".

By the time he died, I was clear that I wanted to transition. After that first conversation I started dressing in the femme clothes I had brought with and stuffed in the bottom of my suitcase. For about 4 days, my father was still alert enough to meet his daughter, and he told he how much he loved his wonderful daughter. At the end, when he was delusional, he even thought I was my mother, coming to take him home.

I often cry when I think of how long I wanted my mother and father to meet, know, and love their daughter. I wanted them to love me for who I really was. I realize, from things dad told me in those last days, that they both knew, mom had even taken me shopping to buy clothes for her. She would wear them once, and put them in the good will so that I could "adopt them". It was so covert, so "under the table" but the reality was that even though they didn't understand it, couldn't get me help, and didn't know what to do about it, they loved me. They just didn't want me turned into a vegetable,

When I finally transitioned, I started with a therapist, got the hormones, and by the time I started working full time as female, I couldn't believe I could be so happy. I knew there would still be hurdles to jump, things to be done, and people who might not accept me, but I have been delighted and amazed at how things have turned out. I went to the family Thanksgiving as Debbie, and the family liked me so much that Debbie got all the presents. When they started to apologize for it I started crying and said "That's so wonderful, thank you for NOT getting Rex any presents". When my father-in-law decided to book a vacation tour for the entire family he ordered my ticked for "Debbie" not Rex. He even asked "Can Debbie please come with is!". On the vacation, he frequently wanted to sit with me at Dinner, and on a few occaisions even sat with me and had Lee at another table. We had such a great time, and he just loved the way he could be silly around me. At one point he "proposed" to a watress and she held out her hand, did a courtsey, and said "YES!!". I started to giggle and he looked at me and started giggling himself, then she started giggling. We were all having such a great time together.

And at work, I have also been delighted at how smooth the transition was. I work as a consultant and did one gig as "Rexxie" because I hadn't legally changed my name. At the next gig, I had filed for the name change and they agreed to call me Debbie immediately. My e-mail account was for Debbie and my correspondence was to and from Debbie. I even had a few women giving me coaching, encouraging me to be the nice sweet lady when that worked, but not to be afraid to pull out the riding crop - or the broom, when that was what was needed to get results.

Perhaps the most amazing of all was my 40 year high school reunion. Girls who had known me since elementary school told me "we always considered you one of the girls". They asked me to pose for pictures with them, they wanted me to join them in conversations, they even followed me into the bathroom and started conversations. It was like I had been a girl all my life and I was the only one who didn't know it back then. One of my male classmates came up and asked "did you have the operation". I asked "why, did you want to seduce me?". He grinned and said "well, your are kinda cute". I let him know that I didn't have the equipment he was hoping for, and was happily married and content being the way I was for now. He was pleased to know that my 38C breasts were "all me" (with a bit of help from Victoria's Secret :-).

[Rachel Smith]

Conversations about suicide with people who might be prone to suicidal ideation make me EXTREMELY nervous. Appeals to rationality seem so utterly weak. I am left just wanting to scream to anyone who might be having suicidal thoughts JUST DON'T DO IT! DON'T DO IT FOR ANY REASON!

Does it help? I hope so.

Pink Person and Lea just to let ya'll know it does help, me at least. It reminds me not to go back to the dark place I was on Christmas Eve 2012.

[DebbieL]

I think that is the most important thing about this site. It gives those who are still struggling and suffering, the experience, strength, and hope of those who have had breakthroughs in this part of our lives, whether that is a completed and successful transition or being at peace with our current state, for now.