Of the 23 studies that met the inclusion criteria, the majority indicated a reduction in suicidality following gender-affirming treatment; however, the literature to date suffers from a lack of methodological rigor that increases the risk of type I error.[2] Patients who received some of their desired gender-affirming surgeries had lower odds of suicidal ideation (aOR, 0.72; 95% CI, 0.63-0.81; p < 0.001) and suicide attempt(s) (aOR, 0.70; 95% CI, 0.53-0.93; p = 0.01) over the past year compared to those who desired gender-affirming surgery but had not received any.[2] The receipt of puberty blockers or gender-affirming hormones was associated with decreased odds of thoughts of suicide or self-harm (aOR, 0.47; 95% CI, 0.26-0.86).[2]

The overall mortality for sex-reassigned persons was higher during follow-up (aHR 2.8; 95% CI 1.8-4.3) than for controls of the same birth sex, particularly death from suicide (aHR 19.1; 95% CI 5.8-62.9).[8] Sex-reassigned persons also had an increased risk for suicide attempts (aHR 4.9; 95% CI 2.9-8.5) and psychiatric inpatient care (aHR 2.8; 95% CI 2.0-3.9).[8] Persons with transsexualism, after sex reassignment, have considerably higher risks for mortality, suicidal behaviour, and psychiatric morbidity than the general population.[8]

In this Danish population-based, retrospective cohort study, results suggest that transgender individuals had significantly higher rates of suicide attempt, suicide mortality, suicide-unrelated mortality, and all-cause mortality compared with the nontransgender population. Standardized suicide attempt rates per 100,000 person-years were 498 for transgender vs 71 for nontransgender individuals (aIRR, 7.7; 95% CI, 5.9–10.2). Standardized suicide mortality rates per 100,000 person-years were 75 for transgender vs 21 for nontransgender individuals (aIRR, 3.5; 95% CI, 2.0–6.3). This study does not separate pre- and post-medical transition periods but provides population-level suicide attempt and mortality rates among transgender people compared with nontransgender controls.

Using Swedish national registers, the cohort study reports: "The overall mortality for sex-reassigned persons was higher during follow-up (aHR 2.8; 95% CI 1.8–4.3) than for controls of the same birth sex, particularly death from suicide (aHR 19.1; 95% CI 5.8–62.9)." It further notes: "This study found substantially higher rates of overall mortality, death from cardiovascular disease and suicide, suicide attempts, and psychiatric hospitalisations in sex-reassigned transsexual individuals compared to a healthy control population." The authors explicitly state: "Our study does not, however, address whether sex reassignment is an effective treatment or not."

In this prospective cohort of 104 TNB youths aged 13 to 20 years, receipt of gender-affirming care, including puberty blockers and gender-affirming hormones, was associated with 60% lower odds of moderate or severe depression and 73% lower odds of suicidality over a 12-month follow-up. After adjustment for temporal trends and potential confounders, we observed 60% lower odds of depression (adjusted odds ratio [aOR], 0.40; 95% CI, 0.17-0.95) and 73% lower odds of suicidality (aOR, 0.27; 95% CI, 0.11-0.65) among youths who had initiated PBs or GAHs compared with youths who had not. This study found that gender-affirming medical interventions were associated with lower odds of depression and suicidality over 12 months.

Clinical gender dysphoria does not appear to be predictive of all-cause nor suicide mortality when psychiatric treatment history is accounted for.[9] Main predictor of mortality in this population is psychiatric morbidity, and medical gender reassignment does not have an impact on suicide risk.[9] Gender dysphoria per se does not seem to predict neither all-cause nor suicide mortality in gender-referred adolescents.[9]

This study is a longitudinal evaluation of the effectiveness of gender-affirming hormones for improving psychological well-being and decreasing suicidality among transgender youth referred to a transgender health specialty clinic at a large Midwest children’s hospital. After gender-affirming hormones, a significant increase in levels of general well-being and a significant decrease in levels of suicidality were observed. Results indicate that gender-affirming hormones are effective in improving well-being and reducing suicidality among transgender youth over time.

Compared with cisgender women, TGD people were more than 5 times as likely to die from suicide or homicide (MRR, 5.62; 95% CI, 2.65-11.91) and from accidental poisonings (MRR, 5.20; 95% CI, 2.22-12.18).[14] In this cohort study of 3,946 transgender and gender-diverse (TGD) people and 3,946 matched cisgender women, TGD people had higher mortality rates than cisgender women, particularly for external causes of death such as suicide and homicide.[14] These findings suggest a need for targeted interventions to reduce excess mortality from preventable causes among TGD people.[14]

A web-based survey of 796 trans individuals in Sweden found: "A total of 37% of respondents reported that they have seriously considered suicide during the past 12 months and 32% had ever attempted a suicide." The study concludes: "The prevalence of suicide ideation and attempts among trans respondents is disproportionately high and is directly correlated with trans-related victimization." This work documents high suicidality among Swedish trans people but does not evaluate changes before vs after medical transition.

This systematic review of 20 studies found evidence that gender-affirming hormone therapy may be associated with improvements in QOL scores and decreases in depression and anxiety symptoms among transgender people.[5] It was impossible to draw conclusions about the effects of hormone therapy on death by suicide.[5] There is insufficient evidence to draw a conclusion about the effect of hormone therapy on death by suicide among transgender people.[5]

Use of GAHT was associated with lower odds of recent depression (adjusted odds ratio [aOR] = .73, p < .001) and seriously considering suicide (aOR = .74, p < .001) compared to those who wanted GAHT but did not receive it. For youth under age 18, GAHT was associated with lower odds of recent depression (aOR = .61, p < .01) and of a past-year suicide attempt (aOR = .62, p < .05). Findings support a relationship between access to GAHT and lower rates of depression and suicidality among transgender and nonbinary youth.

The pooled multilevel estimate was not statistically significant but pointed in a negative direction (log odds ratio = -0.3576; 95% confidence interval: -1.2768 to 0.5617; p=0.4458), suggesting a possible but not definitive protective effect of GAHT against suicidality.[1] The pooled random-effects estimate indicated no statistically significant association between gender-affirming hormone therapy (GAHT) and suicide-related outcomes relative to non-GAHT comparators (pooled HR = 1.85, 95% CI [0.39, 8.77]).[4] The conclusions highlight that while there is a non-significant trend toward a protective effect of GAHT, the evidence is limited by high heterogeneity, influential studies, small-study effects, and the predominantly observational nature of the data.[1]

Standardized suicide attempt rates per 100 000 person-years were 498 for transgender vs 71 for nontransgender individuals (aIRR, 7.7; 95% CI, 5.9–10.2). Standardized suicide mortality rates per 100 000 person-years were 75 for transgender vs 21 for nontransgender individuals (aIRR, 3.5; 95% CI, 2.0–6.3). In this Danish population-based, retrospective cohort study, results suggest that transgender individuals had significantly higher rates of suicide attempt, suicide mortality, suicide-unrelated mortality, and all-cause mortality compared with the nontransgender population. The study covers 3,759 transgender-identifying individuals over 42 years but does not explicitly separate suicide outcomes before versus after medical transition.

Three studies examined suicidality as an outcome, of which 2 reported significant reductions in suicidal ideation (8) or suicidality (10) after 12 months of GAHT. The third study by Tordoff et al (15) found no significant longitudinal changes in suicidality over a 12-month follow-up period within the group of TGD youth that initiated GnRHas, GAHT, or both. Overall, recent findings suggest that GAHT is associated with improved psychosocial outcomes, including reductions in suicidality, although not all studies show significant changes.

Gender-affirming interventions are consistently associated with reduced suicidality.[10] Initiation of GAHT or puberty blockers reduces odds of suicide attempts and suicidal ideation by 38–73% compared to individuals who desire but do not receive treatment.[10] Gender-affirming interventions—including hormone therapy, puberty suppression, and social transition—are consistently associated with reductions in suicidality, especially when embedded in supportive social and family environments.[10]

Across these 42 studies an average of 55% of respondents ideated about and 29% attempted suicide in their lifetimes. Cole et al. (study 1 in Table) examined 318 MTF and 117 FTM patients before/after treatment at a Texas gender clinic. Before treatment, suicide attempts were: All: 15%, MTF: 12%, FTM: 21%. After treatment, suicide attempts were: All: 0%. Brown et al. (study 26) of 28 MTF patients after surgery reported suicide attempt prevalence of 7.14%. Another study (study 60) reported 55.56% suicide attempts before transition and 11.11% after transition among 9 MTF individuals. These small studies suggest reduced attempts after treatment but have limited sample sizes and methodological detail.

Individuals who underwent gender-affirming surgery had a 12.12-fold higher suicide attempt risk than those who did not (3.47% vs. 0.29%, RR 95% CI 9.20-15.96, p < 0.0001).[3] After propensity matching, mortality was 3.59 times greater in patients with a history of gender-affirmation surgery (4.6% vs. 1.3%, RR CI 2.224-5.806, p < 0.0001).[3] Patients who have undergone gender-affirming surgery are associated with a significantly elevated risk of suicide, highlighting the necessity for comprehensive post-procedure psychiatric support.[3]

Compared with the general population, individuals with a gender incongruence diagnosis were about six times as likely to have had a mood and anxiety disorder health care visit, more than three times as likely to have received prescriptions for antidepressants and anxiolytics, and more than six times as likely to have been hospitalized after a suicide attempt. Years since initiating hormone treatment was not significantly related to likelihood of mental health treatment (adjusted odds ratio=1.01, 95% CI=0.98, 1.03). However, increased time since last gender-affirming surgery was associated with reduced mental health treatment (adjusted odds ratio=0.92, 95% CI=0.87, 0.98). In this first total population study of transgender individuals with a gender incongruence diagnosis, the longitudinal association between gender-affirming surgery and reduced likelihood of mental health treatment lends support to the decision to provide gender-affirming surgeries to transgender individuals who seek them.

Out of 5107 trans women (median age at first visit 28 years, median follow-up time 10 years) and 3156 trans men (median age at first visit 20 years, median follow-up time 5 years), 41 trans women and 8 trans men died by suicide. We observed no increase in suicide death risk over time and even a decrease in suicide death risk in trans women. However, the suicide risk in transgender people is higher than in the general population and seems to occur during every stage of transitioning. Of all suicide deaths, 14 people were no longer in treatment, 35 were in treatment in the previous two years. This long-term cohort does not specifically compare pre- vs post-transition but assesses trends in suicide death risk over 1972–2017.

This analysis discusses a key U.S. study that had been widely cited to claim that gender‑affirming surgery reduces suicidality. It notes: "However, following a reanalysis of the data, this conclusion has now been officially corrected to indicate that there is ‘no advantage of surgery.’" The correction states that the original finding of reduced mental health treatment utilization after surgery was not statistically robust, undermining claims that surgery clearly lowers suicidality risk; the corrected paper still does not show increased suicide risk after surgery relative to pre‑surgery in the same cohort.

The study found that suicide among young people <23 ("youth") seeking gender services in Finland is an unusual event (0.3%, or 0.51 per 1,000 person-years).[6] The study also did not detect a statistically significant association between gender reassignment and the risk of suicide.[6] The study reported that youth who were gender-transitioned had a lower risk of suicide over time (adjusted hazard ratio, 0.8; 95% confidence interval 0.2 to 4.0; p-value = 0.8) compared to the general population, while youth who were gender-referred but did not undergo transition had a higher risk (adjusted hazard ratio, 3.2; 95% confidence interval 1.0 to 10.2; p-value, 0.05).[6]

The results of this study indicate that patients who have undergone gender affirmation surgery are associated with significantly higher risks of suicide, self-harm, and PTSD compared to general population control groups in this real-world database. In the second analysis, patients who had undergone gender affirmation had a statistically significant increase in suicide attempts, death, self-harm, and PTSD after completion of gender affirmation in comparison with those who had undergone BTL or vasectomy and had not undergone gender-affirmation. This study compares post-gender-affirmation outcomes with matched controls but does not measure suicide risk in the same individuals before vs after their own transition.

Our study reveals that both male and female patients with gender dysphoria who undergo gender-affirming surgery are at significantly higher risk for adverse mental health outcomes, including depression, anxiety, suicidal ideation, and substance use disorder, compared to those who do not undergo gender-affirming surgery. These findings challenge the assumption that gender-affirming surgery is uniformly associated with improved mental health outcomes and suggest the need for careful psychiatric assessment and follow-up. Patients with gender dysphoria who underwent surgery showed increased odds of suicidal ideation relative to non-surgical patients in the matched cohort.

Suicidality significantly declined from pretreatment to post-treatment (F[1, 426] = 34.63, P < .001, partial η2 = 0.075).[11] Hormone therapy (HT) was associated with clinically meaningful reductions in suicidality over time, extending prior findings with a larger sample and longer follow-up.[11] These findings suggest that medical gender-affirming treatment may contribute to reduced suicide risk among transgender adolescents, although causality cannot be definitively established.[11]

Generally speaking, accessing good quality gender-affirming surgery is associated with a lower risk of suicide attempts – not to mention, a lowered chance of suicidality, psychological distress and smoking. As Daniel Jackson notes in their 2023 literature review, most peer-reviewed research on the topic suggests that gender-affirming surgery is associated with a reduction in the risk of suicide for trans and non-binary people. This article summarizes research but does not itself present original data; it emphasizes that most peer-reviewed studies report decreased suicidality after gender-affirming surgery, while acknowledging ongoing elevated baseline risk among trans populations.

A fact‑checking article about claims made by Elon Musk reports: "The findings, derived from health and population registers in Sweden, indicated that individuals who underwent sex reassignment surgery were more prone to suicide, suicide attempts, and psychiatric admissions." It clarifies that the study "compared 324 ‘sex-reassigned’ individuals in Sweden over a 30-year period" to matched controls, and notes: "Researchers found no statistically significant increase in suicide attempts among individuals who had [surgery] between 1989 and 2003" and that elevated overall mortality was significant "only among individuals who underwent surgery prior to 1989." The piece stresses that the study does not compare the same trans individuals before and after surgery.

Twenty-one studies found a much higher prevalence of suicide-related outcomes in patients post-GAS than in the control group, specifically of suicide attempts and suicide deaths. However, most included studies did not have pre-GAS baseline measurements, limiting the ability to compare suicide outcomes before versus after surgery within the same individuals. This systematic review concludes that transgender and gender diverse individuals who underwent gender-affirming surgeries show higher suicide-related outcomes than general population controls, while also noting methodological limitations and lack of within-person pre/post data.

A detailed critique of common misuses of the Swedish study explains: "Typically, when anti-trans activists refer to ‘The Swedish Study,’ they are citing a 2011 study... The study looked at 324 transgender people who had received sex-reassignment surgery between the years of 1973-2003." It states: "Importantly, the study does not compare transgender people who received gender affirming care with transgender people who did not receive gender affirming care. Instead, it compares transgender people who received care with the general population of cisgender people." The author emphasizes: "Although the study recorded high rates of mortality and suicide... it crucially did not compare the suicide and mortality rates of post-op trans individuals with those who did not receive care or surgery. The study does not substantiate [the] claim" that suicidality is higher after transition than before.

Overall, high levels of suicide ideation and attempts were identified among transgender people.[15] Existing evidence suggests that interpersonal, institutional, and structural forms of discrimination are consistently associated with suicide ideation and attempts among transgender people.[15] There is insufficient longitudinal research to determine how suicidality changes before and after transition-related interventions; most studies are cross-sectional.[15]

67% of transitioning people thought about suicide pre-transition and only 3% post-medical transition (Bailey et al., 2014). This fact sheet reports that suicidal ideation markedly decreased after medical transition in this cited study, although details on sample size, methodology, and publication venue of Bailey et al. (2014) are not elaborated. The document overall notes high rates of suicidality among transgender people but highlights evidence that access to gender-affirming medical care can be associated with reductions in suicidal thoughts.

A statistical summary aimed at lay readers describes the Swedish cohort: "[The study] conducted the longest follow-up study to date on the outcomes of ‘sex reassignment surgery’, covering a period of 30 years (1973-2003) and involving 324 individuals in Sweden." It notes: "The study compared these individuals to matched controls based on birth year and sex, revealing that those who had undergone surgery exhibited a significantly increased suicide risk, with rates nearly 19.1 times higher than their matched controls." This summary reiterates that the comparison is between post‑surgical trans people and cisgender controls, not pre‑ vs post‑transition in the same individuals.

Transgender people who need and receive gender-affirming medical care have a lower prevalence of suicide thoughts and attempts than those who need it but have not received it, according to a new fact sheet by the Williams Institute at UCLA School of Law. An estimated 5% of transgender people who accessed gender-affirming care attempted suicide in the past year compared to 9% of those who needed care but did not receive it. Similarly, 16% of those who accessed gender-affirming care had suicidal thoughts in the past year, compared to 21% of those who needed care but did not receive it.

A commentary citing the Swedish study states: "Ten to 15 years after surgical reassignment, the suicide rate of those who had undergone sex-reassignment surgery rose to 20 times that of comparable peers." Quoting Medicare’s review, it adds: "The study identified increased mortality and psychiatric hospitalization compared to the matched controls. The mortality was primarily due to completed suicides (19.1-fold greater than in control Swedes)..." The article interprets these findings to argue that "Sex Reassignment Doesn't Work," but it draws on comparisons to cisgender controls and does not present data comparing suicidality before and after transition in the same individuals.

Upon deeper examination, the claims of reduced suicidality, including reduced attempts, from pediatric gender-affirming medical care are also not supported by the available evidence.[12] This essay will make the opposite argument that, over the longer term, medical pediatric transition increases, rather than reduces, risks of suicidality, attempted suicide, and completed suicide.[12] The weight of medical research indicates that pediatric medical transition does not reduce suicide or suicidality, and may even increase pediatric suicide and suicidality; further, prohibitions of pediatric medical transition do not increase suicide.[12]

This background item notes that the Swedish sex reassignment cohort study (Dhejne et al. 2011) is often misinterpreted as showing that suicidality increases after medical transition. In fact, the study design was a matched cohort comparing post‑operative trans individuals to cisgender population controls, with no baseline pre‑transition suicidality data for those same individuals. Therefore, the Swedish study cannot directly answer whether individual trans people are more or less likely to die by suicide after medically transitioning than before transitioning.