Dhejne et al. 2011 sex reassignment study

{{gender}}
The '''Dhejne ''et al.'' 2011 sex reassignment study''', informally known as the "'''Swedish study'''", a particular study (Dhejne ''et al.'' 2011<ref name="dhejne"/>) that [[Transphobia|anti-trans]] activists have fixated a lot on,<ref>Lauren Holt (March 31, 2021). [https://www.cnn.com/2021/03/28/us/transgender-rights-arkansas-tennessee-anti-trans-laws/index.html "Transgender rights in the spotlight as Arkansas and Tennessee become latest states to pass anti-trans legislation"]. ''CNN''. Quote: "[...] citing a 2011 Swedish study ​that is frequently cited by those who seek to undermine trans rights and gender affirming health care."</ref><ref name="SwedishStudySiobhan">Siobhan (November 14, 2016). [https://freethoughtblogs.com/atg/2016/11/14/five-years-later-and-they-still-havent-read-that-fucking-swedish-study/ "Five years later and they still haven’t read That Fucking Swedish Study"]. ''Freethought Blogs''.</ref> and may still cite occasionally.

It was nicknamed "the [[Swedish]] study" because its authors and subjects are Swedish.{{nofact}} It will be most frequently referred to prior to about 2021, after which point [[TERFs]] have found enough [[political]] clout that they hardly need it anymore, though it does serve as a historical example in how people will always find some study somewhere that purportedly supports their views. [[ACPeds]]-esque groups have also since provided them with different citations, including other "Swedish studies", often with their own flaws or misinterpretations. These campaigns to twist [[scientific]] research in order to ban or [[FUD]] [[trans]] [[healthcare]] have drawn the ire of the godfather of [[evidence-based medicine]], Gordon Guyatt, among others.<ref>Henry Carnell (September 23, 2025). [https://www.motherjones.com/politics/2025/09/guyatt-transgender-care-youth-medicine-evidence-segm/ "Trans Health Care 'Skeptics' Lost a Key Ally—Now They're Having a Meltdown"]. ''Mother Jones''.</ref>

This article mainly critiques how the study has been interpreted, rather than the study itself. The study's lead author has spoken against the interpretations put forward by anti-trans activists, and these interpretations usually focus on research questions that the study wasn't ever designed to answer.

==TL;DR==
"The Swedish study" was published in ''{{w|PLOS One||,}}'' an [[American]]-based journal that publishes a large amount of content (a {{w|mega journal||;}} this means that the journal has a broad focus and so is not very selective with what topics it publishes on) and so it has a relatively low [[impact factor]]. TERFs falsely claim the Swedish study shows that trans women "[[Biological determinism|retain male-pattern criminality]]" and have higher [[suicide]] rates even after [[gender transition|transitioning]] (specifically [[sex reassignment surgery]]).<ref name="DhejneTA">Cristan Williams (November 2015). [https://www.transadvocate.com/fact-check-study-shows-transition-makes-trans-people-suicidal_n_15483.htm "Fact check: study shows transition makes trans people suicidal"]. ''TransAdvocate''. This interview transcript [https://theconversation.com/factcheck-qanda-was-lyle-shelton-right-about-transgender-people-and-a-higher-suicide-risk-after-surgery-55573 was also confirmed as genuine] by Dhejne in a statement to ''The Conversation''.</ref><ref name="terfiles1">TERFiles, "[https://terfiles.medium.com/academics-anti-transgender-submission-to-parliament-plagiarised-368f1bb7221 Academics’ anti-transgender submission to Parliament plagiarised?]", 3 February 2021</ref> Usage for arguments around suicidality are more common than for criminality. The paper looked at the offending rates of post-operative trans women in Sweden from 1973 to 2003.<ref name="dhejne">Dhejne ''et al.'' (2011). [https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0016885 "Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden"]. ''PLOS One''.</ref> The introduction to the paper makes clear that it isn't seeking to answer "whether [[Sex reassignment surgery|sex reassignment]] is an effective treatment or not." From the paper itself:

{{cquote|[It is important] to note that the current study is only informative with respect to transsexuals persons['] health after sex reassignment; no inferences can be drawn as to the effectiveness of sex reassignment as a treatment for transsexualism. In other words, the results should not be interpreted such as sex reassignment per se increases morbidity and mortality. Things might have been even worse without sex reassignment.|||<ref name="dhejne"/>}}

Otherwise, what the study actually found was that ''only'' the older cohort of trans women (1973 to 1988) exhibited a rate of criminal conviction comparable to that of [[cisgender]] men.<ref name="DhejneTA" /> This pattern was not observed in the study's second cohort (1989 to 2003), with Cecilia Dhejne, the lead author, noting in an interview with ''TransAdocate'' that "differences in mortality, suicide attempts, and crime disappear" for this group.<ref name="DhejneTA" /> In Dhejne's conclusion, the study's younger cohort likely had better outcomes due to having "accessed more mental health care" than previous generations, while the poorer outcomes of the older cohort "likely reflects a time when trans health and [[psychological]] care was less effective and social stigma was far worse."<ref name="DhejneTA" />

Some limitations of the study that were acknowledged by the paper:

{{cquote|Other facets to consider are first that this study reflects the outcome of [[psychiatric]] and somatic treatment for transsexualism provided in Sweden during the 1970s and 1980s. Since then, treatment has evolved with improved sex reassignment surgery, refined hormonal treatment, and more attention to psychosocial care that might have improved the outcome. Second, transsexualism is a rare condition and Sweden is a small country (9.2 million inhabitants in 2008). Hence, despite being based on a comparatively large national cohort and long-term follow-up, the [[statistical]] power was limited.|||<ref name="dhejne"/>}}

==Suicidality==
{{main|Suicide}}
When examining this paper, it's worth realizing that the sex-reassigned transgender people were compared against cisgender [[Experimental control|controls]], rather than against non-sex-reassigned transgender controls, for suicidality rates. This is an important distinction because trans people who underwent sex reassignment may have lower suicidality than those who didn't, but higher suicidality than the cisgender population.

The paper's conclusion states that sex reassignment (which is recognized in the introduction as "the internationally recognized treatment to ease [[gender dysphoria]] in transsexual persons") indeed alleviates gender dysphoria,{{efn|This seems to just have been the assumption of the authors based on previous research they reviewed. The paper doesn't seem designed to have determined this.}} but may not suffice by itself and could be paired with "improved psychiatric and somatic care".

===ICD codes===
Deaths registered under {{wpl|ICD-9}} codes E980 through E989, and ICD-10 codes Y10 through Y34, are included in the Swedish study's criteria for suicide deaths. These codes specifically describe deaths that were (respectively) "undetermined whether accidentally or purposely inflicted" and that were of "undetermined intent".<ref>(2012). [http://www.icd9data.com/2012/Volume1/E000-E999/E980-E989/default.htm "Injury Undetermined Whether Accidentally Or Purposely Inflicted E980-E989 "]. ''ICD9Data''.</ref><ref>(2010). [https://icd.who.int/browse10/2010/en#/Y10 "Event of undetermined intent (Y10-Y34)"]. ''ICD-10''.</ref>

Some of the codes listed under ICD-10 codes Y10 through Y34 in particular look like they have a serious potential to be [[Confounding factor|confounding]] because they include possibly-unintentional [[Drug abuse|recreational drug overdoses]]. (The Swedish study itself notes in its discussion section: "[[Smoking]] was in one study reported in almost 50% by the male-to-females and almost 20% by female-to-males.") Other ICD codes used in the study to denote suicide include deaths from [[antidepressant]]s, and from [[Hormone replacement therapy|hormonal supplements]]. These could be things that trans people would be more prone to, without suicidal intent. Other included codes are "crashing of motor vehicle, undetermined intent" (ICD-10 Y32), and even "unspecified event, undetermined intent" (ICD-10 Y34).

An [[NHS]] Scotland dictionary notes that "codes Y10-Y34 are only to be used where available information is insufficient to enable a legal authority to make a distinction between accident, self-harm and assault."<ref>[https://publichealthscotland.scot/resources-and-tools/health-intelligence-and-data-management/national-data-catalogue/data-dictionary/search-the-data-dictionary/icd-10-other-points-to-note/ "ICD-10 Other Points to Note"]. ''Data Dictionary''. ISD Scotland (NHS Scotland).</ref> A 2017 paper notes that these ICD-10 codes are used in other research to determine suicide deaths, and can be utilized accurately. They do, however, note that researchers cutting ICD-10 codes Y10-Y34 from their criteria could help reduce false positives.<ref>Randall, ''et al.'' (2017). [https://onlinelibrary.wiley.com/doi/epdf/10.1002/mpr.1559 "Emergency department and inpatient coding for self-harm and suicide attempts: Validation using clinician assessment data"]. ''The International Journal of Methods in Psychiatric Research''.</ref>

==Criminality==
[[Prostitution]] (in the sense of selling sex) was illegal in Sweden until 1999 (so for a very large swath of the studied period). This could even have been confounding in the study's measure of criminality and especially violent crime,{{efn|At least if we were trying to determine if transgender women have criminality that is identical in every way to cisgender men, which this study was not actually trying to do. It was measuring criminality as a way to figure out if post-op transsexuals had integrated to society. In that regard, an arrest for being a sex worker was just as much a measure of falling afoul of societal judgement as an arrest for a sexual assault was, unfortunately.}} which it defined as: "homicide and attempted homicide, aggravated assault and assault, robbery, threatening behaviour, harassment, arson, or '''any''' sexual offense". Many legal constituencies that ban prostitution have regarded prostitution (including selling sex) as a ''sexual offense'', and prostitutes have even been put onto sex offender registries for this reason.<ref>Laura Maggi (February 16, 2011). [https://www.nola.com/news/crime_police/federal-lawsuit-challenges-sex-offender-registration-for-prostitutes/article_dba4da5e-672e-5397-9009-339e5f38df12.html "Federal lawsuit challenges sex offender registration for prostitutes"]. ''The Times-Picayune''. NOLA.</ref><ref>Christina Lynch (December 8, 2022). [https://theappeal.org/georgia-sex-offender-registry-traps-people-in-debt/ "How Georgia's Sex Offender Registry Traps People in Debt and Homelessness"]. ''The Appeal''.</ref>

One writer at ''[[Freethought Blogs]]'' shared this observation:
{{cquote|The study never at any point compared the types of crimes for which the two groups were arrested, meaning being arrested for prostitution contributes to the statistic in the same way that an arrest for sexual assault would. And on top of that, this is only true of the older cohort&nbsp;— 1973 to 1988&nbsp;— and that this pattern disappeared in the later cohort, corresponding with better healthcare as well as improved legal and social climates.|||<ref name="SwedishStudySiobhan"/>}}

==Lead author responds==
Cecilia Dhejne, the lead author of the "Swedish study", has called the widespread misrepresentation of her research "very frustrating."<ref name="DhejneTA" /> She has stated that she has "seen professors use my work to support ridiculous claims," and has personally tried to combat the spread of misinformation by "commenting on articles, speaking with [[journalist]]s, and talking about this problem at conferences."<ref name="DhejneTA" />{{efn|As Dhejne notes, it has also been cited for more objective reasons by health researchers.<ref name="DhejneTA"/>}} She added in her ''TransAdvocate'' interview:
{{cquote|The aim of trans medical interventions is to bring a trans person’s body more in line with their [[gender identity]], resulting in the measurable diminishment of their gender dysphoria. However trans people as a group also experience significant social oppression in the form of [[bullying]], abuse, [[rape]] and [[hate crimes]]. Medical transition alone won't resolve the effects of crushing social oppression: social anxiety, depression and posttraumatic stress.

What we've found is that treatment models which ignore the effect of cultural oppression and outright hate aren't enough. We need to understand that our treatment models must be responsive to not only gender dysphoria, but the effects of anti-trans hate as well. That's what improved care means.|||<ref name="DhejneTA"/>}}

==See also==
* [[Littman 2018 ROGD study]]
* [[TERF glossary]]

==Notes==
{{notelist}}

==References==
{{Reflist|3|80%}}

[[Category:TERFs| ]]
[[Category:Transgender]]
[[Category:Transphobia]]

Categories: TERFs, Transgender, Transphobia