Journal Club: The Most Misused Paper in Trans Healthcare Research
A 2011 paper exploring the mental health of trans people is commonly misused by anti-trans individuals and organizations to make points the paper doesn’t support.
by Veronica Esposito
It is one of the most widely misunderstood pieces in the entire scientific literature on transgender people. In fact, it may be the all-time most mischaracterized piece of research on gender-affirming care.
It’s Dhejne et al., 2011, which examined the mental health of trans people who received sex reassignment surgery in the Netherlands between 1973 and 2003. The paper has repeatedly been cited to support false claims that gender-affirming care does not improve trans people's mental health—a question that it never even purported to examine, and that has been explored robustly in many other research papers. The misuses of Dhejne points to a larger issue of research into trans people being politicized for transphobic ends.
This paper has been so widely misunderstood—and so often used for anti-trans purposes—that the paper’s lead author, Cecilia Dhejne, has made multiple attempts to clarify what her paper did and did not say—including a 2017 reddit “Ask Me Anything.” And yet, the misconstruals remain.
So, what did this paper actually find?
Quite simply, Dhejne found that, compared with controls of the same birth sex, transgender people who had received sex reassignment surgery were more likely to end their lives, attempt to end their lives, and spend time in psychiatric inpatient care. These findings also held in comparison to birth-assigned members of their transitioned sex.
Most in the trans community would not find this surprising, as it is well-known that stigma and minority stress can place a mental burden on transgender people, to say nothing of the stresses of making a gender transition, which can sometimes result in losing essential support from friends and even family. Comparing mental health rates of trans and cis people is—as with any comparison of a majority group to an oppressed minority—a very apples-and-oranges comparison.
Based on this research, Dhejne’s conclusion was clear: while sex reassignment surgery could help alleviate gender dysphoria, it alone was not sufficient to bring trans individuals to parity with their cisgender peers’ mental health. Dhejne concluded that this research “should inspire improved psychiatric and somatic care after sex reassignment for this patient group.”
But many have cited this paper in a way that contradicts Dhejne’s actual conclusions. The website Trans Advocate found well over a dozen misrepresentations of Dhejne’s paper in various media outlets, including major ones like Fox News and The Washington Post, which have used the paper to argue against medical transition.
In addition, there are those in the scientific community who have mis-cited Dhejne. For instance, Dr. Steven B. Levine, who has authored multiple research papers against transgender people, cited Dhejne in 2016 to advance his argument that trans people are inherently mentally ill.
The minority rights paradigm, a legal political perspective, borrows the medical model to get patients their desired hormones and surgery but then denies that Gender Dysphoria is any form of illness. WPATH is the authority for this perspective. The Standards of Care portray its guidelines as scientific. It calls upon clinicians to advocate for the transgendered [sic]. Combining science and advocacy produces problems. Science provides a dispassionate view of what seem to be the facts. Advocacy aims at attaining a specific goal, and it musters the facts that support that goal. Science recognizes its own limitations; advocacy is disinterested in emphasizing the limitations of its position. The fact that the suicide rate 10 years after SRS was high is irrelevant to the minority rights paradigm.
Dhejne’s paper has also been used by advocates of laws targeting transgender individuals. For instance, it was reported last year that this study was cited in a Congressional hearing, where Dr. Jennifer Bauwens testified in favor of anti-trans laws. It was also cited in an amicus brief filed in support of Brian Tingley, a marriage and family therapist who sued in order to practice conversion therapy in the State of Washington. This brief blatantly mis-cited Dhejne, claiming “Indeed, among individuals who undergo full transition, the suicide rate significantly increases—not decreases.” The paper was also misrepresented in the 2020 Parliamentary debate around reforming the Gender Recognition Act in the UK.
At times, Dhejne has waged a one-woman campaign to right the misuse of her research. As she told the Trans Advocate in 2022, “I’ve often had to respond myself by commenting on articles, speaking with journalists, and talking about this problem at conferences.” She also stated on a reddit AMA “I am aware of some of the misinterpretation of the study in Plos One. Some are as you say difficult to keep track since they are not published in scientific journals. I am grateful to friends all over the world who notify me of publications outside the scientific world. I do answer some of them but I can’t answer all.”
In her efforts to fact-check misuses of her research, Dhejne has pointed out that her data actually supports the conclusion that gender-affirming care improves factors like mortality and suicide attempts. As she explained, subjects in her research who received sex reassignment surgery during the period of 1989 to 2003 actually had mental health on parity with cisgender people by many (but not all) measures of mental health that she tracked. “If one divides the cohort into two groups, 1973 to 1988 and 1989 to 2003, one observes that for the latter group (1989 – 2003), differences in mortality, suicide attempts, and crime disappear.” Dhejne chalked this up to increased use of mental health support by trans people in later decades as that care became more widely available.
The willingness of anti-trans campaigners to misrepresent Dhejne’s research, and her Herculean efforts to correct the record, are symptomatic of a larger problem with the misuse of research regarding trans people. For instance, an independent analysis conducted by Yale Law School of the Cass Report—which has been used in the UK to justify ceasing gender-affirming medical care for minors—found numerous spots in which the Cass Report misrepresented the research into this care. Similarly, New York Times opinion columnist Pamela Paul has been shown to misrepresent research into gender-affirming care to support her anti-trans viewpoints. Although Dhejne et al., 2011 might be the most mis-cited paper, it is far from the only paper on trans people to be misused by those with an agenda.
Something that has been lost in all the fact-checking around Dhejne’s paper is that her research pointed to a need for more robust services to support trans people in the post-operative period. As she told Trans Advocate, this was the rationale that originally led her to conduct her research: “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.” Ironically, instead of helping advocate for better holistic care for trans people undergoing medical transition, the paper has been swallowed up by exactly the forces of anti-trans hate that Dhejne was trying to support trans individuals against.
The misuse of Dhejne’s research was a major flashpoint in the larger politicization of scientific research into transgender people. It is part of a practice by the anti-trans side of mis-appropriating science for anti-trans ends, Other examples include the widely debunked research paper into “Rapid Onset Gender Dysphoria” by author Lisa Littman, and anti-trans books like Abigail Shrier’s Irreversible Damage, which attempts to assume the mantle of science despite being highly anti-scientific.
Sadly, as with Dhejne’s paper, what is lost in this politicization are the needs of trans people—needs for adequate and affordable medical care, for high-quality mental health support, and for more understanding as to their particular struggles.
Veronica Esposito (she/her) is a writer and therapist based in the Bay Area. She writes regularly for The Guardian, Xtra Magazine, and KQED, the NPR member station for Northern California, on the arts, mental health, and LGBTQ+ issues.