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Page 2 of 13 Larshans et al. Plast Aesthet Res. 2025;12:7 https://dx.doi.org/10.20517/2347-9264.2024.154

Conclusion: Our study highlights the significant issues of thoughts of self-harm or suicidal ideation among
transgender women after genital GAS. Although the prevalence thereof was lower than that reported previously, it
remains concerning. Nevertheless, most participants reported life satisfaction and finding life meaningful post-
surgery. These findings emphasize the need for integrating continuous mental health support with access to GAS
to address the mental health challenges of transgender women after genital GAS, while aiming to improve the
quality of life as the primary goal.

Keywords: Gender-affirming surgery, life satisfaction, mental health, self-harm, suicidal thoughts, transgender
women, vaginoplasty

INTRODUCTION
Sweden has one of the world’s longest-standing traditions of providing subsidized gender-confirming
[1]
medical procedures for individuals with trans experiences . The National Board of Health and Welfare in
Sweden permits patients diagnosed with gender dysphoria (GD) to receive gender affirmation treatment .
[2]
This multidisciplinary treatment includes conversational support, gender-affirming surgery (GAS),
hormone therapy, voice therapy, and hair removal . GAS is classified as highly specialized national
[2,3]
[4,5]
care , which ensures more equitable care, greater patient benefit, and secured accessibility for a growing
patient group . In Sweden, requests for transgender procedures have increased, with a threefold increase
[4-6]
[7]
in Gothenburg from 2013 to 2017 .
Genital surgery is recommended only after meeting specific criteria, including documented GD, legal age,
informed consent, controlled medical or mental health concerns, 12 months of hormone therapy, and living
in a congruent sex role for at least 12 months . These treatments aim to ensure comfort with one’s gender,
[8]
improve psychological well-being, and achieve self-fulfillment [9,10] .

The largest health survey among transgender persons in Sweden, conducted by Folkhälsomyndigheten,
found that 36% of respondents had thought about or attempted suicide in the past year, with higher rates
among younger individuals, before surgery . This is a markedly higher rate than the 3% of individuals aged
[11]
16 years and older in the general Swedish population who reported having considered taking their own lives
at some point during the past year . Similarly, numerous international studies have concluded that
[12]
transgender individuals experience significantly higher rates of suicidal ideation and attempts, as well as a
higher prevalence of mental health issues [13-15] . A US study revealed significant disparities in mental health
outcomes between transgender individuals and the general population. Forty percent of transgender people
have attempted suicide at some point in their lives, compared to 4.6% of the general US population . For
[16]
completeness purposes, Table 1 shows the prevalence of suicidal ideations in patients across various medical
conditions, diagnosis, and social populations [17-23] . Moreover, 48% of transgender individuals reported
experiencing suicidal thoughts during the 12 months preceding the survey, compared to 4% of the general
[16]
population, and 7% had attempted suicide, in contrast to 0.6% of the general population . Additionally, a
Canadian review showed that 55% of transgender individuals reported having had suicidal thoughts, with
[24]
29% attempting suicide during their lifetime . Similarly, a review in India confirmed that transgender
people are at a higher suicide risk compared to the general population .
[25]

Risk factors for suicide include previous suicide attempts, a family history of suicidal behavior, and mental
illnesses, such as mood disorders and schizophrenia . Other factors include impulsivity, anxiety, major
[26]
stress events, substance abuse involving alcohol or opioids, and chronic pain. Individuals with a history of
abuse or trauma, attention deficit/hyperactivity disorder, and those identified as LGBTQ+ are also at higher