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Perioperative Suicide Attempt Risk Before and After Gender-Affirming Surgery: A Person-Year Analysis of the U.S. Transgender Survey
Lee D. Yang^*, Melina Wald, Michael B. Amrami, Christine H. Rohde
Columbia Vagelos College of Physicians and Surgeons, New York City, NY

Background: Transgender and gender-diverse (TGD) individuals experience disproportionately high rates of suicidality. Gender-affirming surgery (GAS) is associated with improvements in dysphoria, but perioperative patterns of suicide attempt risk remain poorly characterized. Methods: Using the 2015 U.S. Transgender Survey, person-year datasets were constructed for respondents who had received GAS as an adult. Suicide attempts were assigned to person-years based on number of attempts and ages of first and last attempts using an Exclude model (retaining respondents with ≤2 lifetime attempts) and a Distribute model (distributing additional attempts evenly between first and last attempt ages). Logistic regression estimated annual suicide attempt odds across six periods relative to surgery (≥2 years before, -1 year, year of surgery, +1 year, 2-5 years after, >5 years after), adjusting for demographic, psychosocial, and transition-related covariates. Results: Among 5876 GAS recipients, 21% reported severe past-month psychological distress, 80% had past serious suicidal thoughts, and 40% had at least one past suicide attempt. The year prior to surgery trended towards significantly increased suicide attempt odds compared with ≥2 years prior (Exclude: OR 1.12, 95% CI [0.84-1.49]; Distribute: OR 1.12 [0.96-1.31]). Neither the year of surgery nor the first postoperative year demonstrated elevated risk relative to baseline. Long-term postoperative periods were associated with substantially lower suicide attempt odds (Exclude: OR 0.73 and 0.40; Distribute: OR 0.74 and 0.62 for 2-5 and >5 years following surgery, respectively). Conclusion: GAS was not associated with increased suicide attempt risk in the perioperative period. The highest risk occurred before surgery, potentially reflecting increasing gender dysphoria and barriers to accessing care. Suicide attempt risk declined substantially in the years following GAS. These findings support the importance of timely, equitable access to GAS and integrated mental health support throughout the surgical pathway.
Models adjusted for BMI, tissue expander size, and axillary irradiation. OR > 1 indicates higher odds with early exchange.

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