Study: Trans kid’s gender implicit; govt report condemns conversion therapy
October 17, 2015
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January 2, 2016

Fact check: study shows transition makes trans people suicidal

A 2011 Swedish study proves that trans people are more suicidal due to transition, are likely rapists and that trans women exhibit male socialization. Or does it?

By Cristan Williams
@cristanwilliams

 

Perhaps you’ve heard that a Swedish study found that trans people who access medical care are more likely to commit suicide. Writing for the Wall Street Journal, former Johns Hopkins chief psychiatrist and anti-LGBT activist Dr. Paul McHugh cited a Swedish study to make the following fact assertion:

A 2011 study at the Karolinska Institute in Sweden produced the most illuminating results yet regarding the transgendered [sic], evidence that should give advocates pause. The long-term study—up to 30 years—followed 324 people who had sex-reassignment surgery. The study revealed that beginning about 10 years after having the surgery, the transgendered [sic] began to experience increasing mental difficulties. Most shockingly, their suicide mortality rose almost 20-fold above the comparable nontransgender population. This disturbing result has as yet no explanation but probably reflects the growing sense of isolation reported by the aging transgendered [sic] after surgery. The high suicide rate certainly challenges the surgery prescription.

McHugh’s fact assertions were uncritically repeated by The American Conservative, Lifesite, The Christian Post, The Washington Times, Newsmax, One News Now, The Libertarian Republic, and Fox News. While McHugh’s misrepresentation of the study was debunked, the “trans medical care = suicide” meme was born. Since McHugh’s Wall Street Journal article, this meme has managed to worm it’s way into everything from news outlets to comment sections.

Echoing McHugh, TERF opinion leader, author and lecturer Dr. Sheila Jeffreys wrote in her 2014 book, Gender Hurts:

There is still a remarkable absence of recent studies that follow up those who have SRS to find out whether this treatment is efficacious despite the great expansion of the industry of transgendering [sic]. A 2011 long-term follow-up study from Sweden found that sex reassignment was not efficacious because after sex reassignment transgenders [sic] had higher risks of psychiatric morbidity, suicidal behaviour and mortality overall than the general population, when using controls of the same birth sex. The study concluded that ‘sex reassignment’ may alleviate ‘gender dysphoria’ but ‘may not suffice as treatment for transsexualism, and should inspire improved psychiatric and somatic care after sex reassignment’ (Dhejne et al ., 2011 ). 1

Jeffreys’ source for “factual material” on trans issues, Linda V. Shanko (AKA “Gallus Mag”) of Gender Trender wrote:2

The only long-term study of transgender outcomes concluded that “Male to Female” transsexuals retain male-pattern criminality, including crimes against women. Are all transwomen predators? Of course not: They are predators at exactly the same rates as any other males. Now that the public is starting to pay attention, that genie won’t be going back into the bottle anytime soon. What is once seen cannot be unseen.

TERF3 Attorney Elizabeth Hungerford of Sex Not Gender cited the study as evidence of the often appealed to yet never quantified “male socialization” TERFs assert trans women forever exhibit. Hungerford said the study “vindicates the experience of many women that transwomen as a group retain–or are unable to fully discard– some male pattern behaviors associated with male socialization… The criminal conviction rates documented in this study provide empirical evidence for this view.”

Fact Checking the Hyperbole

I’ve only scratched the surface of the amount of anti-trans hyperbole that cites the 2011 study titled, Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden by Dr. Cecilia Dhejne, et al. I contacted Dhejne after I witnessed her work used to support the claim that trans women are rapists and she agreed to the following interview:

Cristan Williams: How did you first hear about trans people and when was it that you first met a trans person?

Cecilia Dhejne: I don’t recall when I first heard about someone being transgender, though I think I first became aware of the existence of trans people as a teenager. In 1985 I took classes in sexology and around that time I also participated in a Nordic Association for Clinical Sexology meeting where I heard Dr. Friedeman Pfäflin speak about his work with trans people in Germany. Additionally, at the same conference I was able to hear Dr. Espen Esther Pirelli Benestad talk about hir experience. I began working with trans people clinically in 1999 and from there, I started up the gender team in Stockholm.

Williams: Would you please talk about how you became interested in researching trans health outcomes?

Dhejne: In 1999 when I started the Stockholm gender team, we were conducting diagnostic evaluations to help trans people start their social and medical transition. Our team included psychologists, and a social worker, and we worked in close collaboration with  endocrinologists, plastic surgeons as well as speech and language pathologists at the Karolinska University Hospital.

At that time, the need for quality research was obvious to our team; we wanted our work to be evidence based. For instance, the endocrinologist had continued to see patients post-transition and while many reported that they were quite happy, others reported difficulties. We therefore wanted to better document, measure and understand the needs of our patient population.

If we found a need for a more robust service delivery model to increase treatment efficacy, that would invariably impact programmatic budgets and, of course, those changes would need to be justified by a documented need. Moreover, data driven treatment models can present opportunities to publish findings which, in turn, helps increase the overall quality of evidence-based trans care.

Williams: Before I contacted you for this interview, were you aware of the way your work was being misrepresented?

Dhejne: Yes! It’s very frustrating! I’ve even seen professors use my work to support ridiculous claims. I’ve often had to respond myself by commenting on articles, speaking with journalists, and talking about this problem at conferences. The Huffington Post wrote an article about the way my research is misrepresented. At the same time, I know of instances where ethical researchers and clinicians have used this study to expand and improve access to trans health care and impact systems of anti-trans oppression.

Of course trans medical and psychological care is efficacious. A 2010 meta-analysis confirmed by studies thereafter show that medical gender confirming interventions reduces gender dysphoria.

Williams: Earlier this year an Ohio news outlet cited your study to support the following fact assertion as part of an argument for denying trans people equal rights:

Would the proposed ordinance truly advance the public good and the dignity of our transgender citizens? Significant evidence shows that, after sex reassignment, transsexuals “have considerably higher risks for mortality, suicidal behavior, and psychiatric morbidity than the general population,” according to a long-term cohort study in Sweden reported in 2011.

If current treatment, that is, psychiatric support in dressing and living as the opposite sex and ultimately sex-reassignment surgery, does not benefit transgender individuals, then neither will access to the preferred bathroom. Rational thinking concludes that the proposed ordinance benefits neither the transgender individual nor the general public.

The story references your 2011 study. This study states, “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). 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).” However, those citing your work never seem to note that your study also includes the following very large caveat:

It is therefore important to note that the current study is only informative with respect to transsexual 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. As an analogy, similar studies have found increased somatic morbidity, suicide rate, and overall mortality for patients treated for bipolar disorder and schizophrenia. This is important information, but it does not follow that mood stabilizing treatment or antipsychotic treatment is the culprit.

Moreover, people using your study to support spurious anti-trans fact claims also seem to not understand that your study findings aggregate two chronological groups. In simple language, would you please explain what the above paragraph means and what your study findings show for those trans people transitioning after 1989?

Dhejne: The aim of trans medical interventions is to bring a trans person’s body more inline 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.

Williams: Would you please comment on the below examples of the way your work is being used and represented within the media:

Source: Washington Post

Source: TownHall

Source: Dr. Paul McHugh via LifeSite

Source: Medium

Source: The Dr. Drew Show as noted on Twitter

Dhejne: People who misuse the study always omit the fact that the study clearly states that it is not an evaluation of gender dysphoria treatment. If we look at the literature, we find that several recent studies conclude that WPATH Standards of Care compliant treatment decrease gender dysphoria and improves mental health.

Williams: Other anti-trans activists have seized upon your study to make certain fact assertions about a supposed inherent criminal nature trans women possess, as exemplified by the following twitter exchange:

Using simple language, would you please speak to those using your work to support the fact assertion that trans women and cis men are alike when it comes to perpetrating incidences of rape, murder, torture, etc? In other words, would you please clarify the following:

A.) As to the “male pattern regarding criminality” your study reviewed, would you please speak to whether your sample is representative of the trans population as a whole?

B.) Does your study support the notion that trans women, epidemiologically speaking, are likely rapists?

C.) Did your study show that trans women, epidemiologically speaking, are just as likely to rape cis women as cis men?

D.) In the way that your study’s morbidity and mortality sample is reviewed as two chronological groups, did you use the same chronological metric for your criminality sample and, if so, what did you find?

E.) Is your “male pattern regarding criminality” a simple comparison of percentages of overall conviction rates between cis males and trans women or is it a quantitative conviction category comparison between the two? In other words, trans women (who may experience around a 50% unemployment rate4 5 6) will generally bear a greater burden of convictions associated with social oppression, poverty and homelessness (squatting, loitering, panhandling, prostitution and non-violent crimes such as drug use and petty theft) than cis men. When your study looked at the “male pattern regarding criminality” between cis men and trans women, are you saying that your data shows that cis men are being convicted for crimes associated with oppression, poverty and homelessness at a rate similar to that found in the trans population?

Dhejne: The individual in the image who is making claims about trans criminality, specifically rape likelihood, is misrepresenting the study findings. The study as a whole covers the period between 1973 and 2003. 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. This means that for the 1989 to 2003 group, we did not find a male pattern of criminality.

As to the criminality metric itself, we were measuring and comparing the total number of convictions, not conviction type. We were not saying that cisgender males are convicted of crimes associated with marginalization and poverty. We didn’t control for that and we were certainly not saying that we found that trans women were a rape risk. What we were saying was that for the 1973 to 1988 cohort group and the cisgender male group, both experienced similar rates of convictions. As I said, this pattern is not observed in the 1989 to 2003 cohort group.

The difference we observed between the 1989 to 2003 cohort and the control group is that the trans cohort group accessed more mental health care, which is appropriate given the level of ongoing discrimination the group faces. What the data tells us is that things are getting measurably better and the issues we found affecting the 1973 to 1988 cohort group likely reflects a time when trans health and psychological care was less effective and social stigma was far worse.

There you have it. To be clear:

  • No, the study does not show that medical transition results in suicide or suicidal ideation. The study explicitly states that such is not the case and those using this study to make that claim are using fallacious logic.
  • No, the study does not prove that trans women are rapists or likely to be rapists. The “male pattern of criminality” found in the 1973 to 1988 cohort group was not a euphemism for rape.
  • No, the  study does not prove that trans women exhibit male socialization. The “male pattern of criminality” found in the 1973 to 1988 cohort group was not a claim that trans women were convicted of the same types of crime as cis men.

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  1. Jeffreys, Sheila. “Doing Transgender: Really Hurting.” In Gender Hurts: A Feminist Analysis of the Politics of Transgenderism, 60-61. NY, NY: Routledge, 2014.
  2. “I am grateful, too, to the new wave of radical feminism both online and offline. Radical feminist bloggers such as Gallus Mag from ‘GenderTrender’ (n.d.a) and Dirt from ‘Dirt from Dirt’, among others, have provided invaluable factual material, references and ideas on their blogs, without which it would have been harder to write this book.” – Ibid, viii.
  3. It’s just that I DO want to exclude some trans people from some situations, depending on the context… So yeah, I am a TERF. And I’m not ashamed. At all.” – Hungerford, Elizabeth “June 11 at 2:47pm.” Facebook. June 11, 2015. Accessed June 19, 2015. http://i.imgur.com/GVrakZz.png
  4. 37% Unemployment: Xavier, J., Bobbin, M., & Singer, B. (2005). A needs assessment of transgendered people of color living in Washington, DC. International Journal of Transgenderism, 8(2/3), 31-47. doi: 10.1300/J485v08n02_04
  5. 67% Unemployment: Kenagy, G. (2005). The health and social service needs of transgender people in Philadelphia. International Journal of Transgenderism, 8(2/3), 45-56. doi: 10.1300/J485v08n02_05
  6. 42% Unemployment: Kenagy, G., & Bostwick, W. (2005). The health and social service needs of transgender people in Chicago. International Journal of Transgenderism, 8(2/3), 57-66. doi: 10.1300/J485v08n02_06
Cristan Williams
Cristan Williams
Cristan Williams is a trans historian and pioneer in addressing the practical needs of the transgender community. She started the first trans homeless shelter in the South and co-founded the first federally funded trans-only homeless program, pioneered affordable healthcare for trans people in the Houston area, won the right for trans people to change their gender on Texas ID prior to surgery, started numerous trans social service programs and founded the Transgender Center as well as the Transgender Archives. Cristan is the editor at the social justice sites TransAdvocate.com and TheTERFs.com, is a long-term member and previous chair of the City of Houston HIV Prevention Planning Group.
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  • bat

    This was very interesting and informative. I was glad to hear from Djehne about what conclusions she feels one can fairly make about her work. It’s so frustrating that people have twisted the statistics about crime to imply something about trans women’s rate of violence or their character.

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  • sorry liberals, you just can’t change reality

    “No, the study does not show that medical transition results in suicide or suicidal ideation”.

    You mistake causation with actuality.

    Transgenders enjoy up to 41 percent suicide rates.

    Transgenders that transition also enjoy high suicide rates. Not as high as the non transitional, but significantly higher than the baseline.

    And you mention that mental health access seems to be improving this.

    I have to ask, what does better access to mental health service do for transgenders before they allow their bodies to be surgically and hormonally altered??

    Does this also elicit the same results as mental health care access after surgery and hormones?

    If it does, then the doctors need to lose their for operating on the untreated mentally ill.

    Granted, some individuals do fine, like the guy I worked with. We used to discuss how irritating it was to come down with male pattern baldness, and how God had a wicked sense of humor.

    • Are you trying to be incredibly obtuse in order to play identity politics, or did you make this comment because you’ve really not put critical thought into this?

      • Philip

        One part of Pat Orsban’s comment made sense: Is mental health counseling equally effective before/without transition surgery as it is with/after transition surgery? If the answer is “yes,” then it suggests that the problem is psychological and psychiatric—not to be treated with surgery.

        • But that presumes this exact question hasn’t been intensely studied, published, and verified. Even Drs. Zucker and Blanchard repudiate the postulation you make.

          • Philip

            The 2010 meta-analysis you cited above, in its abstract, says that almost none of these studies have control groups and that “very low quality evidence suggests” that sex reassignment surgery improves quality of life, etc., for a transsexual person. Could you be more specific about where this question has been so thoroughly answered in favor of gender reassignment surgery?

          • With regard to the trans pop, are you making an assertion about α, p, or ŷ… or are you merely positing an Ho?

            Would you mind posting the DOI of the analysis?

          • Philip

            You claimed that the question above had been decisively answered. I went back through your article and found the relevant analysis that you cited (http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2265.2009.03625.x/abstract) which suggested that _almost nothing_ had been decisively answered.

            My question still stands: If mental health counseling for those with transgender dysphoria equally effective for those who do not have reassignment search as it is for those who get reassignment surgery and then receive counseling? If the answer is affirmative, then you have your “null hypothesis”: sex reassignment surgery may not be an appropriate treatment for gender dysphoria. The only fact confirmed—that more care is needed for those who undergo reassignment surgery—already points to the need for psychiatric intervention. My question is just the next step: maybe one only needs psychiatric intervention; maybe all of the great effects that one assumes are coming from surgery are actually coming from something other source like counseling. The lack of controls (groups undergoing surgery who do or do not receive counseling) means that we cannot decisively say anything about the benefit of the surgery. It seems, rather, that because the surgery on its own is not an effective treatment, then it might not be a treatment at all.

          • Tamsin Mc Cormick

            You would have to ask as many post-op transgender women if the surgery did more for them than previous counselling alone.
            You would also need to ask if they needed much counselling after surgery. — I didn’t and it was the surgery plus my HRT that
            gives me the most benefit to this day .

          • That would not be acceptable to Philip it is qualitative and not quantitative data. Philip is suggesting that the only way we can know if people with a gender dysphoria agree to be in a long-term study where medical intervention is randomly withheld as a control. Certainly Philip understands that such a thing is unethical in the extreme; they’re merely falling back on the claim as a way to tacitly support their belief that decades of clinical observations leading to a set of best practices must somehow, someway indicate that medical interventions should be abandoned in favor of reparative therapies.

          • Ah, I see. You seem to be conflating controls with CI, I² and drawing erroneous conclusions.

            Qualitative self-report and/or ethnographic studies are generally, from a pure data perspective, of lesser value than quantitative data. This does not mean that decades of continued peer-reviewed qualitative self-report data is incoherent, as you suggest. The ethical implications of randomly withholding Tx to a GD individual in order to produce a quantitative dataset makes it unlikely that the type of research you’ve moved your dialectical goalpost to can be attained… nor should it. That the unethical research you now want will never (hopefully) be sanctioned, does not, in any way, suggest that the decades of multiple complementary QQL assessments indicate the reality of some imagined huge p-value.

            So, instead of asserting a postulation, please plainly state your Ho.

          • Philip

            Typo correction. The restated question above should say, “IS mental health counseling for those with transgender dysphoria equally effective for those who do not have reassignment SURGERY as it is for those who get reassignment surgery and then receive counseling?

          • Philip

            Cristal, I am not demanding unethical experimentation, nor am I conflating what qualitative and quantitative analyses can accomplish. My point was in response to your claim that the answer to my question above had been “verified.” Nothing has been verified, and the question still stands. I am not drawing erroneous conclusions; I am saying that you are overstepping what the research *does* say: at best, sex reassignment surgery needs psychiatric or psychotherapeutic follow-up; and at worst, it deepens the need for psychiatric or psychotherapeutic intervention, which is the actual treatment. The common element of a psychological treatment suggests that sex reassignment surgery may not be a treatment as such.

            The null hypothesis is that there may be no correlation between sex reassignment surgery and the longterm psychic wellbeing of individuals with gender dysphoria. (The research program would involve having a large group of people who have received similar diagnoses of gender dysphoria, and would establish parameters for following those who had opted to undergo sex reassignment surgery with counseling and those who had opted for counseling only.)

          • I think you misunderstood what I said. I DID NOT say that you were conflating qualitative and quantitative data. I said that you seemed to be conflating controls with CI, I². As for your null hypothesis, the study we’re talking about rejects your null hypothesis.

        • Philip

          Another typo: Cristan. Sorry.

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  • T. E.

    Hi Cristan,
    It appears that Dr. Cecilia Dhejne’s study has been misrepresented, which is unfortunate. Thank you for the clarification, but I do have a question for you that is a bit out of scope…do you believe that trans people should be “tolerated” or “accepted?” If so, what arguments are good for supporting this point?

    Thank you

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  • Anna Clevedon (Formerly James Alistair Clevedon)

    How does writing a lot about how you don’t agree with the study – disprove the findings of the study?
    If you want to disprove it you need facts, not the opinions from people who don’t like its findings, no matter how many letters they have after their name

    • Oh, this comment is absolutely GOLDEN! LOL!

      The study’s own author tells you in this article that the ways her study is being quotemined is contrafactual, SHE has to somehow “prove” to you that her own study doesn’t say what transphobes say it does.

      • Philip

        Again (see my unanswered comment above) the article says much about what the study does *not* say. Could you inform us about what the study *does* say? What are its positive findings?

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  • Philip

    The article ends with what the study does *not* show.

    Can you remind us what it *does* show?

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  • Tamsin Mc cormick

    It’s all a bit like male pattern hair loss in women !!
    Not all women experience it and not all men experience it.
    There may well be a few criminals who are transsexual women. I know of one who was well into crime and now works as a transsexual activist . That doesn’t prove
    that all transsexual women will become activists after a life of crime prior to their transitioning.
    This Mc Hugh person and others need to improve their academic thinking to a level that will endorse their qualifications . As it is all they are managing to prove is their own poverty of any real intellect .

  • Think you have that all wrong, they die cause they get no options or care.

    • Kody

      That’s actually… Exactly what she said here.

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  • Jamie

    I’m transfemme, but I find it extremely frustrating that you didn’t ask and Dhejne did not clarify exactly how MtF criminality compared to male criminality post-1989 in quantitative terms (with the documentation too back it up, since the published study does not divulge those specifics). I get the impression that even in the group after 1989 criminality was still significantly higher than for natal females and that’s not unimportant.

    Also, while I appreciate that you conducted this interview, Cristan, some of your language is a bit loaded in a way I find unfair and and unhelpful. When I’ve heard “TERFS” cite this study re:violence, it’s never been to suggest that trans women are “probable rapists” but merely that they retain male pattern criminality, which is a question worth looking into, and I wish there was more research on it.

    • [ I get the impression that even in the group after 1989 criminality was still significantly higher than for natal females and that’s not unimportant.]

      I think that’s an inference you’re bringing to the subject.

      [When I’ve heard “TERFS” cite this study re:violence, it’s never been to suggest that trans women are “probable rapists” but merely that they retain male pattern criminality…]

      You don’t read GenderTrender’s comment threads much, do you?

      […which is a question worth looking into, and I wish there was more research on it.]

      The study’s author has *just* told you that they don’t “retain male pattern criminality.” I find it interesting that you seem to rhetorically cling to this notion.

      As to seeing if widely varied groups are “more likely” to be abuses, would you also support looking into seeing if “intersex women” are more likely to rape than “cis women”? If we’re going to do that, would not it then be just as important to look into other social categories… like, are “abuse victims” more likely to sexually abuse others? Why not look at whether people with “mental illness” are more likely to sexually abuse others? What about other categories? Shall we institute social control policy based upon these “findings”?

      My point is that the social implications you seem eager to embrace in order to ontologically define groups of diverse and varying populations is nothing more than epistemological demagoguery.

      • Jamie

        That they didn’t exhibit male-pattern criminality is not the same thing as saying they exhibited female-pattern criminality. Hello? It could be that the trans woman pattern of criminality–or, rather, convictions in this case–is in-between these averages. That would be worth knowing.

        It’s been a while since I made the original comment and read the study, so my memory is a bit fuzzy, but I believe the inference I made about even post-89 trans women likely having significantly higher criminal convictions than cis women was based on a reasonable interpretation of the averages cited in the study. IIRC, the figures would pretty much have to indicate either that pre-89 trans women would have had to have had crime convictions waaaay above those of cis men with a bizzarely sharp drop post-89 (and it seems unreasonable to posit a shift *that* huge as being the likeliest case) OR that post-89 still had much higher rates of conviction than cis women.

        I’ll let the mental gymnastics in your last paragraph be, short of remarking that if you believe pursuing that information to be worthless or irrelevant or oppressive, then that sure makes this whole piece looks a bit disingenuous and questionably trustworthy and calls into question whether your failure to inquire about how post-89 convictions quantitatively compared was an innocent omission or not.

        • Jamie

          And my comment re: TERFs is based mostly on pretty extensive interaction I used to have with them in the Discussing gender critical and gender identity group on facebook, which hosts heavyweights like Elizabeth Hungerford. They’re a pretty sour, dogmatic, one-sided bunch (which is why I eventually left the group, when it became clear that extremely little bridge-building was being sought), but I do not think the great majority would cast trans women as *probable rapists* but as being equally threatening as men or almost so. That means a much higher risk, but that is certainly not the same as saying a probable risk.

          • Jamie

            *as saying probable offenders.

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  • Nicole

    Hi, I was just wondering, does the latter cohert not having a male criminality pattern mean that they have a female criminality pattern, or do they have their own unique pattern?

    • She found no difference between cis and trans women. I would guess that she would say that there is no “statistically significant” difference; which, of course means there might, in fact, be some slight frequency “difference” up or down, but not in any meaningful way/outside the margin of error.

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