Men in California who removed their genitals via transgender surgery later try to commit suicide at twice the rate as before undergoing the surgery, a study found.

“The overall rates of suicide attempts doubled after vaginoplasty,” or the removal of the phallus (penis) and simultaneous construction of a vagina-like opening, the study found, even while recognizing that “[r]ates of psychiatric emergencies are high both before and after gender-affirming surgery.”

Researchers examined data on 869 men who received a vaginoplasty, and 357 women who received a phalloplasty in California from 2012 to 2018, according to the study published in the American Urological Association’s peer-reviewed Journal of Urology.