Sex-reassigned persons had 2.8-fold higher overall mortality (aHR 2.8 – 95% CI 1.8–4.3). Suicide mortality was 19 times higher (aHR 19.1 – 95% CI 5.8–62.9). Suicide attempts increased 4.9-fold (aHR 4.9 – 95% CI 2.9–8.5). Psychiatric inpatient care rose 2.8-fold (aHR 2.8 – 95% CI 2.0–3.9). Female-to-males showed higher criminal convictions than female birth-sex controls. Male-to-females retained male-level criminality versus male controls. Female-to-males shifted to male-level criminality post-reassignment. Male-to-females had 6.6-fold higher crime risk than female controls. Violent crime patterns followed sex-typical trajectories post-SRS. Mortality risks held after adjusting for prior psychiatric morbidity and immigrant status. Suicide attempts far higher in male-to-females (aHR 9.3 vs females). Cardiovascular deaths moderately elevated in sex-reassigned persons. Cancer deaths borderline doubled. Risks persisted over 10-year follow-up. Sex reassignment alleviated dysphoria but not morbidity or mortality. Female-to-males elevated for violent convictions versus females. No significant substance abuse increase after adjustments. Accidents not significantly raised post-adjustment. Cohort included 191 male-to-females and 133 female-to-males. Follow-up averaged 11.4 years.