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Trans surgery ‘may be judged’ a mistake by future generations
The surgical removal of healthy breasts from girls who identify as boys is an experiment that future generations may judge harshly, a psychiatrist has warned.
Demand is rising in rich countries for this procedure, often rebadged as “top surgery” or “chest reconstruction” because even the word “breast” is seen as distressing for teenage girls and young women who want a masculine look.
Writing in the prestigious journal, Archives of Sexual Behavior, Melbourne psychiatrist Alison Clayton argues that transgender mastectomy may with time be seen as “dangerous medicine” like discredited past practices such as psychiatric lobotomy, which won a Nobel prize in 1949.
Dr Clayton highlights a similar lack of solid evidence for the benefits of trans mastectomy.
“It is surprising that clinicians and researchers claim chest surgery for youth (who are diagnosed with gender dysphoria) is an evidence-based intervention,” she writes.
She says only a handful of low-quality, short-term studies support claims of mental health benefits for trans mastectomy with teenagers, making this “an experimental treatment” in need of more rigorous, ethics-approved research.
Levi, an 18-year-old Melbourne trans man who says he was a former patient of the Royal Children’s Hospital, is one of the growing number of young adults to use the crowd-funding platform GoFundMe to raise money for top surgery; on Friday he had $2316 towards his $6000 goal.
There are an estimated 10,000-plus GoFundMe top surgery accounts internationally.
In her peer-reviewed letter, Dr Clayton anticipates readers rejecting any parallel between gender medicine for young people today and “cruel historical treatments” such as lobotomy.
She points out those abandoned treatments were “widely celebrated” at the time, including “uncritical press” coverage of “bold medical heroes with the courage to take ‘desperate remedies’ required to cure ‘desperate ills’.”
Meanwhile, researchers from the University of Melbourne and the influential RCH gender clinic suggest it may be ethical to begin offering trans mastectomy in children’s hospitals.
Under-18 trans mastectomy by private surgeons is thought to be uncommon but there is no good data.
In the Wiley journal Bioethics, the Melbourne researchers argue it is discriminatory to deny “chest surgery” to transgender male adolescents when it’s on offer to “other adolescent males” for distress over the condition gynaecomastia or “man boobs”.
The paper, with health ethicist Rosalind McDougall and RCH clinic director Michelle Telfer among the five authors, also cites “privacy” as a factor in favour of chest surgery.
“A transgender male with visible breasts has a body that discloses his transgender status to others, whether he wants this information known or not,” the authors write.
They say the “limited” research on chest surgery with adolescents suggests short-term mental health benefits. They found only two studies, with no long-term follow-up, and admit this makes a risk-benefit analysis difficult.
“However, as in many areas of healthcare, decisions about the care of current patients need to be made despite this uncertainty, based on the available evidence,” they say.
A recent survey of regretful “detransitioners” found it took on average almost four years before young people decided that medicalised gender change was a mistake.
On Tuesday Greens leader Adam Bandt presented to federal parliament a petition with more than 148,000 signatures urging full Medicare coverage for “gender affirming” surgery and hormonal drugs.
“(People) in need of gender-affirming surgery must pay a lot of money, up to $30,000, so they can finally have their outward appearance match how they truly feel on the inside,” the petition launched by Alyssa Kennedy-Whiting says.
Mr Bandt announced a plan to spend $15m a year to cover out-of-pocket expenses for gender affirming medicine. His office did not reply when asked how much of this would go to under-18 patients.
It is Greens policy to allow “transgender young people” access to hormones without a court order. In 2020, the Family Court stressed that judicial approval was sometimes necessary, for example if parents disagree about treatment for a minor.
In 2019, the RCH clinic director Dr Telfer told Victoria’s royal commission into mental health that “many” of her new, “post-pubertal trans male” patients wanted “chest reconstructive surgery”, and the hospital had the expertise but not the funds.
Dr Telfer said there were “no private surgical services available for (trans) adolescents under the age of 18 years in Victoria, leaving them with no option but to seek chest reconstructive surgery interstate or overseas should they be unable to manage their distress until they turn 18 years of age”.
“There is a significant gap in Victoria’s current health care system with the absence of public funding for chest reconstruction surgery despite the high demand for this evidenced-based intervention.”
The RCH-issued “Australian Standards of Care” for minors with gender dysphoria cover “top surgery”, and say the role of mental health professionals includes “counselling of the adolescent and their parents/caregivers on the available options for gender affirming surgical procedures such as chest reconstruction with referral where appropriate”.
Asked whether the RCH clinic referred its patients to private surgeons for top surgery or other “gender affirming” surgery, the hospital said on Thursday it was “not aware” of any such referrals. The clinic takes patients up to the age of 17.
In May, the ABC Australian Story program quoted Dr Telfer as saying: “We don’t provide any surgery (for gender clinic patients). To access surgery, one has to enter the adult system and that only occurs once someone’s over the age of 18”.
One of the studies shown to the royal commission by Dr Telfer included patients as young as 13 referred for top surgery by America’s biggest gender clinic run by physician Johanna Olsen-Kennedy at Children’s Hospital Los Angeles.
In that 2018 study, lead author Dr Olson-Kennedy said there was no previous data showing the effect of chest surgery on minors.
Yet three years before, she had already been promoting this procedure, claiming it was “easy, safe, available, and ‘absolutely lifesaving’,” Dr Clayton says in her peer-reviewed letter to Archives of Sexual Behavior.
Dr Olson-Kennedy, listed as a keynote speaker for next year’s Darwin conference of the gender clinicians lobby the Australian Professional Association for Trans Health, said in 2015 that genital surgery on minors, a more radical procedure than top surgery, was “on the horizon”.
She said “the difficulty of genital surgery is that it is surgical sterilisation and people get super worked up about that … it is a barrier we have to overcome and I think we are going to”.
Dr Clayton warns it may not be straightforward for clinicians to secure informed consent for gender affirming medicine.
“A necessary condition for (informed consent) is clinician honesty, which is not met if clinicians overstate the evidence base or act as ‘cheerleaders’ for transition,” she writes.
RCH says its multidisciplinary gender treatment is based on the “best available medical evidence” and follows “strict clinical governance standards”.
The Australian sought comment from Dr Telfer and Dr Olson-Kennedy.
NoCookies | The Australian
Trans surgery ‘may be judged’ a mistake by future generations
archived 26 Nov 2021 22:09:56 UTC
