All this, and for
what?
The world’s largest dataset on patients who have undergone sex-reassignment procedures reveals that these procedures do not bring mental health benefits. But that’s not what the authors originally claimed. Or what the media touted.
In October 2019, the American Journal of Psychiatry published a paper titled, “Reduction in Mental Health Treatment Utilization Among Transgender Individuals After Gender-Affirming Surgeries: A Total Population Study.” As the title suggests, the paper claimed that after having had sex-reassignment surgeries, a patient was less likely to need mental health treatment.
Well, over the weekend, the editors of the journal and the authors of the paper issued a correction. In the words of the authors, “the results demonstrated no advantage of surgery in relation to subsequent mood or anxiety disorder-related health care.”
But it’s actually worse than that. The original results already demonstrated no benefits to hormonal transition. That part didn’t need a correction.
So, the bottom line: The largest dataset on sex-reassignment procedures—both hormonal and surgical—reveals that such procedures do not bring the promised mental health benefits.
In fact, in their correction to the original study, the authors point out that on one score—treatment for anxiety disorders—patients who had sex-reassignment surgeries did worse than those who did not:
individuals diagnosed with gender incongruence who had received gender-affirming surgery were more likely to be treated for anxiety disorders compared with individuals diagnosed with gender incongruence who had not received gender-affirming surgery.
You would think patients suffering from gender dysphoria would want to know that.
What led to the correction? A deluge of criticisms and letters to the editor.
One of the first scholars to raise questions about the original study was Mark Regnerus, a professor of sociology at the University of Texas at Austin.
Writing at Public Discourse (the Journal of the Witherspoon Institute, which I edit), Regnerus praised the study for having such a robust dataset. But he pointed out oddities in the way the authors presented the results to the public, and which results the media touted.
Here is the article quoted above, and
here is the academic criticism itself.
Some highlights:
- The length of time since starting HRT had no effect on the likelihood of seeking mental health treatment ("treatment of mood or anxiety disorder, or hospitalization after a suicide attempt") in 2015. People who'd started HRT two months ago would be just as likely as those who'd started two years ago. So it doesn't seem to pay off over time.
- The authors claimed they found that for every year post-surgery, patients experienced a statistically significant linear 8% reduction in the odds of being treated for a mood or anxiety disorder in 2015. But this was apparently calculated from the difference between patients in their first nine years after surgery and patients who'd had surgery at least ten years ago. For each "years since surgery" cohort up to nine years, the rate of seeking mental health treatment in 2015 was about 35%. For the ten-plus-years-ago cohort, it drops to 21%.
- Yet there were over 30 times as many "under two years" patients represented as "over ten years" - 574 vs. a mere 19. Four out of the 19 sought mental health treatment in 2015. If only three more of these did, there would appear to be no statistically significant effect! And if three fewer did, they would've found a significant 12% decrease each year! A "significant" population-level conclusion has been drawn hinging upon the outcomes of as few as three people! What should really catch our attention is the similar treatment-seeking rates among all the other cohorts. (Longitudinal conclusions from cross-sectional data should be taken with a grain of salt anyway. It's possible that this less-than-a-decade cohort is more mentally ill than the old-timers, now that the social contagion is attracting vulnerable people who would've never thought to transition otherwise.)
- This critic also calculated the "number needed to treat," a measure of clinical impact comparing the odds ratio of an event (in this case, seeking mental health treatment) in those with versus without an intervention (in this case, "perioperative" diagnosed dysphoric people vs. patients at least two years after SRS). For reference, a NNT under 10 is normally considered good evidence that procedure is worth it. Here, it's a whopping 49: the effect on the odds ratio is so small that we'd need at least 49 surgeries to be performed in order to see one trans person not seek mental health treatment in a given year.
- One major limitation he points out: this is just from a full national registry of the living. We can't know how many SRS patients have been lost to suicide.
If we want to know whether SRS improves anything, this is as good as it gets.
Patient satisfaction surveys are important data, but in this case, they're like asking non-recovering people with eating disorders whether they regret losing weight and want to gain weight back - absolutely not! They would hate to weigh more when they still want to weigh less; irrational levels of suffering feel justified in the name of weighing less. It takes a lot to get to the point of realizing the suffering isn't worth it and never was. It's even harder for trans people to admit it after all their sunken costs. And we with EDs knew we'd be celebrated if we chose to recover and could become healthier and happier like so many others. We knew on some level that this wasn't the way to live, and we'd just need a bigger push to choose to leap to the other side. But it's
transition that's celebrated the way ED recovery is, not detransition, and there's no narrative of a healthy, happy post-detransition life. Of course they're going to claim they did what's best for them. That's the only way to cope!
Yet even when someone with an ED sincerely claims she prefers her current weight over her old weight, we can see she's become a shell of her old self, and she knows it. Her life has become more complicated, more socially and emotionally difficult, and more prone to end in suicide. Similarly, when mentally ill people seek these surgeries, they're objectively no more likely to live mentally healthy lives, according to the data - just mentally ill lives with additional complex needs.
We might tolerate mental health outcomes like this for a money-grubbing cosmetic procedure. If an adult is willing to pay to be an unhappy 6.5/10 rather than an unhappy 6/10, whatever. But for highly invasive, potentially function-destroying surgeries that lead to more complicated and uncertain physical needs, trying to imitate the impossible, all done
in the name of improving mental health? There should be no more question about whether this is ethical.
The two factpills commonly shared to make this point are
- The Dhejne et al study, a previous look at the full Swedish registry of the transgender population, finding that post-SRS individuals commit suicide at a far higher rate than the general population. This says nothing about whether transition works and was never meant to. Maybe they would've committed suicide even more had they not had access. TRAs and Cecilia Dhejne herself have raised this point. When you put it in more familiar, less ideological terms - Veterans who get treatment for PTSD commit suicide at a higher rate than the general population, so I guess they don't need treatment after all - it's easy to grasp why this isn't a fair comparison.
- "41%" - No, 41% of the transgender population does not die of suicide. Think for a second and that's a ridiculous figure. A survey from the Williams Institute found that 41% of transgender respondents had attempted suicide. Dead people can't take surveys. The survey found that this was similar for those who had undergone surgeries and those who hadn't (two separate groups, not the same people before vs. after), but it didn't ask whether these attempts were before or after transitioning. Not going to bother to look into it, but I've heard that this figure hasn't replicated anyway, that more methodologically sound studies have found a lower suicide attempt rate similar to the LGB.
This isn't even the only study that directly finds no mental health improvement (Regenerus references a few more), but as of now it seems to be the most thorough.
Maybe the real number worth spreading is 48. For every surgery in this mentally ill population that successfully appeased the mental illness, 48 were done for nothing. And here we see them.
) ie. the mangled and whittled down remains of his bell end, actually rotted and dropped off at some point and he's either lying or in denial about it just having "skin grown over it."
