Anyways, on the first point of declining suicide attempt rates, there are three key points to keep in mind: (1) Just for those didn't read the study closely enough, when the authors say "gender -affirming surgery" they mean literally any surgery not just SRS. In this study 46% were chest surgeries, in which complications are rare and where outcomes often match expectations AND which tend to be better motivated. (2) Suicide attempts are not necessarily an accurate proxy for actual suicides. Attempted suicides are on average less serious than completed suicides as lower degrees of intentionality and commitment manifests in lower success rate. People who
really want to die tend to do a pretty good job of it.
(3) It's worth keeping in mind the possibility of regression to the mean type effects; this actually would provide a much better explanation for the pattern observed. Why does attempt rate decline monotonically over such a long time period? Recovery period for all surgeries is considerably less than a year. assuming the effect is real then what's causing the reduction from 2-3 to 4-5 years post-surgery? This is probably the bigger concern here.
It is generally expected that any "treatment" will result in an improvement in any transient outcome, since subjects tend to seek treatment when they are at or near their worst. Indeed, anecdotally it is extremely common to observe troons to develop an obsession with a particular anatomical feature
prior to seeking surgery, which can in turn lead to poorer mental well-being in the lead up to surgeries. In this case the problem is actually even worse, because we don't have a pre-surgery baseline. This is highly relevant since when surgeries go wrong, often the distress is front loaded. It's not hard to find anecdotal cases of SRS patients wanting to commit suicide due to complications, only for things to get better after revisions or even just after a year or two.
Anyways, moving on. There is an additional critique of studies of "gender-affirming" surgeries, which is that they are inevitably observational. There's obviously nothing that researchers can really do about this, since it likely isn't feasible (and there may be IRB issues) to perform an RCT. This kind of issue is present in basically all troon treatment studies. It's why theoretical frameworks and ethnographic evidence are so central to navigating the subject.
The salient consideration here is why do people seek these surgeries? I said previously that fixations with a given perceived flaw is common, especially where the patient has poor mental health. Sometimes this fixation is 'reasonable' in that their ability to function is clearly being impaired by it, e.g. masculine facial features making it impossible for them to "pass." In this case it's reasonable to expect that surgery would result in some improvement in their standard of living.
But, more often it is an essentially pathological fixation, where it's not at all obvious how or why a surgery is supposed to improve their life. Generally, they won't be able to explain themselves either, only that they are 'dysphoric' and when pressed the typical reaction is frustration; the torment of knowing that you have no real point. This is a good example:
This is an 18 year old girl who believes herself to be "a man," this belief she developed over a period of ~3 months late in the summer of 2020. She is quite feminine and likely heterosexually-inclined although she has significant difficulties in understanding feelings of sexual attraction, this is not surprising given her highly probable co-morbid autism. Note she doesn't actually have a reason that is explicable to her parents, or to anyone else really. She does not pass, indeed she (in another post) admits that she's "never really been gendered correctly." A mastectomy wouldn't do much to change this. Her attempted justification is a sort of "Alien limb" theory, needless to say, there is no evidence that such a thing could be anything other than psychosomatic; a consequence of her very fixation on her breasts. Again, it would be worth noting that her distress over her breasts has worsened over the past 9 months prior to that she had had long term general anxiety.
The question is thus: what is the course of such a case and how ought it be treated? It seems more than plausible that she wouldn't experience panic attacks over her breasts if she had them surgically removed. However, we might also ask whether her fixation might not be cured by time. This is why etiological considerations are important when considering these sorts of psychological problems. It is also why observational data is difficult to interpret. Etiological considerations also help us understand why some studies pull up curious trends, for example this study
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5440516/. The choice quote is:
But with the caveat:
Which substantially devalues the entire study, but we could still take it as weak evidence for a "honey-moon" effect consistent with exactly the kind of pathological fixation that I've described. Returning to the 18 year old girl, wouldn't we expect something like that for her too? A short term high, that dissipates as in truth nothing much has really changed. Most likely, we'd expect that her deeper problems will continue to dance around and haunt her, to surface new obsessions, perhaps next year it will be her genitals, maybe then her figure. Maybe, she will realize that the year past was nothing, but hysteria -- a senseless groping for a solution to her woes.
That's the real specter haunting over all discussion over the therapeutic benefits of these surgeries, we do not know whether the ideologies and belief systems that propel so much of this; that make these desires
feel important and real, will last. This particular moment rides on the crest of empty, indefensible nonsense beliefs that have come to be widely held, but it's the nature of truth that it is always true, and so will eventually emerge. Falsehoods by contrast are always dependent on the peculiarities of their reigning moments.
That's not to say that there have not always been people who can be described as "trans" nor that such persons won't exist in the future, but that the demographics from where they are drawn have and probably will change and that makes things difficult. It also means that at the non-individual level, the way we treat troonism and all its manifestation will itself alter these things.
www.researchgate.net
