Clinician asks: Is the gender-affirmative model dangerous?

Written by Genspect parent Lynn Chadwick.

Australian psychiatrist Alison Clayton has just published a scathing, well-researched, and peer-reviewed letter to the editor in the Archives of Sexual Behavior, The Gender Affirmative Treatment Model for Youth with Gender Dysphoria: A Medical Advance or Dangerous Medicine?, comparing the current model of affirmative care for gender dysphoria to documented dangerous, even abusive, medical procedures that, in their time, were well received and applauded by the scientific community as well as the general public. She references in particular the abuses of lobotomies (which won a Nobel prize in 1949) and malaria fever therapy, which was claimed to be successful in treating advanced cases of neurosyphilis in the early 20th century.

Clayton begins:
“A knowledge of the history of medicine enriches our thinking about contemporary medical practices. The twentieth century saw many medical advances. It also saw multiple examples of what may be called dangerous medicine. Such medicine is invasive, risky, and lacking a rigorous evidence base, but is enthusiastically embraced and celebrated by members of the medical profession and the public. Then, with the passage of time, such medicine is viewed with more scepticism. It is recognized as not being as beneficial as claimed and as causing more harm than acknowledged. It comes to be mostly seen as misguided, occasionally even criminal. In this Letter, I use a historical frame to background a discussion of the gender affirmative treatment approach for youth with gender dysphoria (GD youth), particularly focusing on masculinizing chest surgery. I ask: Is this approach a medical advance or is it a contemporary example of dangerous medicine? My hope is that the ideas expressed in this Letter will helpfully contribute to the debate about this complex and controversial area of medicine.”

A detailed historical context of these regrettable treatments follows. Clayton then references the current enthusiasm for masculinizing chest surgery performed routinely for young women who identify as male. Clayton explains that the evidence base for such enthusiasm is low, for example:

“Olson-Kennedy et al. (2018), stating there were no prior “data documenting the effect of chest surgery on minors,” undertook a cross-sectional retrospective survey of 68 postsurgical transmasculine youth (72% of the eligible postsurgical population). In 49%, the surgery had been undertaken at younger than 18 years of age, with the youngest being age 13 and the oldest age 24. At the time of the survey, only 14% of the participants were more than 2 years post-surgery. The postsurgical participants were compared with a convenience and non-matched comparison sample of nonsurgical transmasculine youth. The outcome, chest dysphoria, was measured with an unvalidated scale and indicated that the postsurgical participants had less chest dysphoria than the nonsurgical participants. Another notable finding was that testosterone use was associated with increased chest dysphoria. It is important to note that, a few years prior to this study, Olson-Kennedy (2015) had already been promoting chest surgery for minors, describing it as easy, safe, available, and ‘absolutely life-saving.’ This last claim seems contradictory to the 2018 paper which stated there were no previous data on chest surgery in minors. Olson-Kennedy (2015) also stated that ‘full gender-affirming surgery’ in minors was ‘on the horizon’ and noted ‘the difficulty of genital surgery is that it is surgical sterilization and people get super worked up about that…it is a barrier we have to over-come and I think we are going to.’ It seems this barrier is already being over-come, as it has been reported that in the United States genital surgery is being undertaken on GD minors, as young as 15 years old (Milrod & Karasic, 2017).”

Clayton continues: “The studies have significant methodological limitations which mean they are at critical risk of bias and cannot show that chest surgery is causally associated with short-term improved mental health outcomes. They do not provide any information on long-term outcomes and regret rates.”

Moreover: “How will masculinizing chest surgery for GD youth be viewed by future generations? The enthusiasm for it, despite the lack of a rigorous evidence base, suggests that it may be seen as another example of what Valenstein called ‘great and desperate cures.’ Valenstein noted that uncontrolled therapeutic experimentation in medicine is common and has the potential to inflict serious harm in the name of progress.”

On those who have expressed concern about this approach, Clayton writes:
“They note the limited and low-quality evidence base for the benefits, not only of mastectomy as I have done in the Letter, but for early social transition and the hormonal treatments for GD adolescents. Concerns are raised about the irreversible and long-term adverse impacts of these treatments on fertility and sexual function, as well as on bone, brain, and cardiovascular functioning. Concerns are expressed about the sharp, massive, and largely unexplained increase in GD youth, many with psychiatric and neurodevelopmental disorders, presenting to gender clinics. They caution against early social transition, hormonal, and surgical treatments of youth. Some ask: Why are these experimental interventions, with inherent risks and scarce, low-quality evidence for benefits, being implemented outside regulated clinical trial settings?”

Also discussed is the lack of data on regret and detransition. Clayton observes:
“Celebratory stories of medically and surgically transitioned young people are regularly promoted by physicians and the media, adding to the impression of overwhelming beneficial outcomes of this treatment approach. However, there are now increasing reports in the medical literature of regret and detransition, and these give us cause to question the claims of negligible regret rates.”

“Some may argue that informed consent and patient autonomy differentiates contemporary medicine from historical medicine. However, many of these historical treatments did require informed consent, either from the patient or a family member. In addition, informed consent is complex. A necessary condition for it is clinician honesty, which is not met if clinicians overstate the evidence base or act as ‘cheerleaders’ for transition…. Patients’ choices are deeply entangled with other factors, including the influence of their clinicians and medical marketing. Some readers may also reject my discussing contemporary medicine for GD youth along with what they may consider as cruel historical treatments. However, we need to remember that, for the most part, these treatments were not judged as cruel at the time of use, were widely celebrated, and were implemented by well-intentioned physicians who fervently believed that they were helping their patients.”

Clayton concludes by asking:
“How, then, do we best read the affirmative treatment approach for GD youth? Should it be read triumphantly as cutting-edge, ethical, and evidence-based medicine continuing on its progressive march of improving human life? Or is it a manifestation of dangerous medicine, that despite best intentions will cause more harm than benefit to vulnerable youths, and over which future historians and physicians will shake their heads?”

Read the letter in its entirety here. Bernard Lane of the Australian also wrote up this important letter as well as current the state of gender surgery for Australian under-18s in his article, Trans surgery ‘may be judged’ a mistake by future generations.

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