Transition as Treatment: The Best Studies Show the Worst Outcomes

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The treatment for this particular disorder is severe; lifelong experimental medicalization, sterilization, and complete removal of healthy body parts—a treatment Dr. Ray Blanchard, one of the world’s foremost sexologists, calls “palliative”. In spite of its severity, however, medical transition is no longer a rarity. It is the recommended treatment for gender dysphoria, a diagnosable disorder of incongruence between a felt “gender” and one’s natal sex that is undergoing a tremendous increase in prevalence throughout the world. More and more children and adolescents are being diagnosed and are undergoing medical treatment prior even to completing puberty.

For those who express caution or concern there is a familiar retort— “trust the experts”.

This argument, however, makes mockery of the fact that three of the most influential sex researchers of the last couple decades—Ray Blanchard, Michael Bailey, and the recently vindicated Ken Zucker, all have problems with the affirmation-only transition narrative currently being promoted. You could add to this list names like James Cantor, Eric Vilain, Stephen Levine, Debra Soh and Lisa Littman.

I want to invite you to look at the data these and other researchers draw from. What does the peer-reviewed research itself say about the effectiveness of medical transition for those who have gender dysphoria? Do puberty blockers, cross-sex hormones, mastectomies, vaginoplasties, and phalloplasties successfully alleviate the mental and emotional distress gender dysphoric persons face? Findings are varied, as are the political and philosophical perspectives of the researchers, but a careful reading of the literature demonstrates that the best studies show the worst outcomes.

Part of the problem, admittedly, is the studies themselves. It is often represented in the mainstream narrative that medical transition is well-studied and that there is academic consensus around its effectiveness. In reality, the literature is fraught with study design problems including convenience sampling, lack of controls, cross-sectional design, low sample sizes, short study lengths, and enormously high drop-out rates. Very few studies on transition evade these issues. For example, in Nobili’s 2018 systematic review of quality of life studies of transitioned adults, she rates only 2 of 29 studies as high quality.

Two of the largest issues are study length (or time since treatment) and loss-to-follow-up rates. It is well recognized in the literature that the year after medical transition is a “honeymoon period” which “does not represent a realistic picture of long-term sexual and psychological status.” At what point, however, does patient psychology stabilize? After three years? Five years? Ten years? And at what level? Given that pre-pubertal children are being administered cross-sex hormones (12yrs) and undergoing surgeries (13yrs), and that this transitioned experience will span 60-80 years of their lives, shouldn’t we know whether outcomes are positive after 10 years?

Complicating study lengths is the issue of follow-up. Many researchers state that at 20% loss-to-follow-up there are significantly detrimental effects to the reliability of a study. One study that investigated the nature of those lost to follow-up for another surgical procedure concluded “patients with problems are likely to avoid follow-up.” Ruppin & Pfafflin 2015 is one example of a long-term transition outcome study which shows high loss-to-follow-up. It found largely positive outcomes for those who had underwent sex-reassignment surgery on average 13.8 years prior and would probably be the study I would reference if I were trying to demonstrate the long-term efficacy of medical transition as a treatment for gender dysphoria. However, the study has a 49.3% loss to follow-up rate, raising enormous questions about how almost half the initial group fared. As we’ll see there is considerable reason to believe that this loss-to-follow-up group is hiding more negative results than those who agree to partake in the studies.

Three long-term studies have addressed the problem of follow-up loss by taking a look at objective measures available in registry data in their countries. Due to this methodology these studies have either no loss or extremely low loss to follow-up and are able to supply what may be missing in many of the other studies.

Asscheman 2011 (Netherlands) considered the outcomes of 1331 post-HRT transsexuals with an 18.4yr average length since beginning of treatment. The outcomes for the female-to-males seemed generally positive but in the much larger male-to-female group, comprising 72.6% of the total, “total mortality was 51% higher than in the general population, mainly from increased mortality rates due to suicide, acquired immunodeficiency syndrome, cardiovascular disease, drug abuse, and unknown cause.” Breaking this down further they state, “the increased mortality risk in MtF in our cohort was characterized by a high SMR [standard mortality rate] of suicide (of 5.70), AIDS (of 30.2), and illicit drug-related deaths (of 13.2).” The timing of the suicides also provides some important information.  None occurred within 2 years of treatment, consistent with the “honeymoon period” mentioned so often in the literature. However, “there were six suicides after 2–5 years, seven after 5–10 years, and four after more than 10 years of cross-sex hormone treatment”.

Dhejne 2011 (Sweden) is among the most well-known studies on transition outcomes, partially due to its surprisingly negative results and partially due to differences among authors in interpreting the data. The sample was 324 post-surgery transsexuals with median follow-up time of over 10 years, the largest study of those post-SRS [sex-reassignment surgery]. One advantage to the study was that Dhejne compared the sample not only to population data, as with Asscheman, but to matched non-trans controls. Findings included 7.6 times higher suicide attempts than controls and 19 times higher completed suicides. Pyschiatric hospitalization was 2.8 times higher, even after adjusting for prior psychiatric morbidity.

Most recently Simonsen 2016 (Denmark) studied a group of 104 post-SRS transsexuals where the follow-up time was 16.4 years for MtFs and 10.2 years for FtMs. For the first time in a long-term study with little loss to follow-up (2%) there were comparisons prior and post treatment of objective measures. Concerning psychiatric morbidity, “No significant differences were found between the number of MtF and FtM individuals suffering from psychiatric morbidity pre- and post-SRS”. While psyschological problems improved for some in the group, for others it worsened and there was no statistically significant net benefit to the group. Due to the lower numbers in this study, there was no analysis possible of the mortality data, but “ten individuals were registered as deceased post-SRS with an average age of death of 53.5 years” and there were two suicides, both surprising data.

Out of the six long-term outcome studies (>10yrs) which have useful data for mental or psychological functioning, five report mixed or poor outcomes. In addition to the three registry studies above and Ruppin & Pfafflin 2015 there is also Rauchfleish 1998 and Lindemalm 1986. Lindemalm (Sweden) investigated a small clinical sample of 15 post-SRS MtFs where the average follow-up period was 12 years. Although the sample size was extremely small, loss to follow up was only 23.5% with one person having committed suicide post-SRS and another having moved away. Results for mental health and employment were highly mixed, leading the author to conclude “it seems reasonable to expect only marginal improvement psychosocially after surgery. Rauchfleisch (Switzerland) found significant deterioration in his post-SRS clinical sample and states that the negative outcomes, including a high percentage of regret and inability to work, were likely a function of time.

It was the function of time that was investigated recently in Lindqvist 2017 (Sweden), the only longitudinal study of any significant length. It measured health prior to treatment, and at 1, 3, and 5 years post-SRS. Once again loss-to-follow-up was significant, as 103 of 146 dropped out by year five. However, the results are significant and perhaps all the more because of the loss-to-follow up. Although the study is cheerfully titled, “Quality of life improves early after gender reassignment surgery in transgender women”, a careful reading of the data shows it could just have easily been called “Honeymoon effects of transition wear off quickly”. The title is not the only place where, in my opinion, the authors show considerable bias in their presentation of the data. Table 2 is worth looking at and shows a significant increase in all measures of the SF-36 components (both physical and mental) after 1 year, although in comparison to population norms they are still low. However, every component drops at 3 years, and every component except physical functioning drops even further at 5 years. The decreases from 1yr to 5yr are robust and statistically significant, a fact subtly hidden in some of the authors’ language. The authors do suggest a reason for this significant drop in quality of life, namely that it mirrors a decline in quality of life over time in the general population. However, a perusal of SF-36 population norms for Sweden and elsewhere demonstrate the implausibility of this reasoning. Lindqvist’s cohort has a median age of 36 years and quality of life for physical components does not decline much for the general population until after the forties or later, and never significantly over a five-year time frame. For mental component norms, however, quality of life is stable even into much older ages, even increasing in some measures. An objective consideration of the data in Lindqvist and other studies demonstrates that the short-term psychological benefits, where they occur, are often short-lived.

A study that looks at this question from a different perspective is Adams 2017. While the authors are very clearly pro-transition, some of the findings of their meta-synthesis of the literature on suicidality among transgender individuals provoked surprise. “It seems counterintuitive, on the other hand,” they state, “that suicide attempts are lower before transition (ideation 36.1%; attempt 13.1%) than over most other periods (past year attempts being the exception).” For example, suicidal ideation for “past year” was 50.6%, whereas for “before transition” it was only 36.1%. Caution is warranted given the fact that this finding does not represent pre-transition and post-transition groups, let alone the same groups pre and post transition. The categories being compared were trans people prior to transition, trans people in the past year (regardless of transition status), and trans people over the lifetime (regardless of transition status). It is a shocking finding nevertheless, especially in that “before transition” would be a significantly larger time frame than “past year”.

A pattern begins to emerge as we survey some of the best and longest outcome studies on transition—the longer the studies and the better the methods, the more negative the results. A broad understanding of the literature helps us address the controversy surrounding Dhejne’s study mentioned earlier. Dhejne herself has argued that her study should not be used to question the efficacy of transition as a treatment. Some authors have read her results precisely that way, including those who would question an affirmation-only paradigm, such as Stephen Levine and Roberto D’Angelo, and others who would continue to champion transition. Dhejne has argued that because the more recent cohort in her study did not have elevated mortality or suicide attempts compared to controls (although psychiatric hospitalization remained highly elevated), it is likely that more advanced medical treatments and societal acceptance have resulted in better psychological outcomes over time. However, given that the results in the broader literature show that the immediate, and perhaps net positive, psychological effects of transition eventually deteriorate, it seems likely that this is an overly-optimistic, politically correct spin on the data. As D’Angelo 2018 states after interacting with Dhejne’s findings, “Most importantly in relation to suicide, none of the studies undertaken to date have yet established whether gender-reassignment actually lowers the risk of completed suicide as it is generally assumed to do.”

Some of the most recent findings of studies in the five-year follow-up range are also beginning to show cracks in the affirmation-only narrative. Van de Grift 2018 sorted his multi-center European sample into a satisfied and dissatisfied post-surgery group and found that even his “satisfied” group had “significantly more psychological symptoms and lower satisfaction with life” than control samples. Jellestad 2018 (Switzerland) found not only a lower mental quality of life for the surgically-transitioned group than the general population, but that neither hormone treatment nor surgery predicted positive quality of life. Auer 2013 (Germany) investigated a hormone treated clinical group, and in comparison with a control group found “significantly higher mean scores in all psychopathology subscales”, no matter which sex was used as comparison. They conclude, “sex reassignment surgery doesn’t seem to be a major contributor to psychosocial well-being in our transsexual sample. This is in accordance with a recent systematic review and meta-analysis which concluded that although many subjects benefit from sex reassignment, there is also evidence of higher psychiatric morbidity and suicide rates following the procedure.”

There are studies in the five-year range which could be used to argue that transition significantly helps the gender dysphoric (Pimenoff & Pfafflin 2011, Weyers 2009, De Cuypere 2006), but a broad overview of all the medium and long-term studies show, at best, highly concerning results. Although it is a generalization, it is an undeniable and empirically defensible one—the best studies tend to show the worst outcome for transition as a treatment.

Honest interaction with the medical literature throws up enormous warning signs, and adults are not the only ones who will pay the price for not heeding them. How will young people who are medically transitioned prior to adulthood fare psychologically after 30 years of transitioned life? What percentage of the medically transitioned have since detransitioned? How many suicides are contained within the groups that are lost to follow-up? To these and other questions there are few answers. Given that treatment of gender dysphoria includes such drastic measures as the removal of healthy, functioning body parts, the protracted and experimental use of cross-sex hormones, and the permanent circumvention of the normal pubertal process, this is nothing short of scandalous.

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