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[spottedpothos]

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[Redpancreas]

I'm a medical student who is concerned about the expansion of "gender affirming" care that seems to be, at best, not backed by robust science, and at worst, actively harmful. I saw this segment on 60 Minutes about detransitioners and wanted to know your thoughts and how your med schools are addressing gender/medicine.

Here's the segment: Resources for viewers of "Transgender Healthcare"

Medical schools will of course jump on the bandwagon of anything like this to avoid outrage for a lack of diversity and inclusion.

That said, what needs to be backed by science? These people want something and are getting surgery to make that happen. What you're saying is akin to telling women who get breast implants that their desire for larger breasts is not backed by science. Also, who is saying that this surgery is harmful? What is their evidence to suggest that?

In terms of Transgender Care and Gender Affirming surgery, I personally think if someone identifies as the opposite gender, it's a good thing that we have the technology to be able to make the change and anyone calling it a mental illness in 2021 is probably just has an inreconcilable religious or political bias and is just being plain cruel to these people.

 

[spottedpothos]

Medical schools will of course jump on the bandwagon of anything like this to avoid outrage for a lack of diversity and inclusion.

In terms of Transgender Care and Gender Affirming surgery, I personally think if someone identifies as the opposite gender, it's a good thing that we have the technology to be able to make the change and anyone calling it a mental illness in 2021 is probably just has an inreconcilable religious or political bias and is just being plain cruel to these people.

Do we really have the technology to be able to "make the change," though? It's not as though sex can truly be changed. The segment shows one girl who had her breasts removed in less than a year, and one boy who had his testicles removed within three months of seeking care. This seems extremely aggressive to me with long term consequences. And I think we should be a lot more conservative than that when it comes to treating distressed gender nonconforming patients. I don't understand how surgically removing healthy tissue or giving patients hormones (with well-documented negative side effects) is a solution. Diversity and inclusion isn't enough of a reason to do this to patients without robust data on outcomes which we currently don't have.

 

[Dral]

I am just going to leave this here without comment.

Sex Redefined: The Idea of 2 Sexes Is Overly Simplistic

Biologists now think there is a larger spectrum than just binary female and male

www.scientificamerican.com

 

[Dr.SPAC3MAN]

Medical schools will of course jump on the bandwagon of anything like this to avoid outrage for a lack of diversity and inclusion.

That said, what needs to be backed by science? These people want something and are getting surgery to make that happen. What you're saying is akin to telling women who get breast implants that their desire for larger breasts is not backed by science. Also, who is saying that this surgery is harmful? What is their evidence to suggest that?

In terms of Transgender Care and Gender Affirming surgery, I personally think if someone identifies as the opposite gender, it's a good thing that we have the technology to be able to make the change and anyone calling it a mental illness in 2021 is probably just has an inreconcilable religious or political bias and is just being plain cruel to these people.

perhaps OP was saying that there need to be more stringent psych evaluations before committing to drastic life changes. breast implants/size can change, whereas gender reassignment surgery is not as simple. There are plenty of surgical interventions that require psych evals before surgery. The 60 min segment highlighted the fact that there was almost no pushback and surgery was put on the patients 3 months after beginning. At the very least it should be agreed that there should be more research on the lasting effects of reassignment surgery with/without counseling/psych evals beforehand.

 

[spottedpothos]

I am just going to leave this here without comment.

Sex Redefined: The Idea of 2 Sexes Is Overly Simplistic

Biologists now think there is a larger spectrum than just binary female and male

www.scientificamerican.com

Did you watch the segment I linked? This discussion is supposed to be about gender affirming care for young people.

 

[spottedpothos]

perhaps OP was saying that there need to be more stringent psych evaluations before committing to drastic life changes. breast implants/size can change, whereas gender reassignment surgery is not as simple. There are plenty of surgical interventions that require psych evals before surgery. The 60 min segment highlighted the fact that there was almost no pushback and surgery was put on the patients 3 months after beginning. At the very least it should be agreed that there should be more research on the lasting effects of reassignment surgery with/without counseling/psych evals beforehand.

yes, you nailed my point.

 

[FrkyBgStok]

Did the 60 minutes talk about how few people detransition? As you practice medicine, you will see that most of the stuff we do in medicine doesn’t have robust data on outcomes.

Do I think some practitioners are jumping to stuff too fast? Maybe. But I also can’t imagine continuing to live in a body I am at odds with for any longer than I absolutely have to. To just looking at sensitivity and specificity, we need to deny a whole lot of people who they truly are to prevent the very small number of detransitioners. Not worth it to me.

 

[spottedpothos]

Medical schools will of course jump on the bandwagon of anything like this to avoid outrage for a lack of diversity and inclusion.

That said, what needs to be backed by science? These people want something and are getting surgery to make that happen. What you're saying is akin to telling women who get breast implants that their desire for larger breasts is not backed by science. Also, who is saying that this surgery is harmful? What is their evidence to suggest that?

In terms of Transgender Care and Gender Affirming surgery, I personally think if someone identifies as the opposite gender, it's a good thing that we have the technology to be able to make the change and anyone calling it a mental illness in 2021 is probably just has an inreconcilable religious or political bias and is just being plain cruel to these people.

I see that you've edited your comment to add a comparison to elective breast augmentation for cosmetic purposes, which doesn't at all parallel what was discussed in the 60 Minutes segment.

And here's some data: "...the results demonstrated no advantage of surgery in relation to subsequent mood or anxiety disorder-related health care visits or prescriptions or hospitalizations following suicide attempts in that comparison" Psychiatry Online

 

[Dral]

Did you watch the segment I linked? This discussion is supposed to be about gender affirming care for young people.

You said this:

"It's not as though sex can truly be changed."

We are to presume that when you say that you mean "Male and Female"

I was trying to add to the conversation that it is not that simple. People born intersex should be brought into the discussion as well because they are forced into the situation and it's not about choice for them all the time.

I am almost ALWAYS all in for bringing more psychiatric evaluation into these situations...not because it should be considered a psychiatric illness, but because individuals should understand ramifications completely before going through with them.

 

[spottedpothos]

Did the 60 minutes talk about how few people detransition? As you practice medicine, you will see that most of the stuff we do in medicine doesn’t have robust data on outcomes.

Do I think some practitioners are jumping to stuff too fast? Maybe. But I also can’t imagine continuing to live in a body I am at odds with for any longer than I absolutely have to. To just looking at sensitivity and specificity, we need to deny a whole lot of people who they truly are to prevent the very small number of detransitioners. Not worth it to me.

Does it matter how "few" (we don't know the number, because we don't have the data) people detransition when there are no robust standards (which the experts in the clip admitted), no certifications required, and the damage done to these few is lasting and irreversible? That should matter.

On the data:

Psychiatry Online

ajp.psychiatryonline.org

"the results demonstrated no advantage of surgery in relation to subsequent mood or anxiety disorder-related health care visits or prescriptions or hospitalizations following suicide attempts in that comparison"

 

[spottedpothos]

You said this:

"It's not as though sex can truly be changed."

We are to presume that when you say that you mean "Male and Female"

I was trying to add to the conversation that it is not that simple. People born intersex should be brought into the discussion as well because they are forced into the situation and it's not about choice for them all the time.

I am almost ALWAYS all for bringing more psychiatric evaluation into these situations...not because it should be considered a psychiatric illness, but because individuals should understand ramifications completely before going through with them.

The segment wasn't about intersex people. That's a different discussion. We're on the same page, then, RE doing a more robust evaluation and collecting more data before rapidly starting potentially irreversible treatments.

What I said about sex is true: a phalloplasty, for example, can't truly create a penis. And I think the medical profession does harm when it pretends that it can.

 

[Dral]

It's not about intersex, but you asked us what our thoughts were and I gave mine but it's a related charged topic that could involve individuals going back from a sex they were assigned (and possibly regretting it later). *shrug*

I'll leave now since you are dictating what should and should not be discussed here.

 

[spottedpothos]

It's not about intersex, but you asked us what our thoughts were and I gave mine but it's a related charged topic. *shrug*

I'll leave now since you are dictating what should and should not be discussed here.

Not at all. Please feel free to share your thoughts. The reason I want to keep the discussion on topic is because I know this can quickly spiral. Thank you for sharing your thoughts!

 

[Dral]

Not at all. Please feel free to share your thoughts. The reason I want to keep the discussion on topic is because I know this can quickly spiral. Thank you for sharing your thoughts!

That is a good point. I admit that even though I am not transgender nor ever considered it, it is a topic that could very quickly spiral and I admit I get a little charged discussing it (I was friends with a bunch of people in med school who were very involved with LGBTQ issues).

I added to my last post to hopefully give it a little more relevance to the topic. Again, to stay on topic, I believe that robust psych services should be provided to anyone that is considering any type of body modification. I have had vitiligo patients who have disease so severely that they want to bleach all of their skin outright. I will absolutely NOT prescribe the meds to them until they have undergone a thorough psych eval and counseling. In my opinion, the same thing should probably apply here. However, I am up for learning differently if there is anyone here who is more involved in care more specifically centered on transgender issues.

 

[spottedpothos]

That is a good point. I admit that even though I am not transgender nor ever considered it, it is a topic that could very quickly spiral and I admit I get a little charged discussing it (I was friends with a bunch of people in med school who were very involved with LGBTQ issues).

I added to my last post to hopefully give it a little more relevance to the topic. Again, to stay on topic, I believe that robust psych services should be provided to anyone that is considering any type of body modification. I have had vitiligo patients who have disease so severely that they want to bleach all of their skin outright. I will absolutely NOT prescribe the meds to them until they have undergone a thorough psych eval and counseling. In my opinion, the same thing should probably apply here. However, I am up for learning differently if there is anyone here who is more involved in care more specifically centered on transgender issues.

Well said, thank you.

 

[Redpancreas]

perhaps OP was saying that there need to be more stringent psych evaluations before committing to drastic life changes. breast implants/size can change, whereas gender reassignment surgery is not as simple. There are plenty of surgical interventions that require psych evals before surgery. The 60 min segment highlighted the fact that there was almost no pushback and surgery was put on the patients 3 months after beginning. At the very least it should be agreed that there should be more research on the lasting effects of reassignment surgery with/without counseling/psych evals beforehand.

I see that you've edited your comment to add a comparison to elective breast augmentation for cosmetic purposes, which doesn't at all parallel what was discussed in the 60 Minutes segment.

And here's some data: "...the results demonstrated no advantage of surgery in relation to subsequent mood or anxiety disorder-related health care visits or prescriptions or hospitalizations following suicide attempts in that comparison" Psychiatry Online

I don't think that this is just a fleeting thought. From the few people I know that are transgender, it seems like they always had this desire for XYZ and had to hide it. If that's the case, get them to where they want to be. I do think Psychological evaluation is warranted to ensure the patient has capacity before making such a decision. It should kind of be like transplantation where psych/transplant SW get involved. If this is not already being done, then it should.

In terms of harm, I think perhaps research should continue to be done but in the meantime we have the means to get patients something they have wanted to do for a long time with very few side effects immediately apparent although I understand your concern for long term effects whether your fixation for that is derived from truly concern for the patient or a deeply held religious/political belief. I think that's a difficult decision for a transgender person, but one they ultimately need to make with the support of a team pf physicians. I am sure the risks are discussed on an individual level with their physicians involved in the transition. If not, then they should be.

 

[Angus Avagadro]

I'm not sure this is the forum for this discussion. Mods?
I would however like to make a few points.

1 The politics/ activists are way out in front of the science.
2 There is data to support transgender patients lie within the autism spectrum.
3. Sweden,has been treating transgender patients longer than any other country, recently prohibited giving puberty blockers to children unless they are enrolled in a research study.
4. We have a lot to learn in understanding gender dysphoria.
5. I believe a more reasoned conservative approach is warranted until data supports our current treatments, especially when treating children.
6. Our current management hasnt been working very well for a long time.Transferring blame to others not sympathetic to the syndrome for its current results is disingenuous. We need to find better strategies to help these troubled patients.

 

[Redpancreas]

I'm not sure this is the forum for this discussion. Mods?
I would however like to make a few points.

1 The politics/ activists are way out in front of the science.
2 There is data to support transgender patients lie within the autism spectrum.
3. Sweden,has been treating transgender patients longer than any other country, recently prohibited giving puberty blockers to children unless they are enrolled in a research study.
4. We have a lot to learn in understanding gender dysphoria.
5. I believe a more reasoned conservative approach is warranted until data supports our current treatments, especially when treating children.
6. Our current management hasnt been working very well for a long time.Transferring blame to others not sympathetic to the syndrome for its current results is disingenuous. We need to find better strategies to help these troubled patients.

Interesting. I want to see this data.

Edit: Largest study to date confirms overlap between autism and gender diversity

This it?

 

[Goro]

Medical schools will of course jump on the bandwagon of anything like this to avoid outrage for a lack of diversity and inclusion.

That said, what needs to be backed by science? These people want something and are getting surgery to make that happen. What you're saying is akin to telling women who get breast implants that their desire for larger breasts is not backed by science. Also, who is saying that this surgery is harmful? What is their evidence to suggest that?

In terms of Transgender Care and Gender Affirming surgery, I personally think if someone identifies as the opposite gender, it's a good thing that we have the technology to be able to make the change and anyone calling it a mental illness in 2021 is probably just has an inreconcilable religious or political bias and is just being plain cruel to these people.

The point of the 60 Minutes piece was that there is a specific protocol involving lots and lots of therapy for the transitioning process, but some practitioners will literally willy-nilly start giving sex hormones, and then rapidly do or send people to orchiectomies or mastectomies.

The detransitioners who went through this rapid process then regretted it, because it appears that they really weren't trans, but were suffering from depression and gender dysphoria seemed to grow out of that.

EDIT: i just read Angus' post and was surprised to see a possible link the autism. There may be mélange of different gender dysphorias that are , as of now, just stuck into the same silo.

 

[Lawpy]

The point of the 60 Minutes piece was that there is a specific protocol involving lots and lots of therapy for the transitioning process, but some practitioners will literally willy-nilly start giving sex hormones, and then rapidly do or send people to orchiectomies or mastectomies.

The detransitioners who went through this rapid process then regretted it, because it appears that they really weren't trans, but were suffering from depression and gender dysphoria seemed to grow out of that.

In before corporate medicine and liability are blamed to defend overprescribing behaviors

 

[Angus Avagadro]

Interesting. I want to see this data.

Edit: Largest study to date confirms overlap between autism and gender diversity

This it?

A couple were listed when I Googled, that was one.

 

[spottedpothos]

I'm not sure this is the forum for this discussion. Mods?
I would however like to make a few points.

1 The politics/ activists are way out in front of the science.
2 There is data to support transgender patients lie within the autism spectrum.
3. Sweden,has been treating transgender patients longer than any other country, recently prohibited giving puberty blockers to children unless they are enrolled in a research study.
4. We have a lot to learn in understanding gender dysphoria.
5. I believe a more reasoned conservative approach is warranted until data supports our current treatments, especially when treating children.
6. Our current management hasnt been working very well for a long time.Transferring blame to others not sympathetic to the syndrome for its current results is disingenuous. We need to find better strategies to help these troubled patients.

Thank you - I think all of the points you made are important and relevant.

There are a couple of things I'd like to add. The reason I think this is the appropriate forum is that gender affirming care is the model increasingly being taught in medical school. I don't think the evidence supports this model of care for the reasons that you've said and others.

I'd also like to posit that if patients are feeling incredible distress in their bodies, shouldn't other psychiatric disorders be thoroughly screened for? How do we know, for example, that the purported suicidal ideation that results from gender dysphoria isn't stemming from another cause - anxiety, depression, body dysmorphic disorder, etc?

 

[gyngyn]

Moving this to Topics in Healthcare.

 

[Redpancreas]

OK. Thank you Goro & Angus for clarifying points as I was not well versed on the 60 minutes piece and the controversy. I still have some issues with @Angus Avagadro ’s posts

1.) Say there is an association to autism which itself is a cluster bag of stuff. We have stuff like a nonverbal person and then someone with Asperger’s. What kind of autism is this linked to and by which mechanism. What is the implication that transgenderism is linked to autism? Putting it crudely are we supposed to assume autistic individuals are confused and don’t know what’s best for them and that’s why they think they’re the other gender?

2. I think the point of a conservative approach is wise. That said, if someone wants it and they are not deemed to be depressed, anxious, or suicidal and perhaps I will concede not still a child then the decision with risks should be theirs even if they have autism so long as they have decision making capacity.

 

[Angus Avagadro]

All good questions. It could explain the failures with transitioning. Like I said, we have lots to learn about gender dysphoria.

 

[Redpancreas]

All good questions. It could explain the failures with transitioning. Like I said, we have lots to learn about gender dysphoria.

I concede my initial post was presumptive to the argument OP was trying to make. That said, there are a lot of people out there who are just calling this a mental illness because deep down it justifies their political or religious beliefs. I think that’s probably not true in some/many/most and it’s hurtful to the transgender community. I don’t think that’s what you or OP are doing here, obviously.

Has the pendulum swung in the other direction to the extent that any dissonance even medically warranted is seen as hate speech and rejected by the political left? Maybe?

 

[VA Hopeful Dr]

The point of the 60 Minutes piece was that there is a specific protocol involving lots and lots of therapy for the transitioning process, but some practitioners will literally willy-nilly start giving sex hormones, and then rapidly do or send people to orchiectomies or mastectomies.

The detransitioners who went through this rapid process then regretted it, because it appears that they really weren't trans, but were suffering from depression and gender dysphoria seemed to grow out of that.

EDIT: i just read Angus' post and was surprised to see a possible link the autism. There may be mélange of different gender dysphorias that are , as of now, just stuck into the same silo.

Yep, which is why historically you had to live as your gender for at least 1 year before you would be a candidate for surgery.

1 year of hormones is mostly reversible in adults, and we have very good data in kids that 1 year of Lupron to delay puberty doesn't have much in the way of negative long term effects.

 

[differentiating]

Agreed with the above that a small minority who rushed through surgery for gender dysphoria who regret it don't outweigh the majority of individuals for whom it's actively beneficial, so I wouldn't call it harmful by any means. I know individuals who felt that the gender-affirming care they received was life-saving for them. I also don't think your link is evidence that gender-affirming care isn't helpful, either, since you're comparing apples and oranges (individuals with gender dysphoria who wanted/received surgery and individuals with gender dysphoria who did not). There's just not evidence to make a statement as to whether or not there's benefit from that data - if anything, it'd be more helpful to know if those who wanted/received surgery had any change in their use of mental health resources after surgery compared to prior.

Most providers I've seen/rotated with who focus on trans individuals have longitudinal relationships with their patients and start with hormones/puberty blockers (which are honestly fairly benign) long before surgery, so I think standard of care is more in line with the conservative approach people are advocating for, as VA Hopeful Dr pointed out.

 

[Mad Jack]

The detransition rate is 16x lower than the failure rate of back surgeries so... Make of that what you will

 

[Angus Avagadro]

The detransition rate is 16x lower than the failure rate of back surgeries so... Make of that what you will

Not trying to hijack the thread, but the Euros don't operate on back pain unless there is serious neurological impairment. As socialists, they can allow 6 months of PT and conservative therapy. Last I knew, about 85 % of discs heal with out surgery. In America, they have to be back at work in 6 weeks. Surgery doesn't have better success, just gets them back to work sooner. As explained to me by a very wealthy neurosurgeon.

 

[Goro]

Agreed with the above that a small minority who rushed through surgery for gender dysphoria who regret it don't outweigh the majority of individuals for whom it's actively beneficial, so I wouldn't call it harmful by any means. I know individuals who felt that the gender-affirming care they received was life-saving for them. I also don't think your link is evidence that gender-affirming care isn't helpful, either, since you're comparing apples and oranges (individuals with gender dysphoria who wanted/received surgery and individuals with gender dysphoria who did not). There's just not evidence to make a statement as to whether or not there's benefit from that data - if anything, it'd be more helpful to know if those who wanted/received surgery had any change in their use of mental health resources after surgery compared to prior.

Most providers I've seen/rotated with who focus on trans individuals have longitudinal relationships with their patients and start with hormones/puberty blockers (which are honestly fairly benign) long before surgery, so I think standard of care is more in line with the conservative approach people are advocating for, as VA Hopeful Dr pointed out.

Except now we have red states that enjoy tormenting trans kids for the sake of fueling the anger of their base.

 

[dabears505]

I bet in 20 years there will be so many lawsuits filed against doctors who prescribed puberty blockers and pushed gender change in minors. They are not legally allowed to smoke cigarettes, drink alcohol or vote, yet they can make the choice for such radical things done to them? It's so bizarre we have come to this as a society.

 

[VA Hopeful Dr]

I bet in 20 years there will be so many lawsuits filed against doctors who prescribed puberty blockers and pushed gender change in minors. They are not legally allowed to smoke cigarettes, drink alcohol or vote, yet they can make the choice for such radical things done to them? It's so bizarre we have come to this as a society.

I'll take that bet

 

[dabears505]

I am just going to leave this here without comment.

Sex Redefined: The Idea of 2 Sexes Is Overly Simplistic

Biologists now think there is a larger spectrum than just binary female and male

www.scientificamerican.com

This stuff is so ridiculous. Don't give me examples of pathology and present that as evidence of what should be the norm.

 

[Dral]

Maybe the article seems to imply that. It of course shouldn't be the norm. It never would be. That article is good to get people thinking about how intersex individual fit into things however.