Success rates of sex reassignment therapy as a treatment for gender dysmorphia.

Medical Q&A [Moderated]
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This topic perhaps has no clear connection with strength and conditioning, but since you have put up an (for me eye opening) article regarding transgender and sports previously you might already have some insights on this issue. On top of that I really respect Barbell Medicin as a source of nuanced™ information. Keep up the good work!

Recently in Sweden a discussion about the success rates of reassignment therapy for diagnosed gender dysmorphia has flared. One of the reasons for this is a law in the making in which the age is lowered for when a minor can go though sex reassignment therapy without their parents consent. This is obviously a politically very sensitive question where confirmation bias reigns supreme on both sides of the political spectrum. My personal opinion is that if the risk-reward ratio benefits sex reassignment therapy over any other treatment for a given patient, then that should be the treatment of choice. But this statement obviously does not provide any way for practical application without specifics, and the latter is really lacking in the mainstream debate. So what does the scientific literature say?

Some key statistic common in the debate in Sweden are:

  1. (Something like) 30 % of the patients diagnosed with gender dysmorphia have thought of committing suicide.
  2. (Something like) 80 % of the the patients diagnosed with gender dysmorphia also have one or more other psychiatric diagnoses (eg. autism, anorexia, depression, etc). As far as I know these are not citations of peer reviewed scientific papers but statistics from the various institutions responsible for treatments. From what I have heard from the debate, no matter where your bias lies, the question is about the validity of these numbers. But supposing these figures are correct my layman perspective is:
  3. From the former, it is a diagnosis which should indeed be taken seriously.
  4. From the latter, in suggesting treatments of gender dysmorphia one has to consider the possibility that it can be a symptom of some other issue just as the other issue can be a symptom of the gender dysmorphia. Finding out what the relation is should have impact on suggested treatment. From my experience the latter issue seems the general issue with psychiatric diagnoses. That it is hard to know what causes what, and that they rather should be thought of more as symptoms. General guidelines are hard, there is much dependence on the context of the individual cases. So in particular, this increases the risk of the psychiatrists own biases severely impacting the diagnosis. Is there some truth to this interpretation?

There are also case reports of people that after completed sex reassignment therapy regretted it because it didn’t solve their ‘real’ issue and thus ending up worsening their mental health instead. There are also case reports of people having been accepted for sex reassignment therapy but during the time before the actual treatment started has gone through ‘normal’ therapy and realised their problem was something else, i.e anorexia and a general discomfort with ones own body.

Just from a general point of view it is to me not surprising that some people get misdiagnosed, the contrary would in fact be surprising. But since the stakes are high, being that sex reassignment therapy is a one-way ticket requiring medical treatment for the rest of the persons life, I am wondering if there is a too high risk of misdiagnosing due to a lack of scientific research? Is there any scientific statistics of misdiagnosed gender dysmorphia?

I found the following paper on the success rates of sex reassignment therapy (Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden - PMC) . They concluded that even if the treatment removes the gender dysmorphia it does not suffice as a treatment since the mortality rates are not lowered enough. This seems in line with my perspective on the issue, but I am after all just and curious amateur. Is there some general scientific consensus about results like these?

An optional question: Should legislation regarding treatment of gender dysmorphia, especially regarding minors, be put on hold pending more scientific research?

Thanks for all you content!

/Fritiof

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Fritiof,

Thanks for the post. I actually recently was engaged in an instagram discussion (if you can calI it that) rejecting gender affirming care and citing some of these resources. It is interesting, as I have no real opinion on what policies should be in place as again, I am not a law-maker or politician.

I think there are problems with the asserted “data”. For example, how did they assess suicidal ideation and over what time frame? The prevalence of suicidal ideation is ~ 9% in adults, though can be much higher in those with concomitant psychiatric conditions. Also, you would want to know the suicide attempts and actual suicide rate in that same population to put those numbers into context.

With the concomitant psychiatric conditions, again the numbers may be misleading depending on how they were collected, defined, and diagnosed. Lifetime prevalence of any psychiatric condition is 50-60% in all adults, for example.

Regrets after various medical procedures occur quite often, with variability based on demographic, procedure, etc. There are also risks of the medical management for transitioning.This is a pretty complicated decision, no doubt!

That all being said, I am empathetic to the providers and policy-makers who are in the trenches making these decisions. Like much of medicine, this is an imperfect science and I suspect 20 years from now we’lI know more. At this point however, I’m inclined to side with the expert consensus panels that recommend gender-affirming care in adults. In pediatric patients, I think it’s even more contentious, but defer to the expert guidelines on the matter, which will continue to be updated as new evidence emerges.

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The optimist ca perhaps see the lack of science in this area as something positive since improved scientific knowledge stands a chance of resolving some of the political issues. For instance, if through research one manages to improve the diagnosing and treatment, then it maybe doesn’t matter too much whether one is allowed to make the transition without the parents consent at the age of 15 or 18. But that is perhaps a big ‘if’ at the moment.

Tanks for your answer!

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Yea I think the role of science in politics is to be a sort of honest broker of information that answers questions that policy-makers have. However, the problem is when there aren’t a set of universal or near-universally shared values- such as this topic. Science becomes less useful, unfortunately.

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