Caution over transgender surgery and hormonal treatment for minors

Caution over transgender surgery and hormonal treatment for minors

By Rachael Wong

Australia’s biggest gender clinic at the Royal Children’s Hospital in Melbourne has asked for more public money to start double mastectomies on girls under 17 who identify as male.

In July 2019, its director Michelle Telfer claimed that “chest reconstructive surgery” improves mental health. However, Australian psychiatrists have been urged to be “extremely careful” before endorsing “gender affirming” hormonal treatment and surgery for minors after it was found that a highly lauded international study had made false claims that transgender surgery improved mental health.

The 2019 US-Swedish paper published in the prestigious Journal of American Psychiatry had claimed that surgery such as mastectomy or genital reconstruction reduced the need for mental health treatment by 8 per cent a year over the following 10-year period.

This month the journal published a correction, an editorial and letters from a dozen eminent psychiatrists, clinicians and researchers in four countries highlighting multiple errors in the paper, ultimately establishing that the study showed no improvement in mental health after surgery or hormonal treatment.

After reanalysing the data, the authors found “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”.

They admitted that the conclusion that “the longitudinal association between gender-affirming surgery and lower use of mental health treatment lends support to the decision to provide gender-affirming surgeries to transgender individuals who seek them” is too strong.

There is no doubt that many transgender individuals struggle with mental health issues, and they deserve the highest quality health care, but there is no rigorous evidence in favour of treating them with surgery or hormonal treatment.

Not only is such “treatment” unhelpful, but it is particularly harmful when we are talking about major, irreversible surgery or hormone therapy on people whose mental health is already compromised, and for which medical professionals acknowledge the long-term implications are not fully understood (such as the risk of ovarian cancer for females receiving testosterone or sterility for both sexes). This is especially the case for minors, who in addition to any mental health struggles are also dealing with the ups and downs of adolescence and puberty, and are at a stage in life where their brains and decision-making capacities are still developing.

When it comes to women and girls, added to this are the unique pressures they face in the areas of sexual violence, objectification in porn, entertainment and advertising, and the more general body image issues resulting from phenomena like social media, eating disorders, unhealthy interpersonal relationships (e.g. with peers, partners or parents), gender stereotypes, or other cultural expectations, which can cause them to hate their bodies and indeed being female.

In fact, a huge surge in girls wanting to change their gender has been reported in both the US and the UK. Between 2016 and 2017, the number of transgender surgeries for females in the US quadrupled, and in the UK, the number of girls referred for gender reassignment treatment rose by 4400% percent over the past decade. Similar increases have been observed in other Western countries.

However, the number of women who regret their gender reassignment and are seeking to “detransition” is also growing. According to psychotherapist Lisa Marchiano, transition often not only failed to address the complex social and mental health issues these young women were suffering from, but at times exacerbated them or added new issues.

"The young women with whom I have worked became trans identified during adolescence. They frequently did so in the context of significant family dysfunction or complex psycho-social issues. Sexual assault and sexual harassment were common precursors. A majority had an eating disorder at the time they became trans identified. Since detransitioning, most now understand themselves to be butch lesbians. In our work together, they traced complex histories of coming to terms with their homosexuality. Some faced vicious homophobic bullying before they announced their trans identification," she said.

Breast binding, testosterone treatment and mastectomies will do nothing to solve the significant social and mental health pressures facing so many women and girls. While the causes of gender dysphoria are varied and complex, we owe it to them to address these issues, before pushing “treatments” that are at best unhelpful and at worst, exacerbate these issues (or add new ones) and cause further harm.

Rachael Wong is the CEO of Women’s Forum Australia