The success or failure of medical treatment can be evaluated in a variety of different ways. Objectively measurable criteria generally provide the most stable, repeatable, and transferable results. Subjectively measurable criteria, on the other hand, are more vulnerable to unconscious bias and manipulation.
In the context of the “sex reassignment” procedures, patient satisfaction outcomes are often given primary importance. But they are not the only relevant factor for consideration. This is especially true when looking at what happens years out, after transition. We should look past immediate gratification to sustained realities. Long-term studies necessarily give us the fullest picture of transsexuals’ lives.
In order to highlight differences between subjective and objective criteria, I will review and comment on the results of four long-term follow up studies on transsexuals. Here are examples of criteria used to measure the efficacy of “sex reassignment” procedures:
OBJECTIVE: mortality, suicides, hospitalizations, criminal convictions, surgical complications such as rate and severity of infection
SUBJECTIVE: patient-reported satisfaction with surgical appearance or sexual function, “passing” in a particular context, friend/family secondhand accounts
The first two studies analyze objective data, the third study relies solely on subjective self-reporting, and the last study evaluates a mixture of subjective and objective criteria–making it a particularly fascinating example from which to compare findings.
- Dhejne, 2011 study on the mortality rate of 1,331 transsexuals receiving sex cross-sex hormones in Sweden (966 male-to-females and 365 female-to-males).
- Asscheman, 2011 study on the mortality, psychiatric hospitalizations, and criminal convictions of 324 transsexuals who have undergone sex reassignment surgery in the Netherlands (191 male-to-females, 133 female-to-males).
- Smith, 2005 study on the self-reported satisfaction of 162 transsexuals receiving cross-hormone treatment in the Netherlands.
- Leriche, 2008 study on the surgical complication and self-reported satisfaction of 56 female-to-male transsexuals undergoing phalloplasty in France.
Studies 1 and 2: MORTALITY and SUICIDE
The first two studies boast the largest sample sizes (1,331 and 324, respectively). Because of the methodology, these sample sizes are many times larger than those commonly found in studies speculating about possible neuro-structural causes of transsexualism. Both studies also report on the same unambiguous measurement of death– you’re dead or you’re not.
The Dhejne and Asscheman studies both found increased mortality and risk of suicide among transsexuals compared to control groups.
Trans-identification is often presented as a crisis and it is commonly claimed that trans-identified people are suicidal or in danger of being self-injurious because of their self-assessed sex-incongruence. Yet these findings contradict arguments that surgery and/or cross-sex hormones are urgently necessary interventions that prevent suicide and other self-harming behaviors.
Even at the highest institutional levels, even in the WPATH Standards of Care, guidance about access to surgery and hormones often frame suicide as an argument in favor of “sex reassignment” procedures. But I don’t know of any (other?) context where a socially appropriate or clinically “therapeutic” response to suicide threats is to accommodate the demands of the threatener. Suicide is not a bargaining chip. This is not insensitive or punitive, it is the only safe and rational response to give. Suicidal ideations should be immediately evaluated for risk of danger, never negotiated with.
Given the high rates of mortality and suicide despite access to cross-sex hormones and genital surgery (not because of them), the insistence that these treatments function as a panacea for transsexualism must be more widely questioned. It is irresponsible to look at only a fraction of a transsexual’s life. We must consider the full person– including what happens after surgery and after transition. That is what humanity looks like. We have reason to be concerned.
Study 2: CRIMINALITY and MASCULINITY
The second study, Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden, tracked two more objective criteria: psychiatric hospitalizations–you’re admitted or you aren’t, which I will not discuss in depth here– and criminal convictions–you’re found guilty or innocent, not both. The criminalization findings are particularly worthy of discussion. Bold added.
“Criminal activity, particularly violent crime, is much more common among men than women in the general population. A previous study of all applications for sex reassignment in Sweden up to 1992 found that 9.7% of male-to-female and 6.1% of female to-male applicants had been prosecuted for a crime. Crime after sex reassignment, however, has not previously been studied.”
“…regarding any crime, male-to-females had a significantly increased risk for crime compared to female controls (aHR 6.6; 95% CI 4.1–10.8) but not compared to males (aHR 0.8; 95% CI 0.5–1.2). This indicates that they retained a male pattern regarding criminality. The same was true regarding violent crime. By contrast, female-to-males had higher crime rates than female controls (aHR 4.1; 95% CI 2.5–6.9) but did not differ from male controls. This indicates a shift to a male pattern regarding criminality and that sex reassignment is coupled to increased crime rate in female-to-males. The same was true regarding violent crime.“
“Sex reassignment” does not reduce criminality in male-to-females (transwomen). At the same time, it seems to increase criminality for female-to-males (transmen). From a crime reduction standpoint, this is concerning. Further, it vindicates the experience of many women that transwomen as a group retain–or are unable to fully discard– some male pattern behaviors associated with male socialization. To be clear, I am not saying that all transwomen “act like men.” I am saying that some transwomen do seem to “act like men,” even after “sex reassignment” surgery. The criminal conviction rates documented in this study provide empirical evidence for this view.
Now, about trans men. Many people will suspect, and therefore conclude, that increased violent crime among female-to-male trans people is caused by the use of testosterone. This is a comforting but over-simplistic rationale made easily convincing by a steady flow of pop-science articles about animal research and biological essentialism. Independent research about the effects of testosterone on females in a double-blind, placebo controlled experiment (pdf here) investigated whether a causal, not merely correlative, link exists between testosterone and unfair social interactions. The results show that females do not respond to testosterone with increased aggression. In fact, they found the opposite. Testosterone’s effects on certain animals are well known, but new research is showing that the effects on humans are not so clear-cut. Criminality among female-to-male transsexuals should not be so quickly attributed to the use of cross-sex hormone therapy. Biological explanations for violence ignore the complexity of human interactions.
An equally plausible theory is that increased criminal activity among transmen may be a result of identifying with the social constructs of masculinity in general, and the cult of masculinity in particular. Transmen can “authenticate” their identities as men in a few different ways; namely by changing their bodies and/or by expressing masculinity. Transmen may not feel socially validated as “real” men (the goal of transitioning) in any given context if they do not present as sufficiently masculine, whatever that requires. Displays of aggression, domination, and violence– behaviors intrinsic to socially constructed masculinity– may function superficially as proof of identity. This obviously plays out to the detriment of transmen in particular, and all men in general. Gender is toxic to everyone. It is toxic to men and women and transmen and transwomen and intersex people too.
Studies 3 and 4: PATIENT SATISFACTION versus SURGICAL COMPLICATIONS
The third study reports on subjective patient satisfaction outcomes. They are inarguably positive, though it has a smaller sample size than either of the first two studies. The fourth study (which has the smallest sample size), Long-term outcome of forearm free-flap phalloplasty, is different than the others because it analyzes objective surgical outcomes alongside subjective patient satisfaction. There is a stunning disconnect. I appreciate that this particular kind of genital surgery, forearm free-flap phalloplasty, may be poorly designed or executed under the circumstances. Male-to-female vaginoplasty is generally much more objectively successful as a surgical procedure regardless of technique used. Objective success is usually a strong predictor of subjective success, so overall rates of success are expected to be high in both areas.
The results of this particular study actually underscore the point I wish to make: overwhelmingly positive subjective outcomes were reported in spite of significant negative objective outcomes. Just read the abstract. Over a quarter of the participants had serious failures in functional outcomes of one kind or another, yet they still rated their subjective satisfaction with the procedures very highly. This should be a red flag to the researchers.* There are a number of reasons why the results might skewed. I’ve read some very interesting theories, which we can discuss in the comments, but until there is more and better long term research, we can’t be sure. In the meantime, we have reason to be concerned, particularly about complications with phalloplasty.
As this brief review of long term studies illustrates, positive patient satisfaction should be separated from objectively measurably negative outcomes in order to fully understand the efficacy and “success” of “sex reassignment” procedures. We must be skeptical and refuse to accept emotionally motivated claims that are not supported by long term evidence. We must subject these studies to rigorous analysis.
Everyone has an opinion; some are clearly more informed than others.
*I suggest that one way to better validate subjective data in future research might be to use the “Veiled Report” method which makes it nearly impossible to associate a particular respondent with her answers to test questions.
Dhejne C, Lichtenstein P, Boman M, Johansson ALV, Långström N, et al. (2011) Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden. PLoS ONE 6(2): e16885. doi:10.1371/journal.pone.0016885
Context: The treatment for transsexualism is sex reassignment, including hormonal treatment and surgery aimed at making the person’s body as congruent with the opposite sex as possible. There is a dearth of long term, follow-up studies after sex reassignment.
Objective: To estimate mortality, morbidity, and criminal rate after surgical sex reassignment of transsexual persons.
Design: A population-based matched cohort study.
Setting: Sweden, 1973-2003.
Participants: All 324 sex-reassigned persons (191 male-to-females, 133 female-to-males) in Sweden, 1973–2003. Random population controls (10:1) were matched by birth year and birth sex or reassigned (final) sex, respectively.
Main Outcome Measures: Hazard ratios (HR) with 95% confidence intervals (CI) for mortality and psychiatric morbidity were obtained with Cox regression models, which were adjusted for immigrant status and psychiatric morbidity prior to sex reassignment (adjusted HR [aHR]).
Results: The overall mortality for sex-reassigned persons was higher during follow-up (aHR 2.8; 95% CI 1.8–4.3) than for controls of the same birth sex, particularly death from suicide (aHR 19.1; 95% CI 5.8–62.9). Sex-reassigned persons also had an increased risk for suicide attempts (aHR 4.9; 95% CI 2.9–8.5) and psychiatric inpatient care (aHR 2.8; 95% CI 2.0–3.9). Comparisons with controls matched on reassigned sex yielded similar results. Female-to-males, but not male-to-females, had a higher risk for criminal convictions than their respective birth sex controls.
Conclusions: Persons with transsexualism, after sex reassignment, have considerably higher risks for mortality, suicidal behaviour, and psychiatric morbidity than the general population. Our findings suggest that sex reassignment, although alleviating gender dysphoria, may not suffice as treatment for transsexualism, and should inspire improved psychiatric and somatic care after sex reassignment for this patient group.
Henk Asscheman, Erik J Giltay, Jos A J Megens, W (Pim) de Ronde, Michael A A van Trotsenburg and Louis J G Gooren. European Journal of Endocrinology 164 635–642. DOI: 10.1530/EJE-10-1038
Objective: Adverse effects of long-term cross-sex hormone administration to transsexuals are not well documented. We assessed mortality rates in transsexual subjects receiving long-term cross-sex hormones.
Design: A cohort study with a median follow-up of 18.5 years at a university gender clinic.
Methods: Mortality data and the standardized mortality rate were compared with the general population in 966 male-to-female (MtF) and 365 female-to-male (FtM) transsexuals, who started cross-sex hormones before July 1, 1997. Follow-up was at least 1 year. MtF transsexuals received treatment with different high-dose estrogen regimens and cyproterone acetate 100 mg/day. FtM transsexuals received parenteral/oral testosterone esters or testosterone gel. After surgical sex reassignment, hormonal treatment was continued with lower doses.
Results: In the MtF group, 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. No increase was observed in total cancer mortality, but lung and hematological cancer mortality rates were elevated. Current, but not past ethinyl estradiol use was associated with an independent threefold increased risk of cardiovascular death. In FtM transsexuals, total mortality and cause-speciﬁc mortality were not signiﬁcantly different from those of the general population.
Conclusions: The increased mortality in hormone-treated MtF transsexuals was mainly due to nonhormone-related causes, but ethinyl estradiol may increase the risk of cardiovascular death. In the FtM transsexuals, use of testosterone in doses used for hypogonadal men seemed safe.
Yolanda L S Smith, Stephanie H M Van Goozen, Abraham J Kuiper, Peggy T Cohen-Kettenis. Psychological Medicine, 2005, 35, 89–99. DOI: 10.1017/S0033291704002776
Background: We prospectively studied outcomes of sex reassignment, potential diﬀerences between subgroups of transsexuals, and predictors of treatment course and outcome.
Method: Altogether 325 consecutive adolescent and adult applicants for sex reassignment participated: 222 started hormone treatment, 103 did not; 188 completed and 34 dropped out of treatment. Only data of the 162 adults were used to evaluate treatment. Results between subgroups were compared to determine post-operative diﬀerences. Adults and adolescents were included to study predictors of treatment course and outcome. Results were statistically analysed with logistic regression and multiple linear regression analyses.
Results: After treatment the group was no longer gender dysphoric. The vast majority functioned quite well psychologically, socially and sexually. Two non-homosexual male-to-female transsexuals expressed regrets. Post-operatively, female-to-male and homosexual transsexuals functioned better in many respects than male-to-female and non-homosexual transsexuals. Eligibility for treatment was largely based upon gender dysphoria, psychological stability, and physical appearance. Male-to-female transsexuals with more psychopathology and cross-gender symptoms in childhood, yet less gender dysphoria at application, were more likely to drop out prematurely. Non-homosexual applicants with much psychopathology and body dissatisfaction reported the worst post-operative outcomes.
Conclusions: The results substantiate previous conclusions that sex reassignment is eﬀective. Still, clinicians need to be alert for non-homosexual male-to-females with unfavourable psychological functioning and physical appearance and inconsistent gender dysphoria reports, as these are risk factors for dropping out and poor post-operative results. If they are considered eligible, they may require additional therapeutic guidance during or even after treatment.
Leriche, A., Timsit, M.-O., Morel-Journel, N., Bouillot, A., Dembele, D. and Ruffion, A. (2008), Long-term outcome of forearm flee-flap [sic] phalloplasty in the treatment of transsexualism. BJU International, 101: 1297–1300. doi: 10.1111/j.1464-410X.2007.07362.x
Objective: To assess the long-term outcome of forearm free-flap phalloplasty in transsexuals, as obtaining a satisfying neophallus in female-to-male transsexuals is a surgical challenge.
Patients and Methods: We analysed retrospectively 56 transsexuals who had a phalloplasty using a radial forearm free-flap in our department from 1986 to 2002. The complication rate was assessed by regular examination. Patient satisfaction was evaluated by a questionnaire about cosmetic aspects, sexual life and overall satisfaction.
Results: The mean follow up was 110 months; 53 of the 56 patients (95%) currently have a neophallus, after a mean of six surgical procedures. Satisfaction was assessed in 53 patients using a specific questionnaire: 51 (93%) of the patients reported that the phalloplasty allowed them to accord their physical appearance with their feeling of masculinity. There were flap complications in 14 patients (25%); three (5%) flaps were lost, with one each due to early haematoma, cellulitis and late arterial thrombosis. The other 11 flap complications were all transitory, e.g. infection, haematomas and vascular thrombosis. There were prosthesis complications in 11 of 38 patients (29%). Moreover, seven of 19 patients (37%) who had a urethroplasty presented with complex strictures and fistulae that led to perineal urethrostomy.