Evaluating long term studies on the efficacy of “sex reassignment” procedures: objective versus subjective measurements

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.

  1. 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).
  2. 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).
  3. Smith, 2005 study on the self-reported satisfaction of 162 transsexuals receiving cross-hormone treatment in the Netherlands.
  4. 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.[33] 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.

#genderskeptic

#gendercrit

#gendercrit4life

*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. 

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1.

Long-Term Follow-Up of Transsexual PersonsLong-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden

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

Abstract

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.

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2.

A long-term follow-up study of mortality in transsexuals_HORMONES A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones.

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

Abstract

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.

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3.

Sex reassignment outcomes and predictors of treatment Sex reassignment: outcomes and predictors of treatment for adolescent and adult transsexuals

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

ABSTRACT

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.

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4.

Long-term outcome of forearm flee-flap phalloplasty inLong-term outcome of forearm flee-flap [sic] phalloplasty in the treatment of transsexualism

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.

Conclusion: Our study shows that phalloplasty with a forearm free-flap leads to good results in term of flap survival and patient satisfaction. However, there was a high rate of complications. Patients must be clearly informed that the procedure can seldom be achieved in one stage.

13 comments

  1. Reblogged this on I'M NOT "TRANSGENDER" ANY MORE and commented:
    MUCH-needed and brilliant analysis.

  2. […] Evaluating long term studies on the efficacy of “sex reassignment” procedures: objective… (sexnotgender.com) […]

  3. ” 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… Suicidal ideations should be immediately evaluated for risk of danger, never negotiated with.”

    Check out the recent debate on abortion law in Ireland. Completely unrelated to trans issues.

    Ireland’s constitution recognizes an equal right to life of the mother and the fetus (I would not like to debate the merits here, I did not write the amendment, it was passed by referendum when I was a minor and did not even hear about Ireland). Some court cases and a recent hospital tragedy, when a woman died and it was alleged that an earlier abortion would have saved her, necessitated legislation clarifying what kind of danger to the mother makes an abortion permissible.

    The big debate around the law was exactly on whether to include danger of suicide. The law was eventually passed with danger of suicide included.

    Thus there is clear recent precedent, in a Western country, where a certain procedure, otherwise prohibited, is permitted based on suicide ideation. So now you know. (Ireland has a two-tier medical system, private and public, with access to much of the public tier means-tested; so this decision does mean some abortions in case of a threat of suicide will be carried on the public purse, given passage of the means test).

    On the rest of your analysis.

    “Yet these findings contradict arguments that surgery and/or cross-sex hormones are urgently necessary interventions that prevent suicide and other self-harming behaviors.”

    They only contradict a statement that they COMPLETELY prevent any negative outcomes, but such statements are not made by anyone remotely linked to medicine. They might be made by some patients where the value of such statements is primarily therapeutic.

    “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.”

    What insistence? Who actually insists on them being a panacea, as opposed to a key treatment? Do you have a single reference for such insistence?

    The WPATH SoC document insists on a full mental health assessment as a requirement for surgery. It states psychotherapy is “highly recommended though not an absolute requirement”. It does have a statement on follow-up care though I understand you might see it as too short and not binding enough.

    Also, you state the fact that, in the last study, high level of patient satisfaction despite a high level of surgical complications should be a red flag. You posit a dichotomy between objective and subjective results. However, this approach is somewhat dated when medicine is concerned, especially in cases where a complete cure is not within reach (and transsexualism is one such case). Much newer research – and I’m speaking of areas completely unrelated to trans issues – tends to concentrate on “quality of life”, which integrates the objective and subjective parts. There is an ongoing debate in the weight given to such parts in quality of life assessments.

    From a quality of life perspective, the results of the last study simply show that results interact in complex ways. The article states at the start that “obtaining a satisfying neophallus in female-to-male transsexuals is a surgical challenge”, then proceeds to evaluate the results, to date, of one method of meeting this challenge. Note that “satisfying” is a key part of the stated challenge – and with regards to complications, the results seems to show a somewhat low threshold for satisfaction, .

    One possible reason for these results is self-selection for the operation. While male to female transsexuals (identified and specifically diagnosed as such) generally want a vaginoplasty given the access, many female to male transsexuals opt for hormones and top surgery only, specifically because of problems with phalloplasty. So, even though the study is apparently European and access is not an issue, only those who have a very pressing need get the operation at all.

    Note that the article itself does notice the “red flag”. “Despite the high morbidity there was a high (90%) satisfaction rate in the present study. These apparently contradictory results might be explained by the strong motivation of the patients, accumulated after years of administrative stages and medical treatment, which allows them to accept frequent hospitalization, consultations and surgical procedures. It is also possibly a consequence of the considerable time we spend in explaining in detail the various risks of the procedure, and that there were few (5%) serious complications that needed explantation of the phalloplasty.”

    On that same study, note that satisfaction seems to have little relation to sexual intercourse. While satisfaction is at 93%, the article further states that “18 of 56 (32%) patients had satisfactory sexual intercourse with penetration”. So, even if we assume that all of these 32% were satisfies, there remain 61% of the total who did NOT have satisfactory sexual intercourse with penetration yet are satisfied. This seems to confirm the view that the primary cause for surgery is body dissatisfaction as opposed to sexual needs.

  4. Also, factual errors: the second study is in the Netherlands, not Sweden; it analyzes both objective and subjective data, not just objective.

    It is probably the closest to a comprehensive quality of life review of the four studies listed. And for some reason you don’t quote its findings on improvement in psychological functioning (not the same as satisfaction):

    Psychological functioning. At follow-up the
    group functioned psychologically better. Scores
    on Negativism and Shyness had improved.
    Scores on Somatization, Psychopathology, and
    Extroversion showed a tendency towards improvement
    (pf0.006). In general, follow-up
    scores indicated fewer psychological problems
    (Table 2). Comparing pre- and post-test group
    means with Dutch normative data, most scores
    remained within the average range at follow-up,
    although Extroversion scores were below average.
    Somatization scores were high at pre-test.
    The mean Psychoneuroticism score was lower
    after SR [see Table 2 for lower scores on four of
    the eight subscales (p<0.001)]. These scores can
    only be compared with Dutch normative data
    for males and females separately. Both the MF
    (p=0.001) and FM (p<0.001) group showed
    improvement in mean scores. The MFs went
    from above average at pre-test (mean=143,
    S.D.=38.0) to average at post-test (mean=123,
    S.D.=36.0); the FMs went from high (mean=
    143, S.D.=44.8) to above average at follow-up
    (mean=116, S.D.=22.8).

    This information does show that transition treatment leads to improvement in psychological outlook (inasmuch as it can be measured objectively at all).

    Note also that a key aim of the article is to work out predictors for success of treatment, which should be used for assessing eligibility. This work is enabled by Sweden's comprehensive access to medical treatment. The problem with the American system of access based on income is that it is likely to lead to a reverse selection. Those with most severe sex dysphoria tend to function worse and therefore have a lower chance of attaining sufficient income; moreover when they do attain it they tend to be past the optimal age for treatment.

  5. Should have been “the Netherlands” in the last paragraph! But they both have comprehensive access anyway. The Netherlands have a compulsory, heavily regulated private insurance system, Sweden has a tax-funded system.

  6. cerulean blue · ·

    ramendik,

    Do you think it is amusing to compare vaginoplasty and phalloplasty to the life and death situation that defines abortion in Ireland?

    As an Irish resident, certainly you are aware of the incident, only one year ago, that triggered the law you talk about. In Ireland, a court decision made it possible for doctors to terminate pregnancies if the life of the mother was in danger, but in practice, few would do so because this decision was not codified into law. Furthermore, it was the “life” of the mother, not the “health” of the mother that was discussed by the court. Therefore doctors would have to prove that the woman would have died without the abortion. Enter Savita Halappanavar, suffering from a uterine infection and pre-term dilation, who was not allowed an abortion, despite the fact that her fetus– its rights, equal to hers, enshrined into law– was literally killing her.

    Savita died, remember? Most people considered it a big deal, not something to troll with.

    Certainly you are also aware that under the new Irish law that allows women the right to have an abortion if suicidal, this suicidal ideation must be attested to be two psychiatrists and an obstetrician. And of course, you are also aware that this new law still contains the words, “It shall be an offense to intentionally destroy unborn human life,” which forces a woman to biologically support a being that is a parasite (defined as an organism that lives in or on another organism (its host) and benefits by deriving nutrients at the host’s expense) until it is viable, despite any risk to her health, which all of us who have carried a child can attest to.

    Yes, ramendik, if we are dealing in technicalities, there is a country that allows a particular form of surgery if a person is shown to be suicidal. But this country’s law making, its hospitals and schools have long been dominated by religiosity and adherence to doctrines of a church that has long held women as inferior to men. And this suicide clause is one of very few exceptions to an anti-abortion law that would not pass in most western countries. This new law does very little to change the unequal status of women in Ireland.

    I think we can assume that as an Irish resident, no doctor would have a problem removing a tapeworm from your gut, even if animal rights activists claimed it was murder. And if you consider this a poor analogy due to the fact that a tapeworm is not human, no doctor would object to removing living cancerous tissue, which is definitely human, and parasitic, from your body. (*unless, of course you were a woman, and doing so put the fetus at risk. Remember, life not health is the key word in the abortion law.) And importantly, you would not need suicidal ideation for either of these procedures to be done. Of course, neither of these examples are precisely analogous to abortion. It’s ridiculous to imagine someone forcing the implantation of a tapeworm in your body, or somehow giving you cancer. And as you are a member of the 50% of the population that will never be pregnant, let alone need an abortion, there’s no true analogy we can draw. The suicide clause is a bone that was thrown to the 85% of the Irish population that think abortion is permissible in some circumstances and who were disgusted and enraged by Savita’s treatment. This law is something that ineffectively redresses the fact that women in Ireland do not have control over their bodies.

    So with that in mind, how is this law allowing abortion in the face of suicide in any way analogous to a person crying suicide over a desire for cosmetic surgery on a body part? Don’t you see the very real and clear distinction between being forced to serve as a biological host, with all the risks to health attendant to that job, and wanting a body part you are fixated on?

    If you want to make a true comparison, compare a person– like Michael Jackson– fixated on cosmetic surgery claiming he will commit suicide if his nose isn’t reshaped for the umpteenth time.

  7. Cerulean Blue, thank you.

    “Don’t you see the very real and clear distinction between being forced to serve as a biological host, with all the risks to health attendant to that job, and [not] wanting a body part you are fixated on?”

  8. Mikhail Ramendik, thank you for the Sweden/Netherlands correction. It has been attended to.

  9. Good morning Elizabeth,

    These are some interesting studies here I think, but I’m not sure exactly how we should apply them. The criminality study is particularly interesting, but my wonder is how the culture difference between Scandinavia and say the United States may effect those numbers closer to (my) home. Clearly there is a massive social cultural difference there. Additionally does that account for discriminatory convictions? Again I cannot speak for Sweden, but I know in America when a person is discovered to be trans by the police they are treated as less of a victim and more of a criminal regardless of the situation. A story of a woman attacked at a black Friday sale, whose report was taken by police, and promptly discarded,with her being treated as the aggressor, when it was found out she was trans comes to mind. (http://www.queerty.com/akasha-adonis-was-punched-in-the-face-on-black-friday-did-cops-stop-caring-after-learning-shes-trans-20101204/) This obviously isn’t exactly the same, but similar to the way other minorities are profiled. I wonder if that was accounted for, as it makes no mention of it in the study.

    I think your analysis on the increased crime of trans men is spot on. It likely is the result of the same thing that causes all men to behave in that way, the social cultural pressures to be more masculine to be a genuine man. They may feel it even more strongly than other men, because of their trans status.

    As far as the happiness after surgery study is concerned, I’m sure some people report false positive results. With the complications, particular in FtM surgeries, it is hard to imagine how some people could report genuinely being happy with the result. Follow up time periods may result in more falsely positive results, as the sheer psychological relief of finally having completed such a major life step could blind someone from the problems early on. At the same time, for some, regardless of the specific outcome to no longer have the anatomy which has caused you distress for your entire life, to feel like you have done all you can in modern times to address your biggest problem, and feel like you’re finally as happy as you can be in your body, it might be all that they needed. Maybe they can ignore the specific quality of their surgery for the incredible effect it has in their life to feel more at home with themselves. But certainly some report positive results to corroborate their narratives. It’s hard from numbers to differentiate the two, but I’m sure from the face of the patient the difference is obvious. Maybe I’m looking too far into it though.

    Thank you,
    -Kat

  10. Cataloging comment only.

    From page 82 INJUSTICE AT EVERY TURN: A REPORT OF THE NATIONAL TRANSGENDER DISCRIMINATION SURVEY:

    http://www.thetaskforce.org/downloads/reports/reports/ntds_full.pdf

    “When asked “have you ever attempted suicide?” 41% of respondents answered yes.”
    ………….
    “However, there are a number
    of attributes that align with
    an increased rate of attempted suicide. High risk groups include
    visual non-conformers (44%) and those who are generally out
    about their transgender status (44%). Those who have medically
    transitioned (45%) and surgically transitioned (43%) have higher
    rates of attempted suicide than those who have not (34% and
    39% respectively).”
    _____________________

    “The National Gay and Lesbian Task Force and the National Center for Transgender Equality are
    grateful to each of the 6,450 transgender and gender non-conforming study participants who
    took the time and energy to answer questions about the depth and breadth of injustice in their
    lives. A diverse set of people, from all 50 states, the District of Columbia, Puerto Rico, Guam and
    the U.S. Virgin Islands, completed online or paper surveys. This tremendous gift has created the
    first 360-degree picture of discrimination against transgender and gender non-conforming people
    in the U.S. and provides critical data points for policymakers, community activists and legal
    advocates to confront the appalling realities documented here and press the case for equity and
    justice.”

  11. “Those who have medically
    transitioned (45%) and surgically transitioned (43%) have higher
    rates of attempted suicide than those who have not (34% and
    39% respectively).”

    Note the data does not state which of these attempts happened before the transition.

    A plausible scenario is that those who do transition do so under the same pressure of dysphoria that also drives these same persons to attempt suicide because they perceived transition as unavailable (financially or otherwise), simply did not know about it at the time, or perceived i as unsuccessful at some point.

    Another factor is family isolation that those who transition often face. In fact, ALL cases of detransition that I know from references on critical sites (at least MtF) were related to family pressure in some way. One highly publicized case, Ria Cooper in the UK, obviously declared for detransitioning because of family pressure (which was then hailed at radfem sites) – then, according to her twitter, found a boyfriend and quietly stayed transitioned. It is quite plausible that such pressure also leads to some suicide attempts.

  12. Tobysgirl · ·

    This is video is very enlightening. It would seem that many young people have absolutely no idea of the fire they are playing with when they take hormones. This would equate with gross medical negligence. Sex hormones are phenomenally powerful — in very tiny quantities. It has been suggested that testosterone is toxic in and of itself, and explains men’s shorter life spans.

    That said, I’ve been post-menopausal (surgical menopause) for nearly 20 years, have no ovaries, and have no problems with UTIs, yeast, etc. If the urologist this young woman is seeing has so many post-menopausal female patients, she needs to be altering her practice and treating them properly, starting with full panel thyroid tests.

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