Carys Moseley comments on the American Journal of Psychiatry’s recent admission that it was wrong to report gender surgery leads to better mental health.
Last month, the American Journal of Psychiatry published a major correction to a study that had promoted gender reassignment surgery. The study was based on data from nearly the entire population of Sweden. As such, it was promoted as solid evidence that gender reassignment surgery led to better mental health outcomes for patients than not having surgery. The correction admitted that due to problems with its method, the study’s outcome did not make sense of the data used. The editors were forced to conclude that,
“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.”
This new conclusion stands in rather stark contrast to the previous one, and should really have an effect on healthcare policies on gender reassignment internationally.
The aims of the original study
The original study’s aims were as follows:
“to ascertain the prevalence of mood and anxiety disorder health care visits and antidepressant and anxiolytic prescriptions in 2015 as a function of gender incongruence diagnosis and gender-affirming hormone and surgical treatment in the entire Swedish population.”
In other words, medical researchers wanted to discover how often people who had undergone cross-sex hormone and gender reassignment treatment subsequently accessed healthcare due to suffering from depression or anxiety. This included visits to doctors, prescriptions for antidepressants or anti-anxiety drugs, and hospitalisation for suicide attempts. Put more simply, the question was whether these treatments result in people suffering more or less depression or anxiety. It looked at people in Sweden diagnosed with gender incongruence, i.e. transsexualism or gender identity disorder between 2005 and 2015.
Results and conclusions of the original study
The study found that people diagnosed with gender incongruence were six times more likely than others to visit doctors due to mood or anxiety disorders. They were also over three times as likely as other people to receive prescriptions for antidepressant and anti-anxiety drugs. Finally, the likelihood of being sent to hospital after a suicide attempt was six times higher than that of the general population.
Overall, the original study claimed that there was no relation between the number of years they had started cross-sex hormones and how likely they were to have received mental health treatment. Most importantly it claimed that the more time had lapsed since gender reassignment surgery, the less likely people were to have had mental health treatment. On this basis the authors of the study concluded as follows:
“In this first total population study of transgender individuals with a gender incongruence diagnosis, the longitudinal association between gender-affirming surgery and reduced likelihood of mental health treatment lends support to the decision to provide gender-affirming surgeries to transgender individuals who seek them.”
The correction to the study
On 1 August this year the American Journal of Psychiatry published a paragraph correcting the study. Here it is reproduced in its entirety.
“After the article “Reduction in Mental Health Treatment Utilization Among Transgender Individuals After Gender-Affirming Surgeries: A Total Population Study” by Richard Bränström, Ph.D., and John E. Pachankis, Ph.D. (doi: 10.1176/appi.ajp.2019.19010080), was published online on October 4, 2019, some letters containing questions on the statistical methodology employed in the study led the Journal to seek statistical consultations. The results of these consultations were presented to the study authors, who concurred with many of the points raised. Upon request, the authors reanalyzed the data to compare outcomes between individuals diagnosed with gender incongruence who had received gender-affirming surgical treatments and those diagnosed with gender incongruence who had not. While this comparison was performed retrospectively and was not part of the original research question given that several other factors may differ between the groups, 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. Given that the study used neither a prospective cohort design nor a randomized controlled trial design, 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. Finally, although the percentage of individuals with a gender incongruence diagnosis who had received gender-affirming surgical treatments during the follow-up period is correctly reported in Table 3 (37.9%), the text incorrectly refers to this percentage as 48%. The article was reposted on August 1, 2020, correcting this percentage and including an addendum referencing the post-publication discussion captured in the Letters to the Editor section of the August 2020 issue of the Journal (1).”
Why the study was challenged
This correction was printed due to numerous academics spotting problems with the study’s outcomes not matching the statistical methods used. They contacted the journal outlining their criticisms. One of these academics was sociologist Mark Regnerus, who wrote an article in November 2019 in Public Discourse on the matter.
Before launching into his analysis, Regnerus noted that the study already found “no mental health benefits for hormonal interventions in this population.” This is important for two reasons. The first is the popularity of hormones, something he discusses. The second is that given this finding, it is unsurprising that the question of the benefits of surgery would become more important.
In the study, 35% of those who had surgery within the last 9 years then had mental health treatment. This figure dropped to 21% of those who had surgery ten or more years previously. Regnerus took a closer look at the data for post-operative patients and found that as many as 574 out of 1018 of them had had surgery within the last two years. Only 19 respondents had surgery more than 10 years ago. Thus, he worked out that only 4 out of these 19 would have had mental health treatment in 2015.
Regnerus then showed that these very small numbers meant that even a small hypothetical increase or decrease in patient numbers could have led to dramatically different results.
“If a mere three additional cases among these 19 had sought mental health treatment in 2015, there would appear to be no discernible overall effect of surgery on subsequent mental health…. On the other hand, a decrease of just three treated individuals (from 4 to 1 out of 19) … would enable a claim of a 12-percent reduction in mental health assistance from getting the surgery.”
Regnerus went on to show that there was insufficient evidence anyway to back up the confident conclusions of the study:
“The modest effect of surgery hinges on a handful of cases from an earlier era (10 or more years ago) when very few gender dysphoric patients pursued surgery at all.”
He also points out that we don’t know how many Swedes committed suicide after gender reassignment surgery, because the study did not ask this question. This alone is very important given the ubiquitous claim that refusal or disapproval of physical gender reassignment pushes patients to commit suicide.
‘This is not how normal medical research works’
Mark Regnerus observed that it was becoming more difficult to defend objective reasoning in medical research on transgender issues. This is in the face of activist medical ‘research’. He gave as a parallel case ‘research’ published a few weeks later on ‘conversion therapy’ where the lead author campaigns for a ban on this idea.
Regnerus noted the lack of a “defined psychotherapeutic method for treating gender dysphoria” that can be defined as ‘conversion therapy’. He also points out that there has never been a clinical trial that evaluates any such methods to show whether they are helpful or harmful. He concluded by saying that “this is not how normal medical research works.”
American media silence shows bias
Writing for the Federalist, Glenn T Stanton pointed out that none of the American news sites that gleefully reported the original study subsequently reported on this correction. He singled out Reuters, ABC News and US News and World Report in this respect. How’s that for obvious bias?
It is important to realise that this inconsistency matters for us here in the UK as well. The reason is that the study – like many such scientific studies – whilst based on one country, was intended to influence healthcare policy internationally.
With the exception of the Coronavirus, few topics in current healthcare debates are as controversial as gender reassignment. We would expect major American news sites at least to report on this correction, given its medical and social policy implications. Indeed, if this were any other subject, we can guarantee there would be a furore about not correcting a faulty conclusion on such an influential subject.
It is worth pausing to reflect on the significance of choosing Sweden to conduct this study. For much of the twentieth century Sweden was held up as the prototype of the modern cradle-to-grave welfare state with its taxpayer-funded healthcare system. It was treated as a laboratory for progressive policies that could be imitated elsewhere. Because of its modest population size, Sweden has been used for numerous studies on healthcare, with datasets comprised of the majority of the population. This has enabled rational discussion of the effect of healthcare policies on entire countries.
It is obvious that the present study in its original form lived up to the progressive utopian fantasy of Sweden. The reality is that the data from Sweden undermines this caricature. Regnerus puts it well: when it comes to population-level studies of gender reassignment, “this is as good as it gets.” What this means is that given that this study has not found what was originally claimed by its authors, we are unlikely to have another one that proves what they clearly wanted to be the case.
Lessons to be learnt
There are definitely important lessons to be learnt here, by medical researchers, academic journals, journalists, news editors, and healthcare policy makers. Twisting the conclusions of a scientific study to fit a practice that is contrary to medicine is unethical. The truth is that there was a problem with the editorial process at the American Journal of Psychiatry. Usually with a peer-reviewed academic journal of this kind, the editor finds at least two other academics to conduct anonymous peer reviews of articles sent in. In this case it is clear the peer review process itself was biased in favour of gender reassignment, and thus contrary to medicine. This is true of the peer reviewers themselves and of the editor. At the very least, these people do not seem to have wanted to confront the paper on ethical grounds let alone statistical ones.
The problem goes deep, as the AJP is the official journal of the America Psychiatric Association, the mental health professional body for psychiatrists in the USA. Given the USA’s role as the only western superpower, the moral influence of American professional organisations such as the American Psychiatric Association on other western countries is obvious. This makes challenging activism in its own journal all the more necessary.