The American Journal of Psychiatry (AJP) published a study in October 2019, claiming that performing surgeries on transgender-identified people, in an effort to make them look like the opposite sex, led to reduced need for mental health treatment.

The authors asserted that their findings justified providing “gender-affirming surgeries to transgender individuals.”

The AJP received letters complaining about methodology and analysis, so they, along with the authors, reevaluated the study. Now, ten months later, the AJP has published a correction, saying that conclusion was “too strong.”  

The research, “Reduction in Mental Health Treatment Utilization Among Transgender Individuals After Gender-Affirming Surgeries: A Total Population Study,” was conducted by Dr. Richard Bränström and Dr. John E. Pachankis, from the Yale School of Public Health and the Karolinska Institutet in Stockholm.

The doctors examined data from the Swedish Total Population Register of 9.7 million people. Of that number, 2,679 individuals had received a diagnosis of gender incongruence between 2005 and 2015. Of those, 1,018 had received surgery to look like the opposite sex and 1,885 were given opposite sex hormones – what the authors sometimes euphemistically called “hormone replacement therapy.”

Compared with the general population, the researchers explain that those with sexual identity conflicts suffer from:

  • Six times the rate of mental health visits for mood or anxiety disorders.
  • More than three times the rate of prescriptions for depression or anxiety.
  • More than six times the rate of hospitalization after a suicide attempt.

The researchers looked at each of these areas to find whether they were affected by hormones or surgery.

Surgeries and hormones, called “gender-affirming care,” have become the preferred treatment for those who reject their bodies and believe they are the opposite sex, rather than treating and healing the issues that lead to sexual identity struggles.

Bränström and Pachankis reported some reductions in mental health treatment after individuals had surgery, but still showed high levels in each area compared to the general population. The authors said the reduction supported providing “gender-affirming surgeries to transgender individuals.” This message was trumpeted by media outlets, medical organizations and transgender activist groups.

At the same time, the authors found no mental health benefits from giving individuals opposite sex hormones. That result was left out of the article’s title and conclusion, and was largely ignored by the media, medical groups and transgender activist organizations.   

When the study was released, one of the first to review it was Mark Regnerus, a Professor of Sociology at the University of Texas. He questioned the authors’ intent in the very title of his article, “New Data Show “Gender-Affirming” Surgery Doesn’t Really Improve Mental Health. So Why Are the Study’s Authors Saying It Does?”

Regnerus analyzed the data and calculated the “Number Needed to Treat” (NNT), “a measure of clinical impact.” This number estimates “the number of patients that need to be treated in order to have an impact on one person.”

From the data provided by Bränström and Pachankis, Regnerus calculated the NNT and wrote, “In this study, the NNT appears to be a staggering 49, meaning the beneficial effect of surgery is so small that a clinic may have to perform 49 gender-affirming surgeries before they could expect to prevent one additional person from seeking subsequent mental health assistance.”

He said, “That the authors corrupted otherwise excellent data and analyses with a skewed interpretation signals an abandonment of scientific rigor and reason in favor of complicity with activist groups seeking to normalize infertility-inducing and permanently disfiguring surgeries.”

Regnerus concluded, “This is not how normal medical research works.”

Another group of doctors with experience in research, writing about and treating transgenderism looked at the study and wrote the AJP. Board-certified Doctors Andre Van Mol, who practices family medicine; Michael K. Laidlaw, an endocrinologist; and psychiatrists Miriam Grossman and Paul R. McHugh challenged the findings.

Their letter to the editor, “Gender-Affirmation Surgery Conclusion Lacks Evidence,” was published in the August 2020 issue of the AJP. It says that the measured outcomes in the study only looked at the three issues listed above.

The doctors wrote, “This selection excludes completed suicides, suicide attempts without subsequent hospitalization, health care visits and hospitalizations for other medical or psychological issues still related to gender-affirming surgeries, individuals refusing treatment, and individuals choosing self-medication with alcohol or illicit substances.” Research has shown that individuals struggling with their sexual identity often have multiple mental health issues along with higher rates of these other relational and behavioral issues.

They cited other problems with the research, “The lack of control subjects, the limited 1-year time frame, and the avoidance of examining completed suicides and psychiatric hospitalizations are substantial study shortfalls.”

The doctors critique concluded: “The study supports only weak conclusions about psychiatric medication usage and nothing decisive about suicidality. In overlooking so much available data, this study lacks the evidence to support its pro-gender-affirmation surgery conclusion.”

Van Mol is co-chair of the American College of Pediatricians’ Adolescent Sexuality Committee and co-chair of the Christian Medical and Dental Associations’ new Transgender Task Force, where he is one of their national bloggers.

He told The Daily Citizen, “Ours was among several letters to the AJP detailing strong concern that the study findings failed to be supported by the evidence provided.” He said this moved the AJP editors “to seek statistical consultations.” 

According to Van Mol, “The conclusions of those consultations resulted in the study authors reanalyzing their data, of which the AJP correction stated ‘no advantage to surgery’ (i.e., ‘gender-affirming surgery,’ aka ‘sex-reassignment surgery’) was found regarding prescriptions or health-care visits for mood or anxiety disorders as well as post-suicide attempt hospitalizations.”

He said, “The Bränström and Pachankis study had already stated that ‘gender-affirming hormone treatment’ provided no improvement either.”

“The study now seems invalidated,” he concluded. But few outlets, except for some Christian and conservative ones, have reported on the correction.

Van Mol, speaking on behalf of all four doctors, went on to criticize much of the research that supposedly supports surgery and hormones for individuals with sexual identity conflicts. He said, “We are of the conviction that many of the pro-surgery and pro-puberty blocking or cross-sex hormone studies we have read suffer from poor methodology and flawed conclusions.”

Individuals conflicted about their sexual identity, hating their bodies and wishing to live as the opposite sex, deserve our compassion and support. As a group, they struggle with a host of mental health, relational and behavioral issues – at rates far above the general population.

Rather than prescribing irreversible and body-damaging puberty blockers, hormones and surgeries, we should seek to help and heal these individuals, so that they embrace their bodily reality.

Related resources and articles:

Articles from Dr. Andre Van Mol at the Christian Medical and Dental Associations

Focus on the Family Transgender Resources

Gender Confusion and Transgender Identity Articles and Resources from the American College of Pediatricians

The New Atlantis – Sexuality and Gender: Findings from the Biological, Psychological, and Social Sciences

Hospitals and Doctors “Transition” Hundreds of Children with Drugs, Hormones and Surgery

Questioning Drugs, Hormones and Surgery for Youth Confused about Their Sexual Identity

Study Shows “Gender-Affirming” Treatments Don’t Help Transgender Mental Health

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