CRITIQUE – SEGM
30 AUGUST 2020
In October 2019, the American Journal of Psychiatry (AJP) published a study from the Karolinska Institute in Sweden, and the Yale School of Public Health which reported that “gender-affirming” surgeries for gender dysphoric patients are associated with improved mental health outcomes (1). Looking at mental health utilization in the year 2015, a retrospective analysis showed that the more time passed since surgery, the fewer mental services were utilized by patients, with an average 8% reduction in mental health utilization for each year following surgery. From this, the study concluded that surgery has a beneficial effect on mental health, and that benefits continue to accrue over time. However, following a reanalysis of the data, this conclusion has now been officially corrected to indicate that there is “no advantage of surgery.”
Original Study by Bränström & Pachankis (2019)
The study (1) analyzed health records of 2,679 Swedes diagnosed with gender dysphoria between 2005 and 2015 to determine whether hormonal or surgical treatments improved their mental health over time. To approximate mental health outcomes, the authors relied on the count of mental health visits, psychiatric medication prescriptions, and hospitalizations following suicide attempts. It was presumed that the fewer “mental health events” a person experienced, the better their mental health.
While the authors found no evidence of benefits of hormonal treatments (adjusted odds ratio=1.01, 95% CI=0.98 – 1.03), they noted a statistically significant relationship between time since surgery and mental health status (adjusted odds ratio=0.92, 95% CI=0.87 – 0.98). Specifically, the researchers observed that as of 2015, patients who had surgeries further in the past had better mental health than patients whose surgeries were more recent. This “longitudinal association between gender-affirming surgery and reduced likelihood of mental health treatment” was interpreted by the authors as the evidence of a positive, time-release-like effect of “gender-affirming” surgery. The authors opined that this finding should “lend support to the decision to provider gender-affirming surgeries to transgender individuals who seek them.” The conclusions of the study were widely publicized by mass media outlets. The study also made a rapid and significant impact on clinical and public health education.
Vigorous Debate Leads to Correction of Key Finding
After the study was published, many researchers and scientists (including some SEGM advisors) alerted the AJP to multiple serious methodological problems that challenged the study’s conclusion. In response, the AJP editor requested an independent statistical review of the data, which led to a reanalysis of the data and an official correction (2,3). When gender dysphoric patients who received surgeries were compared to those who did not have surgeries, there was no statistically significant difference in their mental health utilization (Figure 1).
Nine months after the study’s original publication, the AJP stated, “the results [of the reanalysis] demonstrated no advantage of surgery in relation to subsequent mood or anxiety disorder-related health care visits or prescriptions or hospitalizations following suicide attempts” (2).
Figure 1. 2015 Mental Health Services Utilization Among Patients Diagnosed with Gender Dysphoria in Sweden Between 2005 and 2015 by “Gender-Affirming” Surgery Status
From Table 1, Bränström, R., & Pachankis, J. (2020). Toward Rigorous Methodologies for Strengthening Causal Inference in the Association Between Gender-Affirming Care and Transgender Individuals’ Mental Health: Response to Letters. American Journal of Psychiatry, 177(8), 769-772.
Range of Interpretations
The results of the Bränström & Pachankis original analysis (2019) and their re-analysis (2020) may be interpreted in a number of ways. They include the possibility that “gender-affirming” surgeries improve mental health, worsen mental health, or that the data are insufficient to draw conclusions about the impact of hormonal and surgical interventions on mental health.
SEGM Position
It is SEGM’s view that the data presented in the original study and the subsequent re-analysis do not support the claim of an expected “reduction in mental health treatment as a function of time since completing such treatment” (14). After the reanalysis of the data, we conclude the following:
- The mental health needs of people suffering from gender dysphoria are significantly greater than those of the general population, which confirms previous research
- No mental health benefit of hormonal interventions was demonstrated
- No mental health benefit of “gender-affirming” surgery was demonstrated
- Specific to the question of longitudinal association between time from surgery and mental health outcomes, due to unaddressed study design limitations, no improvement of mental health with time after surgery was demonstrated
- Despite the higher rate of suicide attempts requiring hospitalization in the “surgery” group, the study design precludes the assertion that that “gender-affirming” surgery is harmful