Thread by @LeorSapir

NEW: The Society for Evidence Based Gender Medicine (@segm) has just published a critical analysis of the new study on regret following "gender-affirming" mastectomy surgery.

Here are the highlights 🧵

The JAMA study (@JAMASurgery) was done on adults who got surgery at median age 27 at the U Michigan (@umichmedicine @UMich) hospital. The authors report "overwhelmingly low levels of regret" and express concern about state laws that restrict these surgeries to adults only.

Using the ROBINS-I tool for assessing risk of bias in non-randomized studies, SEGM concludes that the study suffers from "critical risk of bias." That means that "the results reported by the study may substantially deviate from the truth."

The critical risk of bias finding is due to the "high non-participation rate, important differences between participants and non-participants, and lack of control group."

The median follow-up time for those who received surgery was 3.6 years, which the authors classify as "long-term." Only 1 out of 4 participants were followed up with at >5 years.

Some research indicates average time to regret is 8-11 years, though longitudinal data are missing.

As is typical in this area of research, the non-response rate is very high (41%). What, if anything, can be inferred from this non-response?

SEGM calls attention to two potentially important differences between the response and non-response group that may bias the results.

1. Respondents had surgery more recently than non-respondents (3.6 vs. 4.6 yrs). "Gender-affirming" procedures "are known to have a 'honeymoon' period, with quality of life and satisfaction... starting to fall after 3-5 years."

ncbi.nlm.nih.gov/pmc/articles/P…

2. The response cohort appears to have had more anxiety and depression at baseline, resulting in a confound.

This is a recurring problem in gender med research. See, for example, Michael Biggs' critique of Jack Turban et al.'s 2020 suicidality paper: link.springer.com/article/10.100…

The authors' claim that lack of reversal procedures indicates satisfaction is a "fundamentally flawed" assumption. Some research indicates that regretters will not report back to their transition providers. People who regret a surgery may not seek out another invasive procedure.

Perhaps most important: unlike mastectomies for cancer, "gender-affirming" mastectomies are usually not "reversible." This has to do with the nature of the procedure and the lack of insurance coverage for it (if there's no longer a GD Dx, insurance typically won't cover).

Finally, "gender-affirming" mastectomies are cosmetic procedures. The primary function of breasts is milk production, and according to SEGM, no procedure can restore that function. Hence, the necessary motive may be missing from regretters.

In short, the assumptiom that non-respondents were satified because they did not seek reversal surgery is unfounded. There is no way to know the satisfaction of those who didn't respond. Speculation about reasons should be framed as just that: speculation.

SEGM further notes that the authors "did not attempt to investigate mental health or functional outcomes. Instead, the focus was on self-reported satisfaction."

This is a key point.

The main rationale for "gender-affirming" procedures is that they are "medically necessary" for mental health, not merely cosmetic.

"Satisfaction" is important, but if "medical necessity" is the question, researcher should opt for more objective outcome measures.

SEGM notes another "unexpected finding": a change in "gender identity" in 20% of the surgery/participant cohort.

This raises an important question: if the purpose of surgery is not mental health/QoL improvement or achieving "gender congruence," what is it? How is it different from regular, cosmetic plastic surgery like rhinoplasty?

If the goal is to help people achieve ever-shifting "embodiment goals" (or, as pro-GAC advocate Florence Ashley puts it, helping adults and teens turn their bodies into a "gendered art piece"), questions arise about physician ethical obligations and insurance coverage.

Uncontrolled: As is common in gender med research, the study does not control for confounds like "the passage of time [regression to the mean], attention from medical professionals [Hawthorne Effect], counseling, better control of mental illness, or use of mood-enhancing drugs."

Generalizability: Because participants seem to all be adults who got surgery as adults, the study's result, even if valid, cannot be applied to teenage girls. The decision-making capacity of a 27 year old is not equal to that of a 14 year old.

Conflicts of interest: "There is a fundamental problem with research emerging from gender clinic settings. The same clinicians provide gender-transitioning treatments to individual patients in their practice; serve as primary investigators and custodians of data...

used in research informing population health policies; and increasingly, provide paid expert witness testimony in courts defending the unrestricted availability of hormonal and surgical interventions for minors...

Since any nuanced, balanced statements may be used against them in a court of law when they serve as expert witnesses, they must resort to the lowest common denominator of the 'winner-takes-all' adversarial approach. Such an approach does not tolerate nuance."

SEGM concludes: "Prestigious scientific journals appear to have deviated from their previously high standards... & instead have become vehicles for promoting poor-quality research seemingly to influence judicial policy decisions rather than advance scientific understanding."

SEGM's analysis:

The mastectomy study: https://t.co/tU7G9PA1MMsegm.org/long-term-regr…
jamanetwork.com/journals/jamas…

It's @segm_ebm, not @segm. Apologies to SEGM!