Surgeon's account of gender affirming care

[BettyBooper]

A surgeon has been writing to various bodies for the last two years to raise serious concerns about surgeries and hormones. Noone is willing to take responsibility.

Horrific that this can continue.

His account and the responses he has received here

https://www.scotpag.com/post/gender-reassignment-surgery-a-medical-deception

If you ever watch a show like Botched you get a sense of how eager a lot of people are to trust and believe a surgeon who’s telling them what they want to hear. For young people who are distressed already and within a trusted organisation like the NHS the pressure to believe it’s all true and the surgery will have a magical effect on them must be huge. Young people don’t have much sense of the permanent effect of anything on their bodies, health and self-esteem at the best of times.

If you want to be put off cosmetic surgery for life, Carl Hiaasen's crime novel Skin Tight is very good (and darkly funny).

Of course it was written in 1989 and I doubt if the author, as a partisan Democrat, would want to go near another area of surgery full of cowboy practitioners.

The thing about kids - I had surgery as a very small child, and still have permanent scars from it, but I don't remember it at all. Had these procedures been an option when I was a teenager, I'm not saying I would have opted for them, I'm just saying that despite the signs on my body I probably still didn't have a clear sense of the permanent effects of surgery.

Of course, these days I have extra scars, plus bits of metal holding my bones together, so I'd do anything possible to avoid surgery I didn't actually need.

The sense of invulnerability kids have makes them terribly vulnerable.

Thanks for posting @Seethlaw . I was hoping you might!

My worry is that surgeons will show photos of their good work and will show the limitations of their good work on people of different ages, weights etc but will not show photos of what happens if things go wrong. Even if the 'going wrong' isn't the surgeon's fault. May I ask if you we're you shown any photos of surgery that went wrong?

I might make a separate thread for this ob/gyn's account, but this thread seems a good place to put it for now:

'I had just assumed somebody, somewhere was in charge of making sure that there was an evidence base that these extraordinary treatments that were being performed on young people – puberty blockers, cross-sex hormones, and double mastectomy – were support by extraordinary scientific evidence that showed an incontrovertible long-term benefit.'

https://substack.com/inbox/post/164586786

I’ve just read that.

Chilling and reminiscent of Freeman and the desperate attempt to find ‘therapeutic’ lobotomies had not been abuse in plain sight.

archive.ph/HjXYo

Not by the surgeon, no. Though to be honest, I wouldn't expect it. I was never told the potential risks if things went wrong for the other various surgeries I've had (appendectomy, C-section...)

That said, the pictures I found on the internet showed various levels of success, so I knew what the esthetic risks were. And I knew there were health risks involved just by virtue of it being a surgical act. I didn't depend entirely on the surgeon to prepare me, and so I knew what I could reasonably expect and fear.

That's also the reason nobody is ever going to manage to talk me into a phalloplasty: I've done my research, and no thank you!

But I fear that kids these days don't have the space to do such deep research, and that's absolutely not right.

@Seethlaw But I fear that kids these days don't have the space to do such deep research, and that's absolutely not right.
Yes, I totally agree with this.

I'm guessing the consent form for appendectomy does outline some of the risks but it is often a medical emergency so the option is usually 'have this op or die'! With SRS I would imagine that its success in alleviating dysphoria is going to depend to a certain extent on how good the result is. Which is why I would want to have patients shown bad results and asked to consider how such a potential result might affect their dysphoria. That effectively seems to be what you have done yourself with phalloplasty. Any potential relief of dysphoria is presumably being outweighed by the horror of it going wrong.

Interesting that she says she did not feel well equipped to explore motivations as a surgeon, rather than a Mental Health professional. It's reminiscent of the UK endocrinologists assuming Tavistock GIDS had done the exploration of motivations and some of the more gung-ho GIDS staff assuming CAMHS had done the exploration, whereas in reality a desperately overworked CAMHS was gratefully offloading cases to GIDS as soon as the magic words ' in the wrong body' were mentioned.

Again and again, it seems to come back to the same old story, doesn't it; there's nobody to take overall responsibility. A PP mentioned Victoria Climbié; it just seems to me that after every one of these tragedies, we see the same stories on the TV news: lessons will be learnt, there'll be more inter-agency cooperation between the police, social services, the NHS, etc. I'm talking off the top of my head here, but could it be that the effect of such reforms has in practice just led to responsibility being further diluted and spread around?

Almost as if it's a feature, not a bug

You can't assume a treatment that hasn't been studied properly, like antidepressant drugs in your example, is effective, and then say you can't do a proper study because that would be denying people life saving drugs.

Because you don't know if they are life saving drugs, that's the point of the study. For all you know, they might create greater risks.

There is actually fair bit of controversy about whether SSRIs are effective at all. And they have negative effects too so it's not neutral to give them.

More generally, yes, psychiatry is fairly new, but I've come to my perspective on this from assuming, as most do, that it's acting as a legitimate field of medicine. I have come to the conclusion however that it's not just primitive, but often completely wrongheaded, as full of unfounded superstition as any medieval person, and often doing real harm. That's my experience and observation.

Surely though neither the endos, nor surgeons, would be the appropriate people to be looking into the the mental aspects? They do seem to be operating completely outside normal ethical standards, but there is no way they could or should be responsible for the kids motivations.

I'll be honest, I increasingly don't think psychiatry is real medicine. I don't think I'm speaking from a place of total ignorance on it, as a layperson - my father was under psychiatric care for many years and has been an in-patient on several occasions in a mental hospital, and my dh is currently under care.

For years I worked in adolescent psychiatry (I’m not a psychiatrist) and found it so puzzling that these men and women were physicians, intelligent and medically trained, and yet were so ineffective at psychological care. Too many, it appeared, had gone into the field in an attempt to resolve their own trauma, some attracted by the absolute power dynamic between doctor and patient, some because it was less pressured than ‘real’ medicine. Many with massive egos. The worst were the true believers with the conviction that they were right.

I am hugely sceptical and would be very cautious having psychiatric care for family members. It allows for complete deflection. If a patient disagreed with treatment it was always because of their lack of insight or because transference or projection. An unassailable position to hold. They knew and the patient didn’t.

The few good ones had done something else, the best had first been a nurse, or were humble about what they could achieve and acknowledged benefits generally came from medication, not therapy.

One meta review study found 50-60% of the care by psychiatrists to be of no impact one way or another, 10% to have positive results, and the rest to have been actively harmed by their psychiatric care. There will be some good psychiatrists out there, but difficult to find one. I can imagine gender care attracting the worst of the lot.

I’m due a knee replacement soon. It’s a proven surgical treatment for a genuine physical need. I have already been well informed about the risks, possible complications and it has been made very clear that there will be considerable pain, scarring and that I will need to put a lot of effort in myself to achieve a positive outcome (which is still not guaranteed). I’m a grownup (well, an old lady), understand all the information and have made a truly informed choice (including putting the surgery off for another six months because I didn’t feel it was the right time - yes, the NHS let me do that).
This is good medical practice. What is being done in the name of gender affirming care for young people is the complete opposite.

I've had multiple surgeries, one major surgery. I'm a reasonably intelligent person. I listened to the consultant, I talked to other people, I read up. I think it was as close to informed consent as is realistically possible. I still had no idea what I had agreed to or what I was in for. I had complications after 2 operations. It was mishandled by junior doctors in A&E on both occasions. On one of them I'm lucky to have survived, tbh. There are things I understand now that I couldn't possibly have understood before. I wouldn't have surgery again unless it was life saving. But we are in a time now where surgery has in many ways been trivialised and these so called sex change surgeries are no different.

And then we are talking about teenage girls who have grown up looking at women like Kim Kardashian and believing that surgically altering your body is not just normal but aspirational. I honestly don't think opting for surgery to try and look more boyish is any different to breast implants and a bbl. Two sides of the same coin.

Young women get attention for posting photos of mastectomy scars online. For some young women, this looks like positive attention that they want for themselves.

I was also thinking of creating a separate thread for this but now I've seen this I'll let you do it. It definitely deserves its own discussion. The naivety and lack of critical or ethical thinking are remarkable.

One thing that really struck me when I learned it some years ago around psychiatric care, is that apparently there seem to be better outcomes for schizophrenia, which is one of the most "objective" of mental illnesses, in places outside of the west. Some parts of Africa for example.

So for all that we think we have a better understanding, and have modern drugs, these patients were not better off comparatively. And the model of the disease in some of these places was decidedly "primitive," closer to something like possession.

I agree @DrBlackbird I would be very resistant to having a family member go under psychiatric care, unless I could be very sure who the doctor was. I think many are themselves mentally unhealthy people who make their patients worse off.

I agree up to a point, but no healthcare professional should be carrying out any procedure in a vacuum.

The service specification says:
2.7 Role of the specialist surgeon and surgical team The treating surgeon must have insight into each patient’s history and the rationale that led to the referral for surgery. To that end, surgeons must demonstrate good communication with patients through multi-source feedback as part of their appraisal; and have close working relationships with NHS England-commissioned specialist Gender Dysphoria Clinics and with other health professionals who have been actively involved in their clinical care.

It sounds like the insight expected is as superficial as "this patient's gender-specialty psych consultant says they are dysphoric because of their breasts" and the rationale is "we must alleviate the dysphoria, so their course of treatment involves removing the cause of the dysphoria".

And if the surgeon hears that from the psychiatrist, and are told by everything they read that this is a) the settled international gold-standard model of "gender affirming care" and b) life-saving (implication - if you don't do this they'll kill themselves), they probably don't think much further about it. "Better a live patient with no breasts than a dead one..." etc etc

Add in the halo effect - I'm helping! I'm serving the most marginalised community! Look at what a right-on ally I am! and a young distressed patient who begs you for this surgery, tells you this is the solution to all their problems and their gender expert psychiatric consultant agrees too, you have a perfect situation where the surgeons have very little incentive to say "hang on, I don't do major surgery and remove healthy organs to relieve psychiatric distress".

It's similar to the manipulation of parents into thinking this is the only option for their children. I also think that surgeons who do this are going to be some of the last to come round to admitting that they should not have carried out these surgeries.

I think it was as close to informed consent as is realistically possible. I still had no idea what I had agreed to or what I was in for.

So many patients sign consent forms without understanding the potential complications. They sign because they ‘trust the doctor knows best’. A dangerous position in gender care as many physicians working in that area seek to validate what they do by increasing the patient cohort.

@DrBlackbird thanks for your insightful post. I went to see Benji Waterhouse on his book tour recently (DH enjoyed his book) and although he seems compassionate, empathic and relatively humble I thought how much better it would be not to unleash psychiatrists onto the world following years of intense study and training with little outside experience. There is childhood trauma too. It also struck me that all the patients he talked about who were violent or where the fear, from the medical team, was violence, were male and there didn’t seem to be any insight into that or what it means at a societal level - let alone for the poor women at risk of being killed by their sons, in particular.

I’ve been fortunate to have a really positive experience with psychiatry in my 30s but increasingly I think - as you say - it’s not only primitive but really experimental. Culturally we’re stuck in a medical model of ‘doctor does things to patient’ and that doesn’t work well in psychiatry. To get back on topic I strongly suspect that gender medicine doesn’t attract the best and most dispassionate medics, for lots of reasons. There’s surely a toxic relationship between patients who want to believe that ‘gender’ is their problem and medics who believe they can ‘fix it’. They are locked in a dishonest and harmful belief system together.

I met a woman a few years ago who'd had a hysterectomy but didn't know if her ovaries had been removed. She said she'd been scared and had just signed the forms out in front of her. Didn't want to ask in case she looked foolish. So she's consented but didn't know what to. I suspect this is far more common than the medical profession would like us to believe.

This is why I like the Peter Sullivan approach to check someone’s understanding.

Do you have any questions for me?

If a friend or family member asked you what happened today, what would you tell them?

The answers can be very helpful in showing what they understand about both the intervention, the outcomes and risks.