Surgeons being sued after transgender regrets their life changing decision made at 15 years old.

[Dr. Anonymouss]

Detransitioned teen wants to hold 'gender-affirming' surgeons accountable: 'What happened to me is horrible'

Former transgender teenager Chloe Cole joined 'Tucker Carlson Tonight' to discuss her lawsuit against the doctors who performed a 'gender-affirming' double mastectomy.

www.foxnews.com

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[DarkBluMage]

Detransitioned teen wants to hold 'gender-affirming' surgeons accountable: 'What happened to me is horrible'

Former transgender teenager Chloe Cole joined 'Tucker Carlson Tonight' to discuss her lawsuit against the doctors who performed a 'gender-affirming' double mastectomy.

www.foxnews.com

How awful 😭

 

[AnonymousDoctorGuyPerson]

Queue the folks lining up to weaponize this person in their transphobia.

 

[DarkBluMage]

Queue the folks lining up to weaponize this person in their transphobia.

Wow. This child has been through something traumatic that will forever affect her and your first concern is about people making negative comments regarding transphobia. Crazy

 

[Dr. Anonymouss]

Queue the folks lining up to weaponize this person in their transphobia.

I think what needs to be discussed is why we are allowing 15 year olds the ability to make this life changing decision. As medical providers we all know the frontal cortex doesn’t fully develop until 25 so why do we expect minors to have the decision making capacity to know what they truly want at such a young age. In this case, I do think physicians are at fault.

 

[Goro]

Wow. This child has been through something traumatic that will forever affect her and your first concern is about people making negative comments regarding transphobia. Crazy

Transphobia is a good thing?????

Calling @sloop!

 

[DarkBluMage]

Transphobia is a good thing?????

Calling @sloop!

Where did I say that? Are you trolling right now?

 

[Goro]

Where did I say that? Are you trolling right now?

Wow. This child has been through something traumatic that will forever affect her and your first concern is about people making negative comments regarding transphobia.

OK, I perceive that you were struck by what might be misplaced priorities, but ADGP does have a point.

 

[sloop]

Transphobia is a good thing?????

Calling @sloop!

If she is accurately retelling the story and not omitting several important parts (possible given the fact that there is a pending lawsuit), then several things have probably been done wrong in this case. The surgeon should have referred to a psychiatrist for an evaluation and a letter recommending surgery. This evaluation should have involved a consideration of her dysphoria symptoms and history, as well as her age and reasons for wanting to transition. In my opinion, arresting puberty in a 13 year old female is often indicated when you think there is gender dysphoria and a likelihood of transitioning later. The benefits of doing so often outweigh the risks. 15 is usually too young to be undergoing surgical interventions, though. The risk of detransitioning is higher in the early/mid teens than it is in the late teens and older.

My experience is that there are indeed too many doctors who just focus on what the patient is saying they need rather than doing an actual evaluation. That is, patients will walk in the door saying they are uncomfortable with their biological sex and want to transition, and the providers take this at face value and initiate interventions. Really, anyone involved in this work who is willing to provide gender-affirming care should also be willing to tell patients when they think it is not indicated or not in their best interests at a given time.

 

[Dr. Anonymouss]

If she is accurately retelling the story and not omitting several important parts (possible given the fact that there is a pending lawsuit), then several things have probably been done wrong in this case. The surgeon should have referred to a psychiatrist for an evaluation and a letter recommending surgery. This evaluation should have involved a consideration of her dysphoria symptoms and history, as well as her age and reasons for wanting to transition. In my opinion, arresting puberty in a 13 year old female is often indicated when you think there is gender dysphoria and a likelihood of transitioning later. The benefits of doing so often outweigh the risks. 15 is usually too young to be undergoing surgical interventions, though. The risk of detransitioning is higher in the early/mid teens than it is in the late teens and older.

My experience is that there are indeed too many doctors who just focus on what the patient is saying they need rather than doing an actual evaluation. That is, patients will walk in the door saying they are uncomfortable with their biological sex and want to transition, and the providers take this at face value and initiate interventions. Really, anyone involved in this work who is willing to provide gender-affirming care should also be willing to tell patients when they think it is not indicated or not in their best interests at a given time.

Well said

 

[Dral]

If she is accurately retelling the story and not omitting several important parts (possible given the fact that there is a pending lawsuit), then several things have probably been done wrong in this case. The surgeon should have referred to a psychiatrist for an evaluation and a letter recommending surgery. This evaluation should have involved a consideration of her dysphoria symptoms and history, as well as her age and reasons for wanting to transition. In my opinion, arresting puberty in a 13 year old female is often indicated when you think there is gender dysphoria and a likelihood of transitioning later. The benefits of doing so often outweigh the risks. 15 is usually too young to be undergoing surgical interventions, though. The risk of detransitioning is higher in the early/mid teens than it is in the late teens and older.

My experience is that there are indeed too many doctors who just focus on what the patient is saying they need rather than doing an actual evaluation. That is, patients will walk in the door saying they are uncomfortable with their biological sex and want to transition, and the providers take this at face value and initiate interventions. Really, anyone involved in this work who is willing to provide gender-affirming care should also be willing to tell patients when they think it is not indicated or not in their best interests at a given time.

Great points. I have seen patients with extensive vitiligo who come in requesting monobenzone full body depigmentation treatment so all their skin can be more uniform in tone. Before doing this, we will send the patient to a psychiatrist (ideally who specializes in this sort of thing) to have them evaluated so they know and understand exactly what they are doing and what they can expect. This also serves to document that this due diligence has been performed.

In cases like this, it’s tough to tell patients they shouldn’t get what they think they want. The point is well made that it’s up to the physician(s) to take the time to really understand what is going on with the patient and to help them either get what they want if indicated or to help provide other treatments or options if what they desire may not be the best choice for them at that time.

 

[Proudfather94]

I think what needs to be discussed is why we are allowing 15 year olds the ability to make this life changing decision. As medical providers we all know the frontal cortex doesn’t fully develop until 25 so why do we expect minors to have the decision making capacity to know what they truly want at such a young age. In this case, I do think physicians are at fault.

I agree. You'll be hard pressed to find a doctor willing to tie someone's tubes or do a hysterectomy at that age. I don't see how doing another type of permanent elective procedure should be allowed.

 

[WhereMyLiberalsAt]

Wow. This child has been through something traumatic that will forever affect her and your first concern is about people making negative comments regarding transphobia.

OK, I perceive that you were struck by what might be misplaced priorities, but ADGP does have a point.

No… Their point is to distract from the true conversation to basically say “if you talk about this you might be one of those transphobic people.”

Similar how you commented… You are doing the same thing to distract from the true topic being discussed. Both of you are misplacing the priorities on purpose. However, both of you gave a great example so early in the thread how this conversation gets shut down via **** posting, ad hominem, and red herring. Now every comment will have to start with “I support the LGBTQI+ community but…..” Because they have to worry about their comment being misread on purpose and being called transphobic.

 

[Goro]

No… Their point is to distract from the true conversation to basically say “if you talk about this you might be one of those transphobic people.”

Point taken!

 

[Candidate2017]

The surgeon should have referred to a psychiatrist for an evaluation and a letter recommending surgery. This evaluation should have involved a consideration of her dysphoria symptoms and history, as well as her age and reasons for wanting to transition. In my opinion, arresting puberty in a 13 year old female is often indicated when you think there is gender dysphoria and a likelihood of transitioning later.

Psychiatrists have been sued for giving "clearance" letters for trans surgeries. I decline to write clearance letters because there are no clear scientific guidelines, unlike clearance for transplant and bariatric surgeries for which those patients get a battery of assessments from teams of psychologists and psychiatrists that last for up to a year.

In my experience, there's often a good chance a patient's chief psychiatric complaint is not the main issue. Many people presenting to a psychiatrist for gender dysphoria will have several other psychiatric diagnoses that need to be treated, rather than just cleared for the scalpel.

Great points. I have seen patients with extensive vitiligo who come in requesting monobenzone full body depigmentation treatment so all their skin can be more uniform in tone. Before doing this, we will send the patient to a psychiatrist (ideally who specializes in this sort of thing) to have them evaluated so they know and understand exactly what they are doing and what they can expect. This also serves to document that this due diligence has been performed.

Yes, "psych clearance" just serves to spread the malpractice liability around. That's all.

First, every physician can assess for capacity. Second, a psychiatrist has no crystal ball or voodoo magic to predict how a patient will react status-post going full albino, much less what the hell "monobenzone full body depigmentation" entails and its risks/benefits.

 

[VA Hopeful Dr]

Psychiatrists have been sued for giving "clearance" letters for trans surgeries. I decline to write clearance letters because there are no clear scientific guidelines, unlike clearance for transplant and bariatric surgeries for which those patients get a battery of assessments from teams of psychologists and psychiatrists that last for up to a year.

In my experience, there's often a good chance a patient's chief psychiatric complaint is not the main issue. Many people presenting to a psychiatrist for gender dysphoria will have several other psychiatric diagnoses that need to be treated, rather than just cleared for the scalpel.



Yes, "psych clearance" just serves to spread the malpractice liability around. That's all.

First, every physician can assess for capacity. Second, a psychiatrist has no crystal ball or voodoo magic to predict how a patient will react status-post going full albino, much less what the hell "monobenzone full body depigmentation" entails and its risks/benefits.

All true, but you should have sufficient training to determine if there is a secondary cause of gender dysphoria that if treated, will improve or alleviate the gender dysphoria without the need for any transitioning.

Almost no one else in medicine has the training or knowledge to be able to tease that out.

 

[sloop]

Psychiatrists have been sued for giving "clearance" letters for trans surgeries. I decline to write clearance letters because there are no clear scientific guidelines, unlike clearance for transplant and bariatric surgeries for which those patients get a battery of assessments from teams of psychologists and psychiatrists that last for up to a year.

In my experience, there's often a good chance a patient's chief psychiatric complaint is not the main issue. Many people presenting to a psychiatrist for gender dysphoria will have several other psychiatric diagnoses that need to be treated, rather than just cleared for the scalpel.



Yes, "psych clearance" just serves to spread the malpractice liability around. That's all.

First, every physician can assess for capacity. Second, a psychiatrist has no crystal ball or voodoo magic to predict how a patient will react status-post going full albino, much less what the hell "monobenzone full body depigmentation" entails and its risks/benefits.

There are times when being a doctor means being willing to do things to help patients even when that exposes you to liability. My residency happened to give me specific training on gender dysphoria and I have done several of these evaluations. At the end of the day, it is unreasonable to expect surgeons to have the expertise to diagnose gender dysphoria and anticipate the effect of certain interventions on their psychiatric well-being. I think that we have to be involved. If you do thorough evaluations and follow WPATH guidelines, you can reasonably ensure that you’re providing standard of care.

I agree with you that many patients who think they need surgery are not well-served by it. That’s why I think providers need to be willing to tell patients this when it is the truth, rather than just funnel them towards surgery.

 

[AnonymousDoctorGuyPerson]

Wow. This child has been through something traumatic that will forever affect her and your first concern is about people making negative comments regarding transphobia. Crazy

Yeah that was clearly my first concern

This child isn't here, but people on this forum are and that's who the comment was to.

 

[Dral]

There are times when being a doctor means being willing to do things to help patients even when that exposes you to liability. My residency happened to give me specific training on gender dysphoria and I have done several of these evaluations. At the end of the day, it is unreasonable to expect surgeons to have the expertise to diagnose gender dysphoria and anticipate the effect of certain interventions on their psychiatric well-being. I think that we have to be involved. If you do thorough evaluations and follow WPATH guidelines, you can reasonably ensure that you’re providing standard of care.

I agree with you that many patients who think they need surgery are not well-served by it. That’s why I think providers need to be willing to tell patients this when it is the truth, rather than just funnel them towards surgery.

Thank you and well said. Not really going to expand on what I do and why since it’s not the topic of the thread really. But the big part of why I refer to psych is to help me understand if the patient has any psych condition I’m not able to diagnose and how that could play into their future psych well-being as you say (not just for legal purposes of course). I don’t deal too much with gender dysphoria, but I’m interested to hear how you specifically got that training. Was there a specific clinic for those patients, was it just by way of seeing enough patients over time with an attending who was more familiar, or some other way?

 

[operaman]

I find this a very challenging topic. Thankfully my surgical practice for gender affirming procedures has thus far only been adults so I haven’t yet had to confront this is minors in my practice. I’m also blessed in that I can manage many patients non surgically so that’s always been my plan if/when I do see a minor for evaluation.

For my adult patients I don’t require any sort of imprimatur beyond typical pre-surgical evaluation. I do usually require that we’ve attempted non operative management first, primarily because the literature and my experience suggests they get far better outcomes. My discussions with patients tends to be similar to any other surgical consult where my role is to present information and my experience to help the patient make the right decision for themself.

But this is a very challenging and still young field of practice especially with younger patients. For me personally I’d want to be part of a multidisciplinary group that I knew and respected to ensure patients were getting a thorough evaluation and that we were doing our very best to do no harm. I worry that the zeitgeist could easily pressure both patients and physicians into making decisions.

For my far more experienced colleagues above who do these evals - do you ever do group visits with the patient/family and surgeon? For me, I think having that kind of support in the room would be extremely helpful.

 

[sloop]

I find this a very challenging topic. Thankfully my surgical practice for gender affirming procedures has thus far only been adults so I haven’t yet had to confront this is minors in my practice. I’m also blessed in that I can manage many patients non surgically so that’s always been my plan if/when I do see a minor for evaluation.

For my adult patients I don’t require any sort of imprimatur beyond typical pre-surgical evaluation. I do usually require that we’ve attempted non operative management first, primarily because the literature and my experience suggests they get far better outcomes. My discussions with patients tends to be similar to any other surgical consult where my role is to present information and my experience to help the patient make the right decision for themself.

But this is a very challenging and still young field of practice especially with younger patients. For me personally I’d want to be part of a multidisciplinary group that I knew and respected to ensure patients were getting a thorough evaluation and that we were doing our very best to do no harm. I worry that the zeitgeist could easily pressure both patients and physicians into making decisions.

For my far more experienced colleagues above who do these evals - do you ever do group visits with the patient/family and surgeon? For me, I think having that kind of support in the room would be extremely helpful.

When I did gender dysphoria evaluations, we definitely involved the families of minors. We sometimes also involved the families of adult patients if they wanted those people involved. Regarding the latter, it is often pretty important to involve the social supports of the patient. This is particularly the case for the more involved surgeries, like bottom surgery, that can involve a significant period of recovery during which it will be important for the patient to have somebody help them. I’ve had to counsel several patients about how having bottom surgery as a homeless person with no social supports is not an awesome plan.

Regarding involving the surgeon: I have not done this but would have no problem with it assuming the surgeon was interested. It would probably be useful in some ways. Outside of some academic settings, though, I imagine one question would be figuring out how both physicians could bill for this sort of thing. Honestly I have never looked into that so I’m not sure how that would work.

 

[DarkBluMage]

Yeah that was clearly my first concern

This child isn't here, but people on this forum are and that's who the comment was to.

I’m not seeing your point here. If that even was a concern why choose to talk about something that wasn’t even happening rather than the actual topic at hand which was the trauma this child is currently enduring? Once again, it was clear your main concern was possible transphobia rather than the actual issue present. So why the sarcasm like that’s not what you presented with your comment? Why was it necessary to comment towards an imaginary scenario as if the people on this forum were automatically going to do that and literally no one had even commented on the topic yet?

 

[annoyedpsychiatrist]

The thing about teenagers is that they change their minds. I think its risky performing these surgeries in kids at a young age from a legal perspective, and maybe they should should wait until they're at least an adult and liable for their own choices. Nobody can predict the future. Not the worlds best psychiatrist or worlds best surgeon.

 

[Proudfather94]

The thing about teenagers is that they change their minds. I think its risky performing these surgeries in kids at a young age from a legal perspective, and maybe they should should wait until they're at least an adult and liable for their own choices. Nobody can predict the future. Not the worlds best psychiatrist or worlds best surgeon.

Late adolescents change their major an average of 3 times. If they can't predict what they want to do for an education/ career i'd trust them even less with changing their biological sex which is way more invasive than college.

 

[PathNeuroIMorFM]

Late adolescents change their major an average of 3 times. If they can't predict what they want to do for an education/ career i'd trust them even less with changing their biological sex which is way more invasive than college.

Guess they shouldn't be able to sign up for the army then, eh?

I jest because changing your mind about gender and changing your mind about college major are two very different things. Generally, studies have demonstrated that elementary school children have a solid grasp on what gender they are. However, my 8 year old neice still hasnt told me what she wants to major in yet. She's currently switching between aerospace and princess studies. It's very frustrating.

 

[Captain_Falcon]

Guess they shouldn't be able to sign up for the army then, eh?

I jest because changing your mind about gender and changing your mind about college major are two very different things. Generally, studies have demonstrated that elementary school children have a solid grasp on what gender they are. However, my 8 year old neice still hasnt told me what she wants to major in yet. She's currently switching between aerospace and princess studies. It's very frustrating.

WIth the army though, you have only a 4 year commitment. So although you can't drop out (or change your major on a dime), it isn't the same.

There is no good apples/apples comparison for transgender discussions

 

[PathNeuroIMorFM]

WIth the army though, you have only a 4 year commitment. So although you can't drop out (or change your major on a dime), it isn't the same.

There is no good apples/apples comparison for transgender discussions

In those four years, you can also die, get permanently disabled, breathe in toxic residue from burn pits and get metastatic lung cancer, get PTSD, or worse: become a career soldier. All not uncommon outcomes.

I don't mean to derail this into a war thing, but kids and young people are going to make their own decisions. Some good, some bad. If it's not hurting anyone else, who cares? A kids choice on their gender has as much effect on you as their choice in college major. You guys need to all find a different hill to die on, because this one sucks.

 

[WhereMyLiberalsAt]

In those four years, you can also die, get permanently disabled, breathe in toxic residue from burn pits and get metastatic lung cancer, get PTSD, or worse: become a career soldier. All not uncommon outcomes.

I don't mean to derail this into a war thing, but kids and young people are going to make their own decisions. Some good, some bad. If it's not hurting anyone else, who cares? A kids choice on their gender has as much effect on you as their choice in college major. You guys need to all find a different hill to die on, because this one sucks.

I have a hunch you’re not a parent…

Also god forbid we have people that want to serve in our military as a career and protect our country and freedom… like tf you on about?

 

[annoyedpsychiatrist]

In those four years, you can also die, get permanently disabled, breathe in toxic residue from burn pits and get metastatic lung cancer, get PTSD, or worse: become a career soldier. All not uncommon outcomes.

I don't mean to derail this into a war thing, but kids and young people are going to make their own decisions. Some good, some bad. If it's not hurting anyone else, who cares? A kids choice on their gender has as much effect on you as their choice in college major. You guys need to all find a different hill to die on, because this one sucks.

it affects the surgeon they're suing.

 

[operaman]

As a surgeon I try to set aside my disdain for wokeness and the politicization of these issues.

Generally it seems that operating on minors for this should be very rare, but I hesitate to say there’s no situation where it isn’t warranted simply because medicine is complicated. It’s something I’d like to see studied more as we try to tease out the actual benefits and risks and harms surrounding this entire area of medicine. I can imagine there are probably cases where the harm of not operating outweighs the risks of the surgery. I don’t have a good way to tell them apart though.

As such I would definitely like to see some consensus build around only doing these kind of interventions within the context of a well designed clinical trial. It seems we definitely have equipoise on a number of questions and i would argue we have a duty to try and answer these questions as soon as possible.

 

[Angus Avagadro]

In those four years, you can also die, get permanently disabled, breathe in toxic residue from burn pits and get metastatic lung cancer, get PTSD, or worse: become a career soldier. All not uncommon outcomes.

I don't mean to derail this into a war thing, but kids and young people are going to make their own decisions. Some good, some bad. If it's not hurting anyone else, who cares? A kids choice on their gender has as much effect on you as their choice in college major. You guys need to all find a different hill to die on, because this one sucks.

Does something have to hurt me, or anyone else for that matter to be wrong?

 

[PathNeuroIMorFM]

I have a hunch you’re not a parent…

Also god forbid we have people that want to serve in our military as a career and protect our country and freedom… like tf you on about?

I have a hunch you're not trans. And you might say "I don't need to be trans to have an opinion on this!". I don't need to be a parent to have an opinion on this either.

And I was just making a joke about young people and the military just to make a significant comparison. The military is a huge, life changing commitment, just like being trans that can really **** your life, but people are totally down with 17-21 year olds doing that. I also said I don't want to derail this into a conversation about the military.

it affects the surgeon they're suing.

I don't think it's right that some are suing their surgeons, but that's such an insignificant fraction of trans people, that it might as well not even exist.

Does something have to hurt me, or anyone else for that matter fter, to be wrong?

In the vast majority of cases, that's what exactly defines wrong from right. Murder, theft, suicide, harassment, stalking, etc are all considered "wrong" because it affects other people. I can't think of any instances where doing something that affects another person, is wrong. I'm sure its out there somewhere, but I can't think of anything significant off the top of my head.

Anyway, nerds. I'm not that passionate about trans rights and I doubt I can say anything that will change your minds. I just subscribe to the philosophy that people should mind their own damn business. But by all means, continue to circlejerk about how trans people = bad and we should control their lives because we're all down with fascism. I'll exist this conversation with three words.

"Cope. Seethe. Mald."

lmao

 

[VA Hopeful Dr]

As a surgeon I try to set aside my disdain for wokeness and the politicization of these issues.

Generally it seems that operating on minors for this should be very rare, but I hesitate to say there’s no situation where it isn’t warranted simply because medicine is complicated. It’s something I’d like to see studied more as we try to tease out the actual benefits and risks and harms surrounding this entire area of medicine. I can imagine there are probably cases where the harm of not operating outweighs the risks of the surgery. I don’t have a good way to tell them apart though.

As such I would definitely like to see some consensus build around only doing these kind of interventions within the context of a well designed clinical trial. It seems we definitely have equipoise on a number of questions and i would argue we have a duty to try and answer these questions as soon as possible.

To my understanding doing surgery on trans kids is pretty rare. The major players don't even offer it: Mayo, Cleveland Clinic, and Johns Hopkins won't do it before age 18, same with MGH.

Now that's not to say there aren't places that will do surgery on patients under 18, but it seems like that's the exception.

 

[WhereMyLiberalsAt]

I have a hunch you're not trans. And you might say "I don't need to be trans to have an opinion on this!". I don't need to be a parent to have an opinion on this either.

I don't think it's right that some are suing their surgeons, but that's such an insignificant fraction of trans people, that it might as well not even exist.

And I was just making a joke about young people and the military just to make a significant comparison. I also said I don't want to derail this into a conversation about the military.

In the vast majority of cases, that's what exactly defines wrong from right. Murder, theft, suicide, harassment, stalking, etc are all considered "wrong" because it affects other people. I can't think of any instances where doing something that affects another person, is wrong. I'm sure its out there somewhere, but I can't think of anything significant off the top of my head.

Anyway, nerds. I'm not that passionate about trans rights and I doubt I can say anything that will change your minds. I just subscribe to the philosophy that people should mind their own damn business. But by all means, continue to circlejerk about how trans people = bad and we should control their lives because we're all down with fascism. I'll exist this conversation with three words.

"Cope. Seethe. Mald."

lmao

Yeah, I think you’ve been the most irrational and emotional response yet for not being “passionate about trans rights.”

We aren’t discussing civil right or liberties… We’re attempting to discuss medicine, science, and the roll doctors have in all of this. Your argument isn’t even applicable and it’s full of logical fallacies. Even the way you ended your post was in typical fashion.

I’m glad we have have actual physicians posting and discussing their experience and thought process. To @operaman comment about consensus… Do you really think something like that can be achieved? Even discussing the topic can have people melt down. How can you even write a grant and conduct a study in that type of atmosphere?

 

[Proudfather94]

Guess they shouldn't be able to sign up for the army then, eh?

I jest because changing your mind about gender and changing your mind about college major are two very different things. Generally, studies have demonstrated that elementary school children have a solid grasp on what gender they are. However, my 8 year old neice still hasnt told me what she wants to major in yet. She's currently switching between aerospace and princess studies. It's very frustrating.

They wouldn't be able to join at 15 like some of the people already transitioning. They're different but I was comparing them as both being long term commitments since working to retirement is a pretty big part of your life. Basically I'm saying if the average teen can drop thousands of dollars on classes and then not be sure of their future I wouldn't do an elective procedure on someone even younger than them.

 

[Mr.Smile12]

NYT article 11/14/2022
They Paused Puberty, but Is There a Cost? They Paused Puberty, but Is There a Cost?

 

[operaman]

Yeah, I think you’ve been the most irrational and emotional response yet for not being “passionate about trans rights.”

We aren’t discussing civil right or liberties… We’re attempting to discuss medicine, science, and the roll doctors have in all of this. Your argument isn’t even applicable and it’s full of logical fallacies. Even the way you ended your post was in typical fashion.

I’m glad we have have actual physicians posting and discussing their experience and thought process. To @operaman comment about consensus… Do you really think something like that can be achieved? Even discussing the topic can have people melt down. How can you even write a grant and conduct a study in that type of atmosphere?

Excellent question. I think in this case we will probably have to lean upon our European colleagues who are already doing this very thing. One of the perks of single payer systems is that the single payer can just decide it won’t cover any gender related medication or surgery outside of a clinical trial. They also have a vested interest in answering the question so they can best use limited public funds.

I think you’re right that in America we wont be able to overcome the leftist hold on academia to conduct these studies well. And our political far right seems focused more on using legislation to ban the practice entirely rather than engaging in any kind of scientific debate. Not really an environment where you can conduct really good science, though precisely the environment that needs good science most of all. Sadly I don't think suing surgeons retroactively will have much positive impact either and gets us no closer to understanding the nuances involved here.

ETA: I tried to pubmed search these questions and can't find any RCTs looking at any of these questions in kids. Not even many looking at them in adults! My gut suspicion is that we would find the majority of early gender affirming med/surg interventions in youth have no difference over placebo or other non-op intervention, at least for some period of time. I suspect much of the benefits derived from these interventions comes in the ancillary care and counseling and psychiatric intervention that goes along with the medical treatment. There probably are some subgroups where we find a net benefit, and this is exactly what we need to find out.

 

[sloop]

Guess they shouldn't be able to sign up for the army then, eh?

I jest because changing your mind about gender and changing your mind about college major are two very different things. Generally, studies have demonstrated that elementary school children have a solid grasp on what gender they are. However, my 8 year old neice still hasnt told me what she wants to major in yet. She's currently switching between aerospace and princess studies. It's very frustrating.

There are several problems with the way you’re thinking about this.

First, it is true that in classic gender dysphoria, there is a sense of being the wrong gender at a young age such as in elementary school. The problem is that people with such a classic gender dysphoria history are by no means the only people coming through clinic doors asking for surgery.

Second, knowing what gender you are is not actually the same as knowing you want a particular surgery or that the surgery will improve your psychological well-being. Many trans people never actually get bottom surgery, for instance, because they recognize that the outcomes are often not great and there is a high incidence of complications. It takes a great deal of maturity to be able to assess whether some degree of long-term psychological distress/discomfort may nonetheless be preferable to the risk of surgery.

Third, there is actually a subset of people who express a desire to transition as an actual aesthetic or lifestyle preference. This is a minority, to be sure, but it is a minority whose behavior tends to be driven by personality pathology and results in significant regret.

 

[VA Hopeful Dr]

They wouldn't be able to join at 15 like some of the people already transitioning. They're different but I was comparing them as both being long term commitments since working to retirement is a pretty big part of your life. Basically I'm saying if the average teen can drop thousands of dollars on classes and then not be sure of their future I wouldn't do an elective procedure on someone even younger than them.

So no cosmetic surgery for under 18s? I think a few thousand plastic surgeons would like a word...

And let's not forget all the under 18s having kids, that's kind of a big deal too.

 

[Dr. Anonymouss]

So no cosmetic surgery for under 18s? I think a few thousand plastic surgeons would like a word...

And let's not forget all the under 18s having kids, that's kind of a big deal too.

Cosmetic surgery in minors could be up for debate, most certainly, because these both entail physically changing one's appearance to hopefully feel better about themselves. It is interesting to think about because you have me stumped on why I think one is okay and one isn't. I suppose I just inherently think surgical transitioning is a much greater psychological burden which could come with regret, but I suppose I have to ponder this more.

 

[operaman]

Cosmetic surgery in minors could be up for debate, most certainly, because these both entail physically changing one's appearance to hopefully feel better about themselves. It is interesting to think about because you have me stumped on why I think one is okay and one isn't. I suppose I just inherently think surgical transitioning is a much greater psychological burden which could come with regret, but I suppose I have to ponder this more.

I think there’s definitely a continuum and 18 is somewhat of an arbitrary cutoff to define adulthood. It also isn’t magic - a 17 year old who wants a birthday rhinoplasty is probably capable of assessing risks and benefits and assenting to surgery if their parents agree. But I’d probably feel differently about an 11 year old who doesn’t like how she looks and is getting picked on at school. Seems like you’d want to do some more due diligence to make sure this was really a surgical problem.

The other aspect is that cosmetic procedures typically target an objective issue that both the surgeon and the patient can see. A dorsal hump or a ptotic tip are obvious to the surgeon; we aren’t taking the word of child as the sole evidence of a problem. For gender issues we don’t yet have any objective way to verify the diagnosis itself. I think this adds an important layer of complexity and gives us reason to be cautious.

 

[WhereMyLiberalsAt]

Excellent question. I think in this case we will probably have to lean upon our European colleagues who are already doing this very thing. One of the perks of single payer systems is that the single payer can just decide it won’t cover any gender related medication or surgery outside of a clinical trial. They also have a vested interest in answering the question so they can best use limited public funds.

I think you’re right that in America we wont be able to overcome the leftist hold on academia to conduct these studies well. And our political far right seems focused more on using legislation to ban the practice entirely rather than engaging in any kind of scientific debate. Not really an environment where you can conduct really good science, though precisely the environment that needs good science most of all. Sadly I don't think suing surgeons retroactively will have much positive impact either and gets us no closer to understanding the nuances involved here.

ETA: I tried to pubmed search these questions and can't find any RCTs looking at any of these questions in kids. Not even many looking at them in adults! My gut suspicion is that we would find the majority of early gender affirming med/surg interventions in youth have no difference over placebo or other non-op intervention, at least for some period of time. I suspect much of the benefits derived from these interventions comes in the ancillary care and counseling and psychiatric intervention that goes along with the medical treatment. There probably are some subgroups where we find a net benefit, and this is exactly what we need to find out.

Just found this site, but I’ll investigate it more tomorrow…

Correction of a Key Study: No Evidence of “Gender-Affirming” Surgeries Improving Mental Health

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)...

segm.org

 

[operaman]

Just found this site, but I’ll investigate it more tomorrow…

Correction of a Key Study: No Evidence of “Gender-Affirming” Surgeries Improving Mental Health

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)...

segm.org

You don’t have to read much. It’s a retrospective analysis and rife with all the limitations and biases thereof. In this case, it looks like the reanalysis of crappy data shows no difference at all.

We really need randomized prospective data for these questions. I don’t see any way to overcome the many confounders without it. The biggest one being that any trans group who seeks and gets care is wholly different than those who don’t. Even those who get care often have terrible social situations; those who can’t even get to the doctors must be even worse. As such I think any non randomized study is going to show a positive effect but may not be an effect related to the intervention being considered.

 

[Future_Bone_Docta]

I'm confused though. The parents would have had to give consent, correct? Agreements signed to leave a paper trail?

Unless they somehow had evidence of legitimate coercion, how could they possibly sue the physician?

 

[operaman]

I'm confused though. The parents would have had to give consent, correct? Agreements signed to leave a paper trail?

Unless they somehow had evidence of legitimate coercion, how could they possibly sue the physician?

For malpractice you just need to show deviation from the standard of care and that harm resulted. Other suits will hinge on lack of informed consent which I agree would probably not hold up in this case.

But simply alleging deviation from standard of care and arguing that such a surgery on a minor is itself a deviation from SOC. They could also allege negligence in failing to do adequate psych eval and due diligence.

Whether they can win remains to be seen, but I think they’ve at least got a strong argument to get past summary judgement, namely that a jury would be needed to decide whether this does in fact represent deviation from the standard of care. Clearly the plaintiff won’t have any trouble rounding up some highly qualified and well pedigreed senior surgeons who will testify under oath that this surgery was negligent and reckless and woefully outside standard accepted surgical practice.

The defense will surely find some very woke academic surgeon to testify on their behalf, but that’s going to be a very difficult cross examination given the lack of good evidence for any of this stuff.

My guess is the insurance company settles asap.

 

[Proudfather94]

So no cosmetic surgery for under 18s? I think a few thousand plastic surgeons would like a word...

And let's not forget all the under 18s having kids, that's kind of a big deal too.

I would say no to ones that someone may regret in the future. I just believe the harm/ help ratio for gender reassignment and giving hormones to a teenager that's going to effect their puberty isn't good enough in most cases to make it worth it.
If someone wants to be the other sex so bad that they have major depressive disorder or are threatening or self harming then I would say go ahead. If they can wait until adulthood though when their brain is more mature and they are more likely to make permanent decisions that they are less likely to regret, that would be better.

 

[Angus Avagadro]

I think there’s definitely a continuum and 18 is somewhat of an arbitrary cutoff to define adulthood. It also isn’t magic - a 17 year old who wants a birthday rhinoplasty is probably capable of assessing risks and benefits and assenting to surgery if their parents agree. But I’d probably feel differently about an 11 year old who doesn’t like how she looks and is getting picked on at school. Seems like you’d want to do some more due diligence to make sure this was really a surgical problem.

The other aspect is that cosmetic procedures typically target an objective issue that both the surgeon and the patient can see. A dorsal hump or a ptotic tip are obvious to the surgeon; we aren’t taking the word of child as the sole evidence of a problem. For gender issues we don’t yet have any objective way to verify the diagnosis itself. I think this adds an important layer of complexity and gives us reason to be cautious.

Breast augmentation for 16 yr old cis girls is not unheard of in our area. This makes mammo of posterior breast tissue difficult, and possibly delay early detection. Parents and children don't recognize these risks as they have not known anyone with an advanced cancer found peaking around a radio opaque implant. I am not in favor of cosmetic surgery until adulthood, unless for a severe deformity.

 

[Candidate2017]

All true, but you should have sufficient training to determine if there is a secondary cause of gender dysphoria that if treated, will improve or alleviate the gender dysphoria without the need for any transitioning.

Almost no one else in medicine has the training or knowledge to be able to tease that out.

Yes, I can diagnose gender dysphoria and treat causes masquerading as gender dysphoria. But again, there's no evidence showing psychiatric "clearance" for trans hormonal therapies, penectomies, mastectomies, etc. is predictive of how someone will feel in the future, which is a lot of what these lawsuits are based upon: future regret or decompensation, requiring financial compensation.

BTW gender dysphoria is a controversial DSM psychiatric diagnosis, and I predict it will revoked as a psychiatric disorder just like homosexuality.

There are times when being a doctor means being willing to do things to help patients even when that exposes you to liability.

We are exposed to liability everyday, regardless.

I agree with you that many patients who think they need surgery are not well-served by it. That’s why I think providers doctors need to be willing to tell patients this when it is the truth, rather than just funnel them towards surgery.

In addition to the above, I feel requests for clearance letters are better served by an outside third party like you, rather than me the treating physician, in order to preserve the therapeutic relationship. When a patient, especially a new one, requests I sign off on a letter for them, they desire a transaction not a therapeutic relationship.

 

[nofliesonme]

Transgender surgery in adolescents, is not cosmetic......it is reconstructive.

 

[annoyedpsychiatrist]

We can do things like suicide risk evals but in reality we cant actually predict suicide. We can provide clearance letters but what are we saying in these letters? If gender is fluid and at one point someone identifies one that deviates from how they were born, it stands to reason they could learn more about themselves as they age and question who they are, perhaps identifying in another way. There are many people who are confused about their gender in general. There is all kinds of research out there, sure, but lets put it into a purely logical perspective. Its fine if someone wants this surgery but after informed consent they should be the ones responsible for any positive or negative consequence, which is why this may be better suited to do as an adult, where someone can accept legality. Also people make fairly impulsive choices at that age anyways. The world's smartest 15 year old is still emotionally stupid. Physicians shouldn't be scapegoats when a patient desires to change their mind on a whim.