AJP Issues Correction: No Mental Health Gain from Gender-Affirming Surgery
August 27, 2020
by Andrè Van Mol, MD
The American Journal of Psychiatry (AJP) printed a rare and important correction this month. A study claiming to be the “first total population study of transgender individuals with a gender incongruence diagnosis” was published in the October 2019 AJP titled “Reduction in mental health treatment utilization among transgender individuals after gender-affirming surgeries: a total population study.” Seven letters to the editor from 12 authors, myself included, resulted in a data reanalysis and subsequent correction statement that no improvement was demonstrated with surgical treatment. Now for the setting and major points of my team’s published letter.
The Swedish Total Population Register of 9.7 million people was used to assess the effectiveness of “gender-affirming hormone treatment” and “gender-affirming surgery” in affecting three endpoints: prescriptions for antidepressants and anxiolytics, healthcare visits for mood or anxiety disorders and post-suicide attempt hospitalizations. The study authors, Branstrom and Pachankis, found that gender-affirming hormones offered no effect but that surgery did reduce mental health treatment. They further asserted the finding “provides timely support for policies that ensure coverage of gender-affirming treatments.”
Our team found much to contest in this study when we first assessed it in October 2019. I lead our team quartet—which also included endocrinologist Michael Laidlaw, MD; pediatric and adolescent psychiatrist Miriam Grossman, MD; and Johns Hopkins professor of psychiatry Paul McHugh, MD—to quickly turning those findings into a letter to the editor of AJP meeting their 500-word limit (including citations, ouch), and we were not alone. Seven critical letters, including our own, were published on August 1, 2020, along with remarkable developments explaining why it took 10 months to publish the letters, including a response from the study authors. But first let’s look at the study shortfalls we found.
Branstrom and Pachankis used a retrospective design, not longitudinal, thus asking participants to look back rather than following them along. Qualifying criteria was to be alive in Sweden on December 31, 2014 and to be diagnosed as gender incongruent, and the study was only over a limited one-year time frame, namely 2015. Figure 1 of the study specified being “time since last gender affirming surgery” and went back 10 years. That chart could easily be misinterpreted as a prospective 10-year follow up rather than a “do you recall” scenario. No control group was used either.
Loss to follow up was strongly implied on several metrics. First, the authors reported that 2,679 Swedes were diagnosed with “gender incongruence.” Though a study of this kind with that many subjects is impressive, the numbers are a full order of magnitude below what prevalence statistics from the DSM-5 would project.
So where did they go?
Secondly, the authors only measured three outcomes: prescriptions for anxiolytics and antidepressants, mental healthcare visits for mood or anxiety disorders and post-suicide attempt hospitalizations. Overlooked were completed suicides (obviously those won’t usually have post-attempt hospitalizations); healthcare visits, prescriptions and hospitalizations for the litany of other medical or psychological diagnoses likely related to the gender-affirming hormones and/or surgery; and other contingencies we listed. Such information was available through Sweden’s Hospital Discharge Register, National Patient Register and Prescribed Drug Register, so why not use it?
The third item suggesting loss to follow up was the paucity of gender-affirming surgeries. Table 3 of the Branstrom study shows only 38 percent of people diagnosed with gender incongruence have any type of such surgery, and only 53 percent of those (so now maybe 20 percent of the total) had surgery of the reproductive organs—“bottoms” rather than “tops” surgery. Gender affirming surgery is free in Sweden, so where did these patients go? And for those whose last surgery was 10 or more years earlier, how many completed suicide, died of other related causes or emigrated from Sweden prior to the study timeline?
We concluded our letter by comparing this study to the one we consider perhaps the best of its kind, also from Sweden, the 2011 Dhejne study. The Dhejne team made extensive use of numerous specified Swedish registries—thus revealing the existence of such, all available to Branstrom and Pachankis—and followed everyone in Sweden over a 30-year period who underwent “sex reassignment,” all 324 of them. Selection bias, zero. They used population controls and matching by birth year, birth sex and reassigned sex. They found that 10 years along, the sex reassigned group had 19 times the rate of completed suicides and nearly three times the rate of all-cause mortality and inpatient psychiatric care compared to the general public. With relative ease, the AJP study authors could have chosen to update Dhejne’s findings to the present.
Which brings us back to the August AJP and why seven critical letters took 10 months to see print. Along with the letters, the AJP editors published a “Correction to Bränström and Pachankis,” which explained their discerning the need “to seek statistical consultations.” These consultants “concurred with many of the points raised,” the study authors were asked to reanalyze their data and the results demonstrated “no advantage to surgery” for their three endpoints in the subject population. The authors noted in their response letter that their “conclusion” “was too strong.”
Branstrom and Pachankis sought to generate “support for policies that ensure coverage of gender-affirming treatments.” Their study demonstrated that neither “gender-affirming hormone treatment” nor “gender-affirming surgery” achieved reductions in utilization of mental health services for transgender-identified people in the first of its kind total population study of them. Our team is of the conviction that many of the pro-transition studies we have read fare no better. Fad medicine is bad medicine, and gender anxious people deserve better than the rush to transition.