What’s life like for the transgendered after sexual reassignment surgery?

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Actress Laverne Cox’s appearance as the first openly transgender woman to be featured on the cover of Time magazine in June sparked a deluge of both praise and scorn on social and news media. The featured article discusses the trend of growing acceptance for transgender people – those whose internal sense of their own gender does not conform to the expectations of society based on their physical appearance – in the United States, as well as misunderstandings that pervade.

But transgender issues haven’t just been hot in the celebrity circuit as of late. The same week that Time released its issue, The Wall Street Journal carried an op-ed by Dr. Paul McHugh, the former chair of the Department of Psychiatry at Johns Hopkins, in which he explains why he believes sex reassignment surgery (SRS) is not a viable treatment for gender dysphoria, the diagnostic term for when a person’s physical sex conflicts with their gender identity. SRS is commonly used as a treatment for transsexualism, when a patient feels strongly that their gender is opposite their birth sex. Needless to say, the controversial article was met with a considerable mix of responses.

McHugh supports his view – which goes against the views of the American Psychological Association and medical consensus – with a longterm study by researchers at the Karolinska Institute in Sweden. The majority of research on patients before and after SRS shows improved quality of life and psychological health right after surgery, but long-term evidence is more dubious.

The Karolinska Institute’s study followed a sample of 324 transsexual patients in Sweden, including male-to-females and female-to-males, after undergoing surgery between 1973 and 2003. The researchers found a higher suicide rate in transsexual individuals ten or more years after surgery than in the general Swedish population.

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These results are troubling, and they warrant an explanation with follow-up research. Several questions remain unanswered. Would the suicide rate have been even higher in this group had they not undergone surgery? The study did not evaluate the mental health of patients pre-surgery or compare them with patients who did not opt for surgery. Unforeseen circumstances – such as subsequent divorce and the stigmatization of transgender people in society – are risk factors for suicide that were not controlled for in this study.

The Karolinska Institute researchers do not draw definitive conclusions from the results, but state, “Our findings suggest that SRS, although alleviating gender dysphoria, may not suffice as treatment for transsexualism, and should inspire improved psychiatric and somatic care after SRS for this patient group.” McHugh goes in a different direction, rejecting both sex reassignment and gender dysphoria, which he confusedly compares to body dysmorphic disorder in claiming that it “does not correspond with physical reality.”

But what exactly is physical reality with regard to gender? It is debatable whether maleness and femaleness are “given in nature”, as McHugh puts it, because disorders of sexual development sometimes result in both male and female physical characteristics and hormone imbalances. For instance, XY-genotype individuals with androgen insensitivity syndrome can possess primarily female or male sexual characteristics, or anything in between, depending on the severity of their condition. XX-genotype individuals with congenital adrenal hyperplasia, a genetic disorder of the adrenal glands, may also develop ambiguous sexual characteristics. Consequently, affected individuals are more likely to be transgender. The gender of children born with ambiguous genitalia certainly is not obvious at birth, and gender identity is not always congruous with physical characteristics, or the assignment given to them by the attending doctor.

People with gender dysphoria generally do not suffer from false perceptions about their physical appearance, nor do they always feel negatively about their bodies. Those who seek surgery – and most do not – do so because it is necessary for their psychological health. Rather than lambast SRS, we should admit that it is a beneficial but incomplete treatment that does not resolve the distress that societal issues can put on transgender people. As a doctor, McHugh does no favors by refusing to relinquish an unscientific and outdated outlook on gender.

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