This is amazing. The public relations firm Mediasource, representing the American Society of Plastic Surgeons issued a glowing and newsworthy press release this week titled “Gender Confirmation Surgeries Rise 20% in First Ever Report”.

ARLINGTON HEIGHTS, Ill. – For the first time, the American Society of Plastic Surgeons (ASPS) is reporting on the number of gender confirmation surgeries in the United States. ASPS—the world’s largest plastic surgery organization—found that more than 3,200 transfeminine and transmasculine surgeries were performed in 2016. The procedures can include anything from facial and body contouring to gender reassignment surgeries.”

The press release went on to cite Chicago plastic surgeon Dr. Loren Schechter(*):

“There is no one-size-fits-all approach to gender confirmation,” said Loren Schechter, MD, a board-certified plastic surgeon based in Chicago. “There’s a wide spectrum of surgeries that someone may choose to treat gender dysphoria, which is a disconnect between how an individual feels and what that person’s anatomic characteristics are.

Access to gender confirmation procedures has improved in recent years. In just the first two years of collecting data, ASPS found the number of transgender-related surgeries rose nearly 20 percent from 2015 to 2016. “In the past several years, the number of transgender patients I’ve seen has grown exponentially,” said Dr. Schechter. “Access to care has allowed more people to explore their options, and more doctors understand the needs of transgender patients.”

(*Regular readers will remember Dr. Schechter as the business associate of psychologist Randi Ettner and her husband, who provide dubious and highly paid “diagnosis” and supporting testimony for convicted male murderers who wish to obtain prison funded “sex changes” and subsequent transfer to women’s facilities.)

Anyway, Reuters ran with the story and it took off internationally.

Gender Confirmation Surgeries on the Rise in US” read the headlines. “US Gender Confirmation Surgeries Up 19% in 2016, Doctors Say”.

Media outlets stuck with the same narrative that ASPS/Reuters provided: Surgeries to alter sex characteristics showed a 20% annual increase, likely due to increased media exposure of transgender issues, the removal of Medicare’s blanket ban on coverage, and increased insurance coverage of such procedures under the Affordable Care Act. Some news outlets added testimonials from satisfied customers who felt reborn after surgical procedures.

CBS News used commentary from Gearah Goldstein, a late-transitioning self-employed activist dedicated to medicalizing gender in children and eliminating private sex-segregated facilities for girls in public schools. Goldstein described his psychological relief after undergoing facial feminization surgery performed by Dr. Schechter. New York Magazine’s science writer Jesse Singal tweeted Goldstein’s testimonial as evidence of the efficacy of cosmetic facial feminization surgery for men who identify as transgender.

https://twitter.com/jessesingal/status/867117853320806401

Washington Post science writer Amy Ellis Nutt, who believes that identification with a sex role, or “Gender Identity”, is a biological process that occurs in utero, used a rebirth testimonial from 74 year old Denee Mallon: “When I woke up from surgery, I felt a certain sense of peace and tranquility.”

Business Insider quoted HRC press officer Sarah McBride (formerly Tim McBride):

 “Sarah McBride, a press secretary for the Human Rights Campaign agreed the data is novel and important, adding that “there’s been a real dearth” of statistics about the transgender community until recently.”

Articles quoted various supporting statistics directly from the American Society of Plastic Surgeons survey. Business Insider placed some of the data into a helpful graph. Have a look at the findings:

[this graph has now been removed from the Business Insider article. The article itself has not been redacted]

Even a cursory glance at this “supporting data” reveals that these numbers are meaningless. Equal numbers of male facial feminization and female facial masculinization procedures?! Nonsense. Only a hundred or so mastectomies or breast augmentations?! Only fifteen genital surgeries recorded nationally by the ASPS?! What exactly is being measured here? Not much.

Elizabeth Nolan Brown at Reason.com writes a detailed breakdown of the problem with the ASPS survey and conclusions:

http://reason.com/blog/2017/05/23/gender-confirmation-surgery-2016-stats

Retraction Watch also covered this story:

http://retractionwatch.com/2017/05/23/reuters-removes-story-gender-confirmation-surgery-firm-mistakenly-released-data/

You can read the original (now retracted) Reuters story at NBCNews, which is still running the story with the following notice:

“Editor’s Note: Reuters has withdrawn this story because of questions surrounding the data supplied by the American Society of Plastic Surgeons.”

http://www.nbcnews.com/feature/nbc-out/u-s-gender-confirmation-surgery-19-2016-doctors-say-n762916

Have transgender related surgeries increased by 20% in the past year? We have no idea. They could have spiked by over 300% (insert any figure). Or they could have dropped as more genderists adopt a “non-binary” belief system (or for whatever reason). We just don’t know.

But that won’t stop the international media from pushing the narrative, uncritically, with fake data supplied by the medical gender industry.

Indeed, as of today they are still reporting it.

Story continues to spread. Published today by Mirror Daily

 

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On June 2, 2016 the Centers for Medicare & Medicaid Services (CMS) denied national coverage for gender reassignment surgery after the agency conducted a  year long review which determined that there is no medical evidence of a therapeutic outcome for patients who have undergone these procedures.

 

Excerpts from their report:

 

On December 3, 2015, CMS accepted a formal complete request from a beneficiary to initiate a national coverage analysis (NCA) for gender reassignment surgery.

CMS opened this National Coverage Analysis (NCA) to thoroughly review the evidence to determine whether or not gender reassignment surgery may be covered nationally under the Medicare program.

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In general, when making national coverage determinations, CMS evaluates relevant clinical evidence to determine whether or not the evidence is of sufficient quality to support a finding that an item or service is reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. (§ 1862 (a)(1)(A)). The evidence may consist of external technology assessments, internal review of published and unpublished studies, recommendations from the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC), evidence-based guidelines, professional society position statements, expert opinion, and public comments.

 

The overall objective for the critical appraisal of the evidence is to determine to what degree we are confident that: 1) specific clinical question relevant to the coverage request can be answered conclusively; and 2) the extent to which we are confident that the intervention will improve health outcomes for patients.

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CMS staff extensively searched for primary studies evaluating therapeutic interventions for gender dysphoria. There was particular emphasis on the various surgical interventions, but other treatments including hormone therapy, psychotherapy, psychiatric treatment, ancillary reproductive and gender modifying services, and post-operative surveillance services for natal sex organs were also included because of their serial and sometimes overlapping roles in patient management. The emphasis focused less on specific surgical techniques and more on functional outcomes unless specific techniques altered those types of outcomes.

 

The reviewed evidence included articles obtained by searching literature databases and technology review databases from PubMed (1965 to current date), EMBASE, the Agency for Healthcare Research and Quality (AHRQ), the Blue Cross/Blue Shield Technology Evaluation Center, the Cochrane Collection, the Institute of Medicine, and the National Institute for Health and Care Excellence (NICE) as well as the source material for commentary, guidelines, and formal evidence-based documents published by professional societies. Systematic reviews were used to help locate some of the more obscure publications and abstracts.

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CMS reviewed and considered potential objective measures of function including mortality, psychiatric treatment, and attempted suicide. None of the longitudinal studies in which patients served as their own control, however, comprehensively tracked changes in these events as objective measures of function before and after surgery. Events such as suicide and institutionalization were mentioned incidentally when describing patients excluded from a follow-up study or during the study (Heylens et al., 2014; Ruppin, Pfafflin, 2015). Other times investigators tracked these functional outcomes (e.g., psychiatric out-patient treatment, psychiatric in-patient treatment, and substance abuse) for the most current prior year (Ruppin, Pfafflin, 2015).

 

The most comprehensive study with functional endpoints, the Swedish study that followed all patients who had undergone reassignment surgery (at mean age 35.1 years) over a 30 year interval and compared them to 6480 matched controls, identified increased mortality and increased psychiatric hospitalization (Dhejne et al., 2011). The mortality was primarily due to completed suicides (19.1-fold greater than in control Swedes), but death due to neoplasm and cardiovascular disease was increased 2 to 2.5 times as well. The divergence in mortality from the Swedish population did not become apparent until after 10 years. The risk for psychiatric hospitalization was 2.8 times greater than in controls even after adjustment for prior psychiatric disease (18%). The risk for attempted suicide was greater in male-to-female patients regardless of the gender of the control. Unfortunately, the study was not constructed to assess the impact of gender reassignment per se. The finding of this study, again, demonstrated that reassignment surgery does not return patients to a normal level of morbidity risk and that the morbidity risk is significant, because of its clinical importance, its persistence over the interval of data collection and the increase in risk over time for the individual.

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The currently available evidence has limitations:

 

  • There were design deficiencies. All but one of the studies were observational in nature. All but two were non-blinded. The accompanying loss to follow-up suggests that there is selection bias and that the population that seeks treatment for gender dysphoria is not the same population that undergoes reassignment surgery without hesitation or regret.
  • The psychometric and psychosocial function endpoints are not well validated.
  • There were limitations of the psychosocial endpoints and of the data collection of other hard functional outcomes. Evidence on mortality and especially suicide was stronger. The mortality and psychiatric hospitalization rates even after vetting in highly structured programs are of concern.
  • There are insufficient data to select optimal candidates for surgery.
  • The results were inconsistent, but negative in the best studies, i.e., those that reduced confounding by testing patients prior to and after surgery and which used psychometric tests with some established validation in other large populations. (Atkins et al., 2004; Balshem et al., 2011; Chan, Altman, 2005; Deeks et al., 2003; Guyatt et al., 2008a-c; 2011a-e; Kunz, Oxman,1998; Kunz et al., 2007 and 2011; Odgaard-Jensen et al., 2011).

Data on reassignment surgery performed on geriatric patients or follow-up data in geriatric patients who had reassignment surgery in the distant past is anecdotal (Orel, 2014).

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Based on a thorough review of the clinical evidence available at this time, there is not enough evidence to determine whether gender reassignment surgery improves health outcomes for Medicare beneficiaries with gender dysphoria. There were conflicting (inconsistent) study results – of the best designed studies, some reported benefits while others reported harms.

 

The quality and strength of evidence were low due to the mostly observational study designs with no comparison groups, potential confounding and small sample sizes. Many studies that reported positive outcomes were exploratory type studies (case-series and case-control) with no confirmatory follow-up. Due in part to the generally younger and healthier study participants, the generalizability of the studies to the Medicare population is also unclear. Additional research is needed. This proposed conclusion is consistent with the West Midlands Health Technology Assessment Collaboration (2009) that reported “[f]urther research is needed but must use more sophisticated designs with comparison groups.” WPATH also noted the need for further research: “More studies are needed that focus on the outcomes of current assessment and treatment approaches for gender dysphoria.” Further, as mentioned earlier, patient preference is an important aspect of any treatment. With that in mind, CMS is interested in knowing from the patients with gender dysphoria what is important to them as a result of a successful gender reassignment surgery.

 

Knowledge on gender reassignment surgery for individuals with gender dysphoria is evolving. The specific role for various surgical procedures is less well understood than the role of hormonal intervention. Much of the available research has been conducted in highly vetted patients at select care programs integrating psychotherapy, endocrinology, and various surgical disciplines and operating under European medical management and regulatory structures. Standard psychometric tools need to be developed and tested in the patients with gender dysphoria to validly assess long term outcomes. As such, further evidence in this area would contribute to the question of whether gender reassignment surgery improves health outcomes in adults with gender dysphoria.

 

Because CMS is mindful of the unique and complex needs of this patient population and because CMS seeks sound data to guide proper care of the Medicare subset of this patient population, CMS strongly encourages robust clinical studies with adequate patient protections that will fill the evidence gaps delineated in this decision memorandum.

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Currently, the local Medicare Administrative Contractors (MACs) determine coverage of gender reassignment surgery on an individual claim basis. The Centers for Medicare & Medicaid Services (CMS) proposes to continue this practice and not issue a National Coverage Determination (NCD) at this time on gender reassignment surgery for Medicare beneficiaries with gender dysphoria. Our review of the clinical evidence for gender reassignment surgery was inconclusive for the Medicare population at large.

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Read the complete evidence review and text of Medicare’s denial of a national coverage determination for ‘Gender Reasignment Surgery” here:

https://www.cms.gov/medicare-coverage-database/details/nca-proposed-decision-memo.aspx?NCAId=282

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