November 13, 2012
From today’s NPR article “Inmate Sex Change: Should We Pay And Does The Surgery Actually Work?” by award-winning journalist and syndicated health columnist Judy Foreman:
“As the controversy continues to swirl over sex change surgery for convicted murderer Michelle Lynn (formerly Robert) Kosilek (there’s a hearing this month on whether taxpayers should pay for her electrolysis), I got to wondering about some of the questions this case raises.
Certainly, prisoners are entitled to basic health care. But do we really owe her a sex change operation?
Especially if — as some of the evidence I uncovered suggests — it wouldn’t leave her in substantially better mental health than she is in today?
I confess: I’m not sure I would even ask this question if I were sympathetic to her in the slightest. But I’m not. She is a convicted murderer. She is in prison for a reason, and a very good one.
But, that aside, back to my quest for facts: How well does sex reassignment surgery (SRS) work in the first place?
Here’s some data: There was a major study in 2011 by the Karolinksa Institute.
Using data from Swedish registers, they studied 324 people — 191 male-to-females and 133 female-to-males — who had SRS between 1973 and 2003. For each SRS patient, the researchers randomly selected 10 people from the general population who had not had SRS. From this group, two control subjects were matched to each SRS patient — one with the same sex and age as the patient at birth and the other, with the same age and sex as the patient after SRS.
All-cause mortality was three times higher for people who had SRS and deaths by suicide were also higher. People who had the SRS were also at higher risk for hospitalizations for non-gender related psychiatric problems. It’s not totally clear why people who get the surgery get worse. But the authors conclude,
“Persons with transsexualism, after sex reassignment, have considerably higher risks for mortality, suicidal behavior and psychiatric morbidity than the general population. Our findings suggest that sex reassignment, although alleviating gender dysphoria, may not suffice as treatment for transsexualism…”
So, in other words, the surgery does get rid of “gender dysphoria,” meaning deep unhappiness with one’s biological sex. But it doesn’t seem to help much with other mental health issues, including suicidality.
If that’s true for Kosilek, I wondered, why should taxpayers foot the bill?
The Karolinksa researchers did caution that for SRS patients their findings didn’t necessarily mean the surgery didn’t help at all: “Things might have been even worse without sex reassignment.”
I wouldn’t be so swayed by this pessimistic study except that it’s methodologically much better than previous research, including an oft-cited 2010 Mayo Clinic study.
Researchers performed a systematic review and meta-analysis of 28 studies of hormone therapy and sex reassignment involving 1093 male-to-females and 801 female-to-males.
The studies were observational and most lacked controls. Overall, in the Mayo review, 80 percent of people who had the sex reassignment reported significant improvement in gender dysphoria, as well as significant improvement in psychological symptoms and quality of life.
But, as the Mayo researchers themselves note, all of these conclusions were based on “very low quality evidence due to the serious methodological limitations of included studies.”
In data-speak: garbage in, garbage out.
Ben Klein, senior attorney for Gay and Lesbian Advocates and Defenders, doesn’t see it that way. “All studies have limitations,” he told me, “but if you look at the overwhelming trend of a significant number of studies, all point to the same conclusion – that sex reassignment surgery is the only effective treatment for gender identity disorder.”
But I’m not buying that — pooling a bunch of bad studies doesn’t yield good data.
It makes more sense to wonder why the surgery doesn’t have better long-term results. One reason, suggests Renee Sorrentino, a Harvard Medical School psychiatrist who runs the Institute for Sexual Wellness in Quincy, is that by the time a person seeks sex change surgery, gender dysphoria has usually been a problem for a long time and is often accompanied by significant traumatic experiences, including bullying. Those deep psychological wounds may not be so easily healed.
That said, I know a transsexual woman, Sara Herwig, who has been helped by the surgery and now feels like a “congruent person.” So I called her.
“The thing to remember about SRS or general reconstructive surgery is that it is not a silver bullet,” she said. “You still have to deal with everything in life that everybody has to deal with. It’s not going to have a big impact on clinical depression or other kinds of mental illnesses.”
Fair enough, but did she believe taxpayers should be on the hook for Kosilek’s surgery?
Herwig has mixed feelings, “My initial reaction is that nobody paid for mine. Health insurance doesn’t cover it. I understand her desire to have the surgery, but … vast numbers of other people I know have had to pay for their own. I do think there need to be reforms in health insurance so such surgeries are covered. But I don’t think the taxpayers should pay for someone to have that kind of surgery.”
In the end, I concluded, neither do I.
And as for this month’s hearing regarding hair removal?
Give me a break. I have a couple of eyebrows I’d like taxpayers to have waxed for me.”