Why you should care

Sex-change surgery might offer only a physical fix for complex psychological problems. 

The problem began for Walt Heyer when he was just 5 years old, when he says his grandmother routinely slipped him into dresses, gushing about how she’d prefer him as a girl. Nearly 40 years later, a psychiatrist diagnosed him with gender dysphoria and approved him for sex reassignment surgery. Then came divorce, surgery and a life as Laura Jensen. The euphoria did not last long. After learning of his transition, his company fired him as he continued to pay child support. He began drinking and overdosed on cocaine.

After rehab, he enrolled in a counselor certification program and saw transgender patients grappling with depression and other psychiatric disorders. Wondering whether he had an undiagnosed disorder, he saw another psychiatrist. The new diagnosis? Dissociative identity disorder; he had developed distinct male and female identities. “I was misdiagnosed.”

Sex-reassigned people had a five- and threefold higher risk of attempted suicide and psychiatric disorders, respectively.

Nowadays Heyer, who’s on a lifelong hormone regimen to reverse the changes, is an ardent advocate against sex-reassignment surgery. And he may have a point: What if the procedure is an invasive physical solution for an inherently psychological problem? Given that people with gender dysphoria often struggle with other psychiatric disorders, surgery might offer a superficial fix that neglects an underlying web of issues. Disentangling them might resolve gender dysphoria without the need for sex reassignment surgery, which has become increasingly easier to obtain. (The Affordable Care Act now makes it possible for transgender individuals to purchase insurance plans that cover the procedure.)

Not to discount gender dysphoria as a distinct — and often devastating — psychiatric disorder. Those who suffer it experience deep discomfort with their own gender and a strong, persistent desire to be the opposite gender. An estimated 700,000 adult Americans are transgender, and 80 percent of sex-reassigned patients examined in a 2010 Mayo Clinic study experienced an improvement in treating their gender dysphoria, consistent with other research findings. “Generally speaking, the results are positive,” said Anna Glezer, an assistant professor of psychiatry at the University of California, San Francisco.

But these studies looked at relatively few patients and often lacked controls. Karolinska Institutet researchers published one of the few controlled, large-scale, long-term follow-up studies in 2011. They looked at 191 male-to-female and 133 female-to-male patients who had undergone surgery between 1973 and 2003, matching each with 10 randomly chosen people who hadn’t undergone surgery as controls. Their findings? Sex-reassigned people had a five-fold higher risk of attempted suicide, and were three times as likely to have a psychiatric disorder.

Indeed, many sex-reassigned individuals have grappled with gender dysphoria for years, as well as major depressive disorder or other psychiatric disorders, according to some studies. Surgery doesn’t just make them “go away.” A follow-up of Johns Hopkins Hospital patients after sex reassignment surgery found that they struggled with the same relationship and emotional problems they had before the procedure.

And if the medical community recommends psychiatric care, not cosmetic procedures, for people suffering from anorexia and body dysmorphic disorder, despite those patients’ belief that changing their appearance will solve their problems, why not do the same for gender dysphoria patients? In fact, surgery might worsen their self-image. Some develop an addiction to plastic surgery, even seeking back-alley procedures.

Given the scarcity of methodologically strong research showing that sex reassignment surgery improves the treatment of gender dysphoria, is the procedure — which drastically alters an otherwise-healthy body — even medically appropriate? After surgery, “you’re thinking you have finally become who you were,” Heyer said. But it “was never necessary to find out who your true self was.”

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