Here’s a new article in the Journal of Sexual Medicine that investigated the effects of gender-changing surgery on both males and females (over 18) with a diagnosis of gender dysphoria. The results won’t make gender extremists happy, as in both cases rates of mental distress, including anxiety, and depression, were higher than those having surgery than those not having surgery after two years of monitoring. However, this doesn’t mean that the surgery shouldn’t be done, as the authors note that other studies show that people undergoing surgical treatment are, over the longer term, generally happy with the outcome. The main lesson of the paper is that people who do undergo such surgeries should be monitored carefully for post-surgical declines in mental health.
Click the headline below to read.
The authors note that there are earlier but much smaller studies that show no decline in mental health after surgery, but these are plagued not only by small sample size, but also by non-representative sampling reliance on self-report, and failure to diagnose other forms of mental illness beyond gender dysphoria before surgery. The present study, while remedying these problems, still has a few issues (see below).
The advantages of this study over earlier ones is that the samples of Lewis et al. are HUGE, based on the TriNetX database of over 113 million patients from 64 American healthcare organizations. Further, the patients were selected only because they had a diagnosis of gender dysphoria and no record of any other form of mental illness (of course, it could have been hidden). Patients were divided into four groups (actually six, but I’m omitting two since they lacked controls): natal males with gender dyphoria who had or didn’t have surgery, and natal females with and without surgery. Here are the four groups, and I’ve added the sample size to show how much data they have:
Cohort A: Patients documented as male (which may indicate natal sex or affirmed gender identity), aged ≥18 years, with a prior diagnosis of gender dysphoria, who had undergone gender-affirming surgery.
Cohort B: Male patients with the same diagnosis but without surgery. [Cohorts A and B had 2774 patients.]
Cohort C: Patients documented as female, aged ≥18 years, with a prior diagnosis of gender dysphoria, who had undergone gender-affirming surgery.
Cohort D: Female patients with the same diagnosis but without surgery. [Cohorts C and D each had 3358 patients.]
A and B are the experimental and control groups for men, as are C and D for women. Further, within each comparison patients were matched for sex, race, and age to provide further controls. And here are the kinds of surgeries they had:
To be included, all patients had to be 18 years or older with a diagnosis of gender dysphoria, as identified by the ICD-10 code F64. This criterion was chosen based on literature highlighting elevated mental health concerns for transgender and nonbinary patients with gender dysphoria [15, 16]. Gender-affirming surgery cohorts consisted of patients with a documented diagnosis of gender dysphoria who had undergone specific gender-affirming surgical procedures. For transmen, this primarily included mastectomy (chest masculinization surgery, CPT codes 19 303 and 19 304), while for transwomen, this encompassed a range of feminizing procedures such as tracheal shave (CPT code 31899), breast augmentation (CPT code 19325), and vaginoplasty (CPT codes 57 335 and 55 970). These surgeries were identified using clinician-verified CPT codes within the TriNetX database, allowing for precise classification.
Note that there were a lot more “bottom” surgeries for trans-identifying men (as the authors call them, “transwomen”) than for trans-identifying women (“transmen”). Men prefer to change their genitals more often than women, even though, if you know how vaginoplasties are done, you have to be hellbent on getting one. (I don’t know as much about the results of getting a confected penis.)
I’ll be brief with the results: in both comparisons, those patients who had surgery had a significantly higher postsurgical risk of depression, anxiety, suicidal ideation, and substance abuse. But surgery had no effect on body dysmorphia: the obsession with flaws in one’s appearance. Here are the tables and statistical comparisons of cohorts A vs. B and C vs. D, and the effect of surgery is substantial (results on women are similar though differences are smaller). Some of the differences are substantial: anxiety in men, for example, was nearly five times higher in those who had surgery than those who did not.
As you see, there are significant differences for everything save body dysmorphia, for which there are no differences at all. The authors conclude that yes, at least over the two-year measurement period (again, mental states were monitored by professionals, and were not due to self report). Given that surgery does seem to improve well being over the long term, as the authors note twice, they conclude that the results provide more caution about taking care of patients who have transitional surgery:
The findings of this study underscore a pressing need for enhanced mental health guidelines tailored to the needs of transgender individuals following gender-affirming surgery. Our analysis reveals a significantly elevated risk of mental health disorders—including depression, anxiety, suicidal ideation, and substance use disorder—post-surgery among individuals with a prior diagnosis of gender dysphoria. Importantly, however, our results indicate no increased risk of body dysmorphic disorder following surgery, suggesting that these individuals generally experience satisfaction with their body image and surgical outcomes. Notably, the heightened risk of mental health issues post-surgery was particularly pronounced among individuals undergoing feminizing transition compared to masculinizing transition, emphasizing the necessity for gender-sensitive approaches even after gender-affirming procedures.
Possible problems. There are two main limitations of the study noted by the authors. First, individuals electing surgery may have higher levels of distress to begin with than those who didn’t, so the elevated rate of mental disorders in the surgery group could be artifactual in that way. Second, patients who have had surgery may be wealthier or otherwise have more access to healthcare than those who didn’t, and so higher rates of mental distress could result simply from a difference in detectability.
Now I don’t know the literature on long-term effects of surgery on well-being, so I’ll accept the authors’ statement that they are positive, even though patients with greater well being could, I suppose, still suffer more depression and anxiety. But those who are looking to say that there should be no surgery for those with gender dysphoria will not find support for that in this paper. What they will find is the conclusion that gender-altering surgery comes with mental health risks, and those must be taken into account. It’s always better, when dealing with such stuff. to have more rather than less information so one can inform those contemplating surgery.
When I was writing Faith Versus Fact, I sometimes visited professors in our Divinity School, located right across the Quad. I discovered that the faculty was divided neatly into two parts. There were the Biblical scholars, who addressed themselves wholly to figuring out how the Bible was made, the chronology of its writing, comparisons of different religions, and so on. Their questions were basically historical and sociological, and I found that, as far as I could tell, most of this group were atheists.
Then there were the real theologians: the believers who engaged in prizing truth out of the Bible, and taking for granted that yes, there was a god and somehow the Bible had something to tell us about him. These I had little use for. Indeed, if you look up “theology” in the Oxford English Dictionary, you find this as the relevant definition. It describes the second class of academics who inhabit the Div School—the ones who accept that there is a god:
After writing my book, and having to plow through volume after volume of theology, including theological luminaries like Langdon Gilkey, Martin Marty, Alvin Plantinga, William Lane Craig, John Polkinghorne, Edward Feser, C. S. Lewis (cough) and Karen Armstrong, I finished my two years’ of reading realizing that I had learned nothing about the “nature and attributes of God and His relations with man and the universe.” That, of course, is because there is no evidence for god, and the Bible, insofar as it treats of things divine, is fictional. Yes, there is anthropology in the Bible, as Richard Dawkins notes below, but it tells us absolutely nothing about god, his plan, or how he works. If you don’t believe me, consult the theologians of other faiths: Hindus, Muslims, and yes, Scientologists. They find a whole different set of “truths”! There is no empirical truth that adds to what humanists have found (as Dawkins notes below “moral truths” are not empirical truths), but only assertions that can’t be tested. (Well, a few facts are correct, but many, like the Exodus of the Jews from Egypt and the census that drove the Jesus Family to Bethlehem, are flatly wrong.)
The discipline of theology as described by the OED is a scam, and I’m amazed that people get paid to do it. The atheist Thomas Jefferson (perhaps he was a deist) realized this, and, when he founded the University of Virginia, prohibited any religious instruction. But pressure grew over the centuries, and I see that U. VA. now has a Department of Religious Studies, founded in 1967. So much the worse for them.
In the end, the only value I see in theology comprises the anthropological, sociological, and psychological aspects: what can we discern about what people thought and how they behaved in the past, and how the book was cobbled together. I see no value in its exegesis of God’s ways and thoughts.
And so I agree with what Richard says in the video below. Here he discusses the “value” of theology, but the only value he sees is as “form of anthropology. . . the only form of theology that is a subject is historical scholarship, literary scholarship. . . that kind of thing.” (“Clip taken from the Cosmic Skeptic Podcast #10.”)
I just wrote a piece for another venue that partly involves theology (stay tuned), and once again I was struck by the intellectual vacuity and weaselly nature of traditional theologians. And so I ask readers a question:
What is the value of theology? Has its endless delving into the nature of God and his ways yielded anything of value?
And I still don’t think that divinity schools are of any value, even though we have one at Chicago. After all, concerning their concentration on Christianity and Judaism, they are entire schools devoted to a single work of fiction. Granted, it’s an influential work of fiction, and deserves extra attention for that, but trying to pry truth out if it. . . well, it’s wasted effort and money.
I asked this question five years ago, noting that Dan Barker defined theology as “a subject without an object.”
A few kindly readers, such as ecologist Susan Harrison of UC Davis, have sent in photos, so the feature is not yet moribund. Susan’s narrative and IDs are indented, and you can enlarge the owl photos by clicking on them.
A winter visit to the owls of Bob Dylan Country
Many North American owls are not regularly migratory like songbirds, but will shift many miles to the north or south depending on yearly weather conditions and prey availability. Once every five or more years, the northernmost Midwest receives a winter influx of Boreal Owls (Aegolius funereus). The arrival of this handsome little raptor is so exciting that some birders will travel from as far away as (say) California for a weekend to see it.
Having heard about the Boreal Owls in January, I reached out to a local guide and arranged a late February trip to Two Harbors, Minnesota on the north shore of Lake Superior. On our first day it seemed I might have waited too long. The weather had warmed and no owls had been reported for a few days. We spent 10 fruitless hours cruising the roads and staring obsessively into the willows, alders, and small spruce along the verges. Had the owls moved back north?
Our second day dawned as clear and cold as a proper Minnesota winter morning. Not half an hour into our renewed search, a teardrop-shaped gray bundle stared back at us from the roadside shrubbery. With a nod to Bob Dylan, “Highway 61 Revisited” describes exactly how we found this owl!
Our first Boreal Owl:
Later that day we saw another one at Sax-Zim Bog, a famous destination for seeking overwintering owls of multiple species.
Our second Boreal Owl:
We were greatly helped by the close-knit network of regional owlers who share sightings with one another over an app. They guard information closely to spare owls from excessive attention.
Owlers at our second Boreal Owl sighting:
Having achieved success with the elusive Boreal Owl, we cruised around Sax-Zim Bog looking for the magnificent and more regularly occurring Great Gray Owl (Strix nebulosa). These are similar to Boreal Owls in being boreal forest inhabitants, nonmigratory, and shifting farther south in some years. We found a very sleepy owl perched along a roadside.
Great Gray Owl:
Finally we looked for Snowy Owls (Bubo scandiacus), which unlike the other two, undergo a regular winter migration to this area from their breeding grounds in the high Arctic. In most years they reach only the northern tier of US states, but they wander much farther south every now and then. They seem to be highly adaptable; one reliable place to see them, in fact, is the industrial district of Superior, Wisconsin. I think Bob Dylan would approve of their taste in gritty, down-to-earth surroundings.
Snowy Owl: