Living in the U.S., chances are you get some regular mail that you never signed up for — a magazine, a journal, a sales flier. As medical professionals, we also get these free journals related to our field. We don’t always have the time to fact-check a publication. And with names that appear to be legitimate, we might take information at face value. This is especially true if we are reading an article about a topic loosely related to our work. We can think that we are learning. I know I do this at my kitchen counter when I am waiting for my meal to cook or am taking a break from parenting.
But when publications send out articles that are not based on peer-reviewed research, it can create misinformation that may impact care.
A recent article in a free circular aimed at endocrinologists discussed the practice of chest masculinization in transgender and nonbinary (TGNB) individuals, focusing on the age when this surgery is performed and the ethics behind it. The article contended that children are making these decisions for top surgery at an incredibly young age, as early as 13 years old.
While some youth may undergo top surgery at this age, this is certainly not the average age of top surgery for TGNB folks. Suggesting it leads to an unfair and emotionally provocative way to characterize this very important surgery — and might be a subtle tactic by anti-trans advocates to negatively impact health care for TGNB individuals.
While there are some individuals who obtain top surgery at 13, current WPATH Standards of Care (SoC) suggest that surgery occurs at 18 years of age, when individuals can consent to their own treatment.
Frequently, insurance coverage follows the SoC and does not provide insurance coverage until that time. In addition, individuals who seek chest masculinization surgery are oftentimes required to have two letters of support from a therapist or other health care provider. If they are under 18, they need their parents’ consent. So, it is inaccurate to think that a 13-year-old will be able to make a decision to have surgery on their own, without the support of their parents or their health care providers.
The article’s author noted that medicine has made mistakes in the past when it comes to care. The author added that it would be interesting to see how providers react in the future to supporting youth in their decision to transition medically, including hormone blockers and hormone replacement therapy, and surgery.
Yet, the major medical atrocities of the past, like the Tuskegee Syphilis Study and the Holmesburg Prison experiments, were done with a paternalistic view that medical professionals knew better than their patients, and these interventions oftentimes did not fully explain care and regularly preyed on marginalized folks to conduct medical experiments.
Still, the effects of these experiments and care based on racist, sexist, and xenophobic attitudes can be felt.
Quite differently, transition-related care is driven by the patient and, if the individual is under 18, the patient’s parent. As physicians continue to adhere to the principles of biomedical ethics, we need to keep autonomy, justice, beneficence, and non-maleficence in mind. In addition, there have been multiple additions to the Hippocratic Oath to include these principles and more social justice tenets.
In many of these articles, the actual data are hidden, obscured, or missing.
For instance, in the piece on chest masculinization, the research on patient satisfaction is minimized, as is the low rate of regret, which is often due to complications from the surgical procedure rather than the procedure itself.
In fact, multiple studies have noted that individuals feel better about their bodies after surgery and are less depressed. The data instead suggest that more practitioners are needed to perform these surgeries, provide the medication, and support individuals with mental health challenges. There are far too few providers who specialize in care for TGNB folks, which can lead to long waitlists or a lack of adequate providers.
As health care providers, we need to be mindful of the information we take in and question the sources of the information. Is this written by an expert? A journalist? A person with lived experience? While some pieces may appear to be based in science and have credibility, they may instead be driven by a political ideology.
Even if we don’t take everything in these articles at face value, the headlines and pull quotes we casually scan can do subtle, insidious harm. The unconscious biases individuals begin to form after reading these pieces can impact the care they provide for patients moving forward, as well as research agendas, public and private support within medical settings and in our private lives. We need to be aware of the cumulative effect of these types of articles.
This is not the first, but a stream of articles that has been sent by free, non-peer-reviewed journals that get into the hands of many providers.
Without expertise in the field, it is easy to think that these treatments are unsafe and dangerous to youth. While we will never be able to have a full randomized trial to understand the benefits of affirmative treatment for TGNB individuals, we can look to the peer-reviewed research currently in place to bolster our education in this area. More importantly, we can also listen to our patients and learn about their needs from them directly.
Christy L. Olezeski is a psychologist.
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