Tuesday, November 19, 2019

Mark Regnerus is Consistent, I'll Give Him That

Where is the peer-reviewed research to support the absolutist pronouncements of religious conservatives regarding transgender people?
Mark Regnerus
Once again Dr. Mark Regnerus demonstrates his subordination of empirical science to religious dogma.
via Austin Institute
Mark Regnerus attempts to discredit some new research demonstrating general satisfaction with gender confirmation surgery. Dr. Regnerus' arguments are esoteric and hypothetical yet he has authored a post at Witherspoon Institute's blog titled: New Data Show “Gender-Affirming” Surgery Doesn’t Really Improve Mental Health. So Why Are the Study’s Authors Saying It Does? Regnerus poses a rhetorical question that is easily answered.

The subtitle of this post reads:
Data from a new study show that the beneficial effect of surgery for transgender people is so small that a clinic may have to perform as many as 49 gender-affirming surgeries before they could expect to prevent one additional person from seeking subsequent mental health treatment. Yet that’s not what the authors say. That the authors corrupted otherwise-excellent data and analyses with a skewed interpretation signals an abandonment of scientific rigor and reason in favor of complicity with activist groups seeking to normalize infertility-inducing and permanently disfiguring surgeries.
Wow!

I will get back to Regnerus but first, the study in question was released on October 4, 2019. I was aware of this paper and I know one of the investigators. The paper is titled: Reduction in Mental Health Treatment Utilization Among Transgender Individuals After Gender-Affirming Surgeries: A Total Population Study.
The aim of this study was to ascertain the prevalence of mood and anxiety disorder health care visits and antidepressant and anxiolytic prescriptions in 2015 as a function of gender incongruence diagnosis and gender-affirming hormone and surgical treatment in the entire Swedish population.
Conclusions:

In this first total population study of transgender individuals with a gender incongruence diagnosis, the longitudinal association between gender-affirming surgery and reduced likelihood of mental health treatment lends support to the decision to provide gender-affirming surgeries to transgender individuals who seek them.
There are a few reasons that I did not write about this study:
  1. To understand this study I would have to fully appreciate how Swedish medicine approaches the treatment of gender dysphoria in contrast to United States practice.
  2. I cannot separate results that are derived from prescription usage vs. results derived from “health care visits.” I will explain why that is important and Regnerus pays no attention to the matter.
  3. If I apply U.S. practice to the study results, I believe that the benefits of gender confirmation surgery are understated.
According to the study, “Years since initiating hormone treatment was not significantly related to likelihood of mental health treatment.” Regnerus rephrases this as: “The study found no mental health benefits for hormonal interventions in this population.” Regnerus' statement is inaccurate. The study found that people are not less likely to require mental health therapy.

Not considered is the fact that, to qualify for gender confirmation surgery, a patient must have been on hormones for at least a year. The patient must also demonstrate consistent and continuous counseling. The individual providing that counseling has to be one of the two mental health professionals recommending gender confirmation surgery. Therefore, mental health visits might actually increase for some patients receiving hormones; those intending to qualify for surgery.

Gender confirmation surgery is a major procedure. Patients are encouraged to continue counseling. Furthermore, surgery does not relieve minority stress. The fact that they continue counseling does not diminish satisfaction with the surgery. Therefore, while the researchers find a reduction in transgender healthcare following surgery, that reduction is probably understated. I have no way of determining the effect of prescription medications on my supposition.

In 2018 Psychiatry Online provided An Interview With Hansel Arroyo, M.D., on Transgender Psychiatry. That is the same journal that published the study in question.

Dr. Arroyo is Director of the Transgender Psychiatry Fellowship and Assistant Director of Psychiatry at the Icahn School of Medicine at Mount Sinai in New York City. Clearly he is an expert. He states:
Well, we know that transgender kids who have family support do better in school and do better professionally down the road. We know that helping patients transition decreases psychological distress, depression, and anxiety. We really need to educate patients and their support network on the importance of support through this experience. We know that the rate of suicide in the transgender community is about eight times higher than the general population; the risk is around 40%. That’s a big number, and it’s scary. However, we know that treating patients who have gender dysphoria with hormone therapy can decrease that risk. We also know that patients who have had surgical interventions often express high rates of surgical satisfaction.
Getting back to Dr. Regnerus, he wrote that “the beneficial effect of surgery for transgender people is so small that a clinic may have to perform as many as 49 gender-affirming surgeries before they could expect to prevent one additional person from seeking subsequent mental health treatment.” Yet Regnerus concedes, regarding the adjusted odds ratio, “I cannot replicate without having data access.”

Regnerus claims to have calculated an unadjusted ratio. Scientists adjust an odds ratio (which is a scientific term) due to factors that are called confounding variables. Suppose, for example, we were comparing two high schools. One had a graduation rate of 70% while the other graduated 95% of its students. On the surface, the second school is the more proficient.

Suppose you knew that the first school specialized in educating at-risk youth typically raised by a single parent in poverty. The second school is one of NYC's specialized high schools for gifted students like Stuyvesant High School. The City of New York has a unified examination for entry into one of these schools. Of the nine specialized high schools, Stuyvesant has the highest score cutoff for entry. A scientist comparing these schools would adjust for what are obviously confounding variables. The first of those school might actually be the more successful.

Dr. Regnerus knows this better than I do. Without data access we have no idea how the odds ratio (OR) was adjusted. An unadjusted odds ratio is irrelevant. Notice how the immodest assertions in the subtitle are framed with diminished certainty in the text (emphasis added):
The study’s trumpeted conclusion may hinge on as few as three people in a data collection effort reaching 9.7 million Swedes, 2,679 of whom were diagnosed with gender incongruence and just over 1,000 of whom had gender-affirming surgery.
The use of the word “may” rather than might is a rhetorical choice. May expresses what could be factual. Might expresses a hypothetical. “Might” was the more correct word. Dr. Mark Regnerus is a very smart guy who is well trained. Historically, and in this case, he subordinates science to religious tenets.

Aside from trying to pass off an unadjusted odds ratio as relevant, the choice of outlet — Witherspoon Institute — is telling. This blog is edited by anti-transgender defender of the faith and all-around douchebag, Ryan T. Anderson.

Witherspoon is headed by an Opus Dei numerary, Luis E. Tellez, Tellez is also the chairman of Regnerus' Austin Institute and he was one of the founders of National Organization for Marriage. Tellez was instrumental in funding Regnerus' thoroughly discredited study which purports that the children of same-sex couples are disadvantaged.

Regnerus' response to a study demonstrating satisfaction with gender confirmation surgery is bullshit. Aside from the fact that Regnerus is promoting an unscientific statistical premise that happens to coincide with his religious views, recent research concludes that there is overwhelming satisfaction with gender confirmation surgery measured by a quality of life assessment.

The Catholic Church vigorously asserts (citing Genesis 1:27) that transgender people do not exist. Dr. Regnerus is a known warrior for the faith. As of December 31, 2018 Witherspoon was sitting on assets of $6,931,984. I am sure that ample funds exist from Witherspoon and other conservative Christian sources to fund research that Regnerus could hope to publish in a respectable peer-reviewed academic journal.

Polemics abound. Where is the peer-reviewed research to support the absolutist pronouncements of religious conservatives regarding transgender people? Why does such research not seem to exist?

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