'Top surgery'

A children's hospital talks up transgender mastectomy for minors

Photo by Alexander Grey on Unsplash

Staff at the gender clinic of an Australian children’s hospital are being given a rosy view of double mastectomy as “an integral part” of medicalised gender change with high levels of satisfaction.

Although the publicly-funded clinic in Brisbane, Queensland, does not itself offer this surgery, an internal “work instruction” document for staff tells them that the Family Court has judged transgender-identifying girls as young as age 15 to be competent to consent to the removal of their healthy breasts.

“Chest reconstructive surgery… is considered an integral part of the transition process for many trans males and non-binary young people with chest development [meaning females with breasts] and has low complication rates and high levels of satisfaction,” the document for staff says.

Often promoted as “top surgery”, this intervention is the third stage of the so-called Dutch protocol for treating the distress of gender dysphoria, with puberty blockers and opposite-sex hormones being the first two stages.

The Dutch pioneers of the protocol withheld surgery until age 18, but key restrictions and safeguards of their approach have been relaxed internationally, especially in English-speaking countries following the Americanised “gender-affirming” model, which pushes for earlier, easier access to medical interventions.

The evidence base for medicalised gender reassignment of minors has been shown to be very weak and uncertain by systematic reviews reported since 2020 in Finland, Sweden, the United Kingdom and the U.S. state of Florida.

Litigation has begun in several jurisdictions where “detransitioners” who come to regret medical interventions conclude that their real problems, underlying gender distress, were not explored or treated. Practitioners of gender-affirming medicine claim it alleviates dysphoria, improves mental health and save lives.

---

Video: “They said that the rate of regret is less than one or two per cent”, American detransitioner Chloe Cole tells her story

Go private

The work instruction document for Queensland’s gender service offers two gender-affirming treatment guidelines with clinical tips and criteria for working with patients “who choose to access this [surgical] treatment privately”.

This raises questions about the extent to which the children’s hospital enables double mastectomy for patients under age 18.

The number of children enrolled in the Brisbane-based gender service grew from 48 in 2014 to 635 in 2021, according to data obtained under freedom of information law.

Earlier this month on social media, an account identifying as a 15-year-old “trans man” gave an upbeat user’s guide to successfully navigating “top surgery” as a minor in Queensland with willing parents.

The young person, a biological female, said that Dr. Brian Ross, a psychiatrist in private practice who works part-time at the Queensland Children’s Hospital gender clinic, wrote the surgery referral letter.

“He wrote my letter after one appointment, no push towards my wishes and wished me luck for the future and said he’d be willing to help where he could. lovely guy, would go again. after one appointment,” the young person said in the social media post.

Asked online about the apparent ease of this evaluation, they replied: “i felt like it should be easy like that since im very forthcoming about my dysphoria and how id like to solve that, future plans for myself etc… im sure not every psych is as helpful as mine was, sometimes theres gatekeepers, just be sure to do your research!”

Other posts by this account revealed a suicide attempt, the “do it yourself” purchase of testosterone while waiting for an appointment at the Queensland gender clinic, and interest in a future hysterectomy.

It is not clear if the young person was still on the gender clinic waitlist or had become a patient of the clinic at the time of the surgery referral in May or when the mastectomy was performed earlier this month. Context suggests Dr. Ross saw the 15-year-old in his private practice.

The work instruction for the clinic says that “in exceptional circumstances it may be in the best interest of an older adolescent under 18 years to consider chest reconstructive surgery before adulthood.”

The decision “should be made by agreement of the adolescent, their parents and the multidisciplinary team, in liaison with a surgeon,” the document says.

---

Video: Dr. Johanna Olson-Kennedy, director of the gender clinic at Children’s Hospital Los Angeles, outlines a study in which girls 33 girls younger than age 18 underwent “chest surgery”; two were 13 years old

“In 2019, the [Royal Children’s Hospital Melbourne gender] clinic director Dr. Telfer told Victoria’s royal commission into mental health that ‘many’ of her new, ‘post-pubertal trans male’ patients wanted ‘chest reconstructive surgery’, and the hospital had the expertise but not the funds… Asked whether the clinic referred its patients to private surgeons for top surgery or other ‘gender-affirming’ surgery, the hospital said [in November 2021] it was ‘not aware’ of any such referrals”—news report, The Australian, 27 November 2021

Natural diversity

Binding on all staff who come into contact with Queensland gender clinic patients, the work instruction document endorses the gender-affirming treatment approach and claims that “being transgender, non-binary or gender diverse [is] a part of the natural spectrum of human diversity.”

To support its promotion of irreversible surgery, the document cites a systematic review of the evidence without explaining to staff its shortcomings as a guide to treatment outcomes for minors.

The 2021 review by Bustos et al covered 22 studies reporting satisfaction levels after treatment, but most patients were adults, a different group from today’s gender clinic caseloads dominated by teenage females with atypical dysphoria.

Only five of the studies reviewed had a follow-up time of more than one year. The literature suggests that treatment regret may take several years to appear.

Another 2021 review essay, by Australian psychiatrist Dr. Alison Clayton, focused more sharply on the few available studies involving mastectomy with trans-identified female youth. (Only two studies turned up in both reviews. The work instruction document for gender clinic staff does not cite the Clayton paper.)

Dr. Clayton concluded that only a handful of low-quality, short-term studies supported claims of mental health benefits for trans mastectomy with teenagers, making this “an experimental treatment” in need of more rigorous, ethics-approved research.

“In my opinion, it is surprising that clinicians and researchers claim chest surgery for [gender dysphoric] youth is an evidence-based intervention,” she wrote.

“A necessary condition for [informed consent] is clinician honesty, which is not met if clinicians overstate the evidence base or act as ‘cheerleaders’ for transition.”

Writing in the journal Archives of Sexual Behavior, Dr. Clayton argued that trans mastectomy might in time be seen as “dangerous medicine” like discredited past practices such as psychiatric lobotomy, which won a Nobel prize in 1949.

She pointed out that the abandoned mistakes of medicine such as lobotomy and malaria therapy were “widely celebrated” at the time, including “uncritical press” coverage of “bold medical heroes with the courage to take ‘desperate remedies’ required to cure ‘desperate ills’.”

Other news and opinion on trans mastectomy—

“Demand for [chest surgery or trans mastectomy] during adolescence is increasing. However, few paediatric hospitals make this intervention available to adolescents. This paper focuses on the following ethical question: Should clinicians make chest surgery available to transgender male adolescents? We argue that making chest surgery available to transgender male adolescents under some circumstances is ethically justifiable for three reasons, based on the concepts of beneficence, privacy, and non-discrimination”—McDougall et al, bioethics paper involving researchers from the University of Melbourne and the gender clinic at the Royal Children’s Hospital Melbourne, 2021

“The consequences of what happened to me have been profound: possible infertility, loss of my breasts and inability to breastfeed, atrophied genitals, a permanently changed voice, facial hair. When I was seen at the [U.K.] Tavistock clinic, I had so many issues that it was comforting to think I really had only one that needed solving: I was a male in a female body. But it was the job of the professionals to consider all my co-morbidities, not just to affirm my naïve hope that everything could be solved with hormones and surgery”—detransitioner Keira Bell, Persuasion magazine, 7 April 2021

“There are no official statistics on how many minors receive top surgeries each year in the U.S. The New York Times surveyed leading pediatric gender clinics across the country: Eleven clinics said they carried out a total of 203 procedures on minors in 2021, and many reported long waiting lists. Another nine clinics declined to respond, and six said that they referred patients to surgeons in private practice. [One surgeon who promotes herself on TikTok] said she performed 13 top surgeries on minors last year, up from a handful a few years ago. One hospital, Kaiser Permanente Oakland, carried out 70 top surgeries in 2019 on teenagers age 13 to 18, up from five in 2013, according to researchers who led a recent study. ‘I can’t honestly think of another field where the volume has exploded like that,’ said Dr Karen Yokoo, a retired plastic surgeon at the hospital”—news report, The New York Times, 26 September 2002

“The suit was filed on behalf of Layla Jane (Kayla Lovdahl in the lawsuit), a young [American] woman who was medically transitioned as a child. Layla Jane is seeking justice against the Permanente Medical Group, Kaiser Foundation Hospitals, and the clinicians who facilitated her transition from age 12 to 17. This process included puberty blockers, cross-sex hormones, and a double mastectomy performed when she was just 13 years old”—news report, Reality’s Last Stand, 15 June 2023

“[The Journal of American Psychiatry has] had to publish an extraordinary correction to a 2019 U.S.-Swedish paper hailed as a global breakthrough in a field where even gender-affirming clinicians admit the evidence is short-term and low-quality. The peer-reviewed paper was the first to use official Swedish data, which is unusually comprehensive, to claim that surgery such as mastectomy or genital reconstruction reduced the need for mental health treatment by 8 per cent a year over the ensuing decade. ‘No longer can we say that we lack high-quality evidence of the benefits of providing gender-affirming surgeries to transgender individuals who seek them,’ said study co-author Prof. John Pachankis, who directs the LGBTQ Mental Health Initiative at Yale University… [The following year on 1 August 2020] the American journal published a correction, an editorial and letters from a dozen psychiatrists, clinicians and researchers in four countries identifying multiple flaws in the 2019 paper, with the conclusion that the data showed no improvement in mental health after surgery or hormonal treatment”—news report, The Australian, 18 August 2020

“A well-known 30-year Swedish follow-up study [Dhejne et al 2011] compared medically transitioned individuals to [non-trans] age-matched peers on key measures of morbidity and mortality. The study found sharply elevated rates of suicide among transitioned adults (19 times higher than controls overall, and 40 times higher for female-to-male individuals), and significantly elevated all-cause morbidity and mortality, with survival curves between transitioned adults and their [non-trans] matched controls markedly diverging at the 10-year mark and beyond”—Levine & Abbruzzese, journal article, Current Sexual Health Reports, April 2023

Note: Children’s Health Queensland, the body responsible for the gender service, has refused to answer any questions about its processes on the grounds that GCN is not “a recognised news media outlet”. Dr Ross was contacted for comment. GCN does not dispute that gender-affirming clinicians genuinely believe their interventions help vulnerable young people