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One of the open questions on the trans issue is just how big is the problem, really, particularly as it relates to children, and how often they're prescribed irreversible medical procedures. One attempt to answer it is the Stop The Harm Database, they go over insurance / Medicaid / VA claims and try to find procedure and NDC codes relevant to gender affirming care. According to them something to the tune of 14,000 minors received hormones, blockers, or surgeries between 2019 and 2023, with 5,747 of them getting some form of surgery. That report is not without criticism, we discussed it before and it was pointed out that the number includes laser hair removal as a surgery, so at first glance it looks like the "central example" of the kind of gender surgery that would cause people to freak out is actually a lot less frequent. However, evidence keeps accumulating that the numbers are just as bad a trans-skeptics are indicating, and perhaps even worse.
First, a small sanity check. The first pediatric gender clinic in the US opened in 2007, Stop The Harm now has 54 in it's database. These 54 clinics have to pay their bills somehow, and that implies a throughput that is probably more consistent with the 14K number being accurate, rather than an overestimate. Of course that alone tells us nothing, a clinic can offer a wide range of non-invasive services, like psychological support, or hell perhaps they do keep the lights on with laser hair removal.
If you followed the culture war for a while, you might remember that originally the argument was "no one is doing gender surgeries on minors, chud", but the actual healthcare providers are sometimes so far away from the culture war front, that they don't realize what they're doing is controversial, and proudly show it off. Here's Keiser Permanente's paper on how many gender-affirming mastectomies they performed on minors between 2013 and 2020. In that period they had 209 patients, the majority taking place at the end, as the trans trend was gaining momentum. They helpfully provide a chart of the incidence rate, and point out it increased 13-fold during that period, to a rate of 47.7 per 100K. The incidence rate gives us an opportunity to run another sanity check. If we take the population statistics by age and sex from 2020, add up the girls aged 13-17 (the age group from the paper; about 3.18% of the total population), multiply that by the total population from the 2020 census (331,449,281), we get 10,540,087 girls matching the demographic from the paper, and when we multiply that by the incidence rate, w get a grand total of 5027 potential mastectomies in the whole country, for 2020 alone. Now, again, that's just a sanity check. Kaiser Permanente is in California, the bluest of blue states, so I'm happy to grant that the incidence rate in other parts of the country is likely lower*, but it does hint at the Stop The Harm numbers not being insane, and the surgery statistics not being carried by laser hair removal.
So has someone tried to run a proper estimate for the whole country? On one hand we have a JAMA paper - National Estimates of Gender-Affirming Surgery in the US giving us 3.7K mastectomies for the 12-18 age group, between 2016 and 2019. Now there's a bit of an issue here in that the authors decided to include 18 year olds in the group, so we have no clue as to how many surgeries were done on minors. I'm pretty sure this is deliberate obfuscation on the parts of the authors, as I've seen multiple people ask one of them for the 12-17 numbers, and them going "oh, haha, sorry that's how we grouped, and it would be too much trouble to go back and recalculate it now". When other academics (from SEGM, I think) asked for the raw data, they went with "lol, no". I wish I could link it, but this was in a Twitter thread that took place around the time the paper got published (3-ish years ago), so I don't even know how to begin looking for it.
On the other hand we have the Manhattan Institute's """report""" giving us from 5,288 to 6,294 mastectomies between 2017 and 2023, and I put it in quote marks because it looks more like an article to me. They say they got their hands on an insurance database, and presumably they ran the right queries, but I'm still salty about the lack of detail on methodology. That said, this number does not actually contradict the JAMA paper. Note that in that paper they ran the numbers for 2016-2019 - the period when the trans trend was just picking up. 2019 was without doubt the year with the most mastectomies in their paper, not just by the Manhattan Institute's chart, but by Kaiser Permanente's as well. Further the MI chart would give us between 1700 and 2500-ish mastectomies for the years 2017-2019 - well within the bar given in JAMA. It's in fact lower, as 2016 saw a lot fewer mastectomies, if you go by KP's incidence rate, and you wouldn't reach 3.7K even if 2016 was exactly equal to 2017. This however is expected because, like I mentioned, the JAMA paper includes 18 year olds. All in all, despite my gripes with how the article is written, the numbers seem perfectly consistent with the numbers given by """mainstream""" sources.
We brought up a few factors that could imply they numbers are overestimated, but are there any pointing to them actually being underestimated? The MI believes even their liberal estimates are undercounting the actual numbers:
That last bit might raise an eyebrow. Normally, I'd say it reminds me of a bit I once saw in an Adam Curtis documentary, about how the OG Neocons were screaming about the USSR building up a massive fleet of submarines, and when it was investigated and they found no such thing, they started screaming that this means the Soviets have a massive fleet of stealth submarines. In this case, however, well bear with me...
The link at the end of the quoted paragraph leads to a story about Dr. Ethan Haim and Vanessa Sivadge, whistleblowers from the Texas Children’s Hospital who exposed it for still providing gender-affirming care, even as the hospital officially announced it's putting a stop to them. For their trouble, they were rewarded by Biden siccing the FBI on them. The case of Dr. Haim is one of the biggest affronts to justice I saw in recent years, but I'd need an entirely separate effort post to go over that. The article slowly builds a decent-ish case that the hospital may have illegally billed Medicaid for the gender affirming procedures, but it's not directly relevant to my argument. The interesting bit is when you followed these two down the rabbit hole. They testified in congress about this matter, and Vanessa Sivadge, as far as I understood her testimony claims to have personally witnessed the doctors putting down the wrong ICD code in their diagnoses:
Now, these congressional testimonies always felt a bit too generic to me, so we don't get much beyond a "trust me, bro", even if it's backed by a threat of perjury. Dr. Haim for his part never claimed to see it personally, but the issue seems to have become a personal hobby horse of his, and if you follow him you can see he dug out a lot of interesting things, like, for instance this fact-sheet, which he also testified about, from the Campaign For Southern Equality. They sent it out to gender clinics, and outright come out and say "hey, these (gender dysphoria related) codes are commonly rejected by insurance providers, try using ones like 'E34.9 Endocrine disorder, other' instead". Or how about this coding update from the American Medical Association where they recommend doctors stop using the code for gender affirming breast reduction/removal and use either the one for "treatment or prevention of breast cancer", or "reduction mammaplasty"?
Ok, so we have a few institutions encouraging the use of alternative diagnosis / procedure codes, how much of an impact could that have on the national estimates of incidence. Well, much like with Kaiser Permanente happily informing us on how many mastectomies they performed, some pro-trans researchers happily estimated the impact of using alternative codes for us:
From what I'm seeing, about half of the trans patients taking hormones might be hiding under E34.9 “Endocrine disorder, other”, which is pretty important as Stop The Harm might include laser hair removal, but it does not include code E34.9 (they do did manage to grab all the relevant mestactomy codes, despite the AMA recommendation, however).
As a side note, the hospital, that the authors of the second paper are affiliated with, recently received a subpoena from the DOJ, demanding records related to pediatric gender-procedures, which they decided to completely ignore, almost like they have something to hide. The DOJ's petition to enforce compliance has now been granted, so I suppose we will, at some point, find out if they were on the up and up.
Ironically legal issues might be yet another way of providing us with yet another sanity check. One more interesting thing that popped up on my feed from following Dr. Haim is this court case, here's the interesting bit:
The TRUE Center is in Colorado. According to Stop The Harm Colorado saw a combined total of 240 patients taking hormones or puberty blocker. In other words, the numbers found by the court, for a single clinic, for a single year, were 2-3x greater than the numbers from Stop The Harm for the entire state for the entire period from 2019 to 2023. @gattsuru called their numbers eyepopping, it might their own they were being conservative.
[caveat : I'm not especially concerned about hormones for 16+, and I don't really get the object to 17+ mastectomies. These processes do have risks and side effects, but they're relatively well-bounded and understood, and combined with the drastically reduced incidence of desistance by those age ranges, the harm calculations just aren't looking that severe. I could be persuaded on these things -- I have been persuaded that use of puberty blockers were not just a minimally-harmful experiment but instead ranged from ill-advised to active malpractice, and the prominence and tolerance of bad actors from that sequence does leave me more cautious about the evidence and documentation for hormone therapy for the 16-18 range -- but I've had too many serious medical interventions before I was 18 for the 'mutilate' or 'consent' frameworks alone to really hit. Younger hormone therapy seems to have serious impact on bone health, and the long-term effects of orochidectomy and hysterectomy are much more serious and much harder for teenagers to understand.]
There are definitely clinics without surgical capabilities (or in jurisdictions that prohibit surgical intervention for minors), so psychological support and pharmaceutical interventions and such clearly can suffice for some businesses, and naively I'd expect that while the individual compensations are higher for surgical intervention, the bread-and-butter by definition is a lot more likely to come from recurring stuff. Dunno if there are any public figures, though.
Eh, I get this is playful overstatement, but the extent minor insurance tomfoolery is tolerated is pretty important to recognize. Unless you're Haim, the feds really don't get involved in Medi* stuff unless it's hilariously overt or big amounts of cash are floating around, and sometimes not even then. Just fucking up ICD codes is wrist-slap stuff at best. Which is why it's a big concern... but it also means that it's a lot less of a big overt scandal if it's proven.
Some discussion here
I'm not quite so optimistic; there was a mess of legal interplay here that would have gotten less favored political actors disbarred, and while requests for emergency relief have been denied so far, the jurisdiction charlie foxtrot is enough a mess it's possible the summary statistics will only be released if O'Connor defies procedure.
To be clear, eyepopping was more a reference to the 5k surgery interventions, but yes, the discrepancy between TRUE's claimed patient count and that available to other observers is concerning. Similarly, SEGM estimates a maximum of 1k masectomies on under-18s per year, and I'd consider them gender-critical in a way that would give higher-end estimates whenever possible. If they're vastly underestimating things, that's a concern regardless of the merits or demerits of the procedures simply because we can't possibly measure the outcomes on things that we don't know are happening.
They're irreversible, 17 is still in the "crazy teenager" years, and even for the purposes of gender dysphoria, they don't seem like something that can't wait a few years. I of course have my issues with blockers / hormones, but I at least understand the logic, that at a certain age you have to pick a path, and it will be very complicated to roll it back if you do it later. There's a potential compromise I could see, where instead of mastectomies they'd be doing breast reduction, with preservation of function.
Where do you get that from? From what I understand desistence is still pretty understudied.
I appreciate you been evenhanded on this, and I was trying to do the same. I wouldn't have anything against asserting general minor insurance tomfoolery, but asserting tomfoolery that conveniently supports my point didn't feel fair, and I wanted to make it clear I find any potential skepticism completely valid.
Huh, I can't believe I didn't catch that at the time.
This would be lower than the STH number, but not by much (and that's expected as they include other forms of surgery, including the infamous laser hair removal).
Yeah, that's fair, and has some practical arguments in its benefit anyways. Apologies, I'm just used to seeing them merged together. I think there's some moderate arguments for reducing total surgeries in cases desistance is extremely unlikely -- an FTM with the unfortunate genetics to have D-cup breasts at 16 and who's had a stable identity since 12 is in an awkward place where they're going to go under the knife twice for something that they're pretty confident about -- but complication rates for these procedures are low enough that it's a plausible compromise from an ethical perspective.
Whether it's an enforceable one is harder. Ideally, we'd just have enough trust... but we clearly don't, and that distrust is well-founded, hence this discussion. There would definitely be aggressive action by both patients and to straddle the line of what's 'just' an aggressive reduction, and there's even some process arguments to not be entirely dishonest when doing so (afaict, 'masculinizing mastectomy' is already much more likely to leave lymph nodes in place compared to conventional mastectomy; "inverted T" procedures are structurally more similar to a breast reduction to an A or AA and are actually used by some trans men as their final masculinizing top surgery already). There's a few clear markers -- removal of the nipples, lymph nodes, milk ducts, yada -- but we can't exactly those to end up on the medical file even if there were agreement on them being the 'right' dividing line.
Which is probably the broader problem.
That's a reasonable criticism, a lot of the data is either low-confidence or coming from suspect sources, and there are adult desisters.
But if the numbers were even comparable to the most optimistic trans activists claims of 'low' pre-puberty desistance, we'd be talking 1%, and that's still well over three thousand people in the United States alone. If adult desistance were the majority or a sizable fraction, as gender-critical people claim with some support for pre-puberty, we'd have FtMtFs by the tens of thousands at this point, especially in the aftermath of the Fox Virian lawsuit.
It's hard to make that match up with reality as we see it. That's a low confidence claim -- there have been enough changes in FtM demographics that something could have changed in 2023 on the intake side, or 2026 on the outtake side; it's possible the entire measurement system is so badly corrupted we can't see a 1-in-100 signal of a 700k+ population -- but for all it's just absence of evidence, it is still signal. And the most plausible explanations are either low rates of adult desistance or very early desistance that is being handled, despite a doctrine that I agree shows insufficient patient safeguards for this specific case.
Fair.
Yeah. Not sure if that reflects coincidence, genuine number, taking from the same underlying source, or being bamboozled by the same misdirection.
EDIT:
I guess my problem's that we allow a lot of other crazy teenager years to do irreversible things without dire and traumatic medical need. Hell, we force or psuedo-force it in many circumstances. I don't buy the suicide prevention arguments and I understand that many social conservatives are opposed to other cosmetic surgeries in this age range, and I understand that this is deeper than a piercing or (most) tattoos, but it's hard for me to put it in the category of something they can't understand well enough to make decisions just because some 1:10000 or 1:1000 risk that they won't.
Some of that's just because this feels like salami-slicing -- if 17-year-olds are crazy, then so are 19-year-olds, and well we don't let 20-year-olds drink alcohol, and 24-year-olds can't be trusted with rental cards -- that someone will make even if you have a very principled end-state, but there are just also pragmatic arguments.
A complete ban on 'top surgery' for a trans guy is, in a large portion and probably majority of cases, going to be a serious constraint on their romantic opportunities at a time a lot of normal people start forming exactly those relationships: boobs tend to be pretty polarizing for straights and gays and lesbians alike. For the genetically (un)lucky, passing becomes impossible, and while that's not a massive value from your perspective, it's clearly something a lot of adult trans men do put a lot of effort into. These do, I recognize, become less serious if we accept significant breast reduction surgeries as a separate category.
From a practical standpoint, a surgical intervention at 17 makes it possible to 'turn a new leaf' at college, in ways that having the procedures done at college do not. That's most extreme in states that require surgical intervention to recognize legal transition, but even outside of those constraints, there's just a massive difference from 'Aiden-who-was-Alice' and 'Aiden-who's-short-and-really-shy-in-showers'. There's some downsides to this goal from a social conservative perspective -- I would argue it makes desistance a lot less likely, and soccons would argue that it's closer to love bombing -- but it's worth noticing as a motivation.
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