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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.
I find both sides of this CW rather tiresome. The pro-trans "well, if half of the class in fifth grade wants puberty blockers, just let them have puberty blockers" is obviously wrong, but the anti-trans side is just as bad.
With parental consent (PC), a 16-yo can marry a 30-yo and bear his children in a lot of states. Or a 17-yo (with PC) can enlist in the army and get blown to pieces in some war on another continent. Or he could murder someone domestically (without PC) and be executed for that, until the liberals in the SCOTUS put a stop to that in 2005. And of course every 10-yo has the ability to kill themselves (without PC), not granted by the SCOTUS but by physics (i.e., God). Sadly, suicide is the second or third most common cause of death for teens (though homicides are ahead of suicides in the 15-19 group, second only to accidental injury, which I find even more fucked up).
I think that the bodily integrity of people whom we don't consider to have the ability to fully consent is an important good, and one should not make it too easy for them to get irreversible changes done to their bodies.
That being said, I do not consider mastectomies to be that irreversibly life-altering. If you change your mind, you can still get implants, and we have the tech to prevent any kids you might have from starving to death (and arguably had the tech for 10k years or so).
Bottom surgery is a different category, but the fact that you focus on mastectomies likely means that it is exceedingly rare in minors. And while we are discussing genital surgery without medical indication in minors, we should probably acknowledge that the median case is not the 15-yo getting her breasts removed, but the baby getting circumcised for religious reasons of his parents.
With regard to puberty and interventions, I will notice that 'natural' is not the same as 'good'. 'Natural' is when half of the kids die before puberty, and nobody remotely sane would suggest we go back to that. We have seen how God has planned out human life, and collectively decided "fuck that guy". The natural fate of a 12-yo with no health anomaly is not puberty. It is death through asphyxiation within minutes -- basically everywhere in the observable universe.
That being said, I doubt that most people's lives would be improved by accepting/deciding that they are trans. A lot of kids have issues with their identity around puberty, for most of them accepting their birth gender is likely the best outcome as far as quality of life is concerned. But there is certainly a subset who have a different gender identity hardwired and would be harmed not helped by letting puberty happen.
This means that medical interventions must be made based on trade-offs. Anticipate how the patient would view the intervention with 20 years of hindsight. Try to minimize the excepted reduction in QALYs -- no matter if it is due to suicide, sterility, surgical interventions etc. This involves guesswork, but every moral decision in the real world involves guesswork. Sometimes you will still decide wrongly and mess up a patient's life, either way. It also involves not being in the trenches of the CW. If you think that every trans-related intervention in minors is either good, you have not grasped the complexity of the situation. If you think every intervention is bad, likewise.
Are mastectomies more or less irreversibly life-altering than anorexia or bulimia? If schools were actively encouraging their students to pick up these habits, and hiding this fact from the students' parents, would that be more or less acceptable than the current status quo?
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