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Voices of regret

Did a new study capture the whole truth about “top surgery”?

In a widely derided excerpt from his new book, Ultra-Processed People, Dr Chris van Tulleken claims that exercise cannot make you lose weight — or, in other words, “variation in body fat percentage is unrelated to physical activity level”. As evidence, van Tulleken cites a study which he claims found that miners, despite their daily physical toil, had the same calorie expenditure as office workers.

A closer inspection of the source seems to show that van Tulleken has misinterpreted what the experiment found. However, even before delving into the citation, this is a claim that ought to arouse suspicions. Variation in body fat is unrelated to activity level? Really? If you just think about people you know in your own life, this probably doesn’t pass a basic sense check. Personally, I can’t think of a single person at all serious about exercise (meaning they exercise fairly intensely several times per week) who is significantly overweight.

This in itself doesn’t prove causation. Some might argue that people with naturally faster metabolisms are more likely to enjoy sports, for whatever reason, and that’s why you don’t tend to see obese marathon runners. Perhaps that’s true. It nonetheless makes sense for our strongly held assumption to be that physical activity does impact weight. If someone tells you it doesn’t, they are probably wrong.

A similar principle can be applied to the discussion surrounding a study published last week, which reported essentially negligible levels of regret in people who have had “top surgery” — that is, double mastectomy to masculinise the appearance of a female chest as part of a gender transition. The study reported that, out of 139 adult survey respondents, the mean decision regret score was 4.8 out of 100. The median and interquartile range were both 0.0, meaning at least three quarters of respondents reported zero regret out of 100.

These rates are very low, given that people regret all sorts of surgeries. Surgery is a physical trauma to the body, which can result in lasting scarring and sometimes chronic pain or numbness; in addition, it doesn’t always fix the underlying issue quite as well as the patient hopes. It therefore makes complete sense that some people might express a degree of regret. In a news report about the study, one surgeon is quoted as saying approvingly that he was “surprised” that the study found regret rates to be so “very, very low”. He confessed, “I was thinking we’d see a little bit of higher regret numbers, like we sometimes do with other kinds of surgeries.”

So, is the case closed? Should the medical establishment give itself a big pat on the back for discovering this wonderful new intervention? Is trans activist Katy Montgomerie correct to say that those who disagree with these findings simply want to “[take] healthcare away from those who need it”? Should the Miami surgeon who brands herself “Dr Teetus Deletus” continue marketing the procedure to teens on TikTok?

Non-negligible numbers of women and girls do regret these surgeries

We should be given pause by, amongst other things, a growing weight of anecdotal evidence which shows that, despite what this study claims, non-negligible numbers of women and girls do regret these surgeries. “Detransitioners” — people who seek to reverse gender transition — are now so numerous and so established as a phenomenon that they have held multiple conferences. Increasingly large numbers have spoken publicly about their regrets over top surgery specifically.

In a particularly compelling in-depth account, detransitioner Grace Lidinsky-Smith recounts that “a disturbing, never-abating sensation of numbness and occasional pain had replaced what I now realized was the natural feeling of my intact body. And almost immediately after the surgery, the dread of regret started to sink in. Whatever I thought I was getting into, I had failed to contend with the fleshy reality.”

Such stories are not difficult to find. When a colleague and I wrote about detransition for The Critic magazine back in 2020, we reported that the “detrans” subreddit, a message board aimed at people who are either reversing transition or thinking about doing so, had over 15,000 members. It now has 50,000.

Granted, not all members of this online community will really be detransitioners. Of those who are, not all will have had “top surgery”, and not all will regret it if they did. From a quick browse, though, it is easy to find what appear to be many genuine accounts of young people in severe distress.

One such post begins: “I’m a 17 year old girl with a flat chest, a deep voice, a visible Adam’s apple and some facial hair. There’s no reason for me to continue to live.” Another recent commenter writes: “Constantly seeing other women with their bodies intact serves as a reminder of my loss. I cry all the time too. I think about the day of my surgery and the seconds before going under — how I wish I could go back and save myself.”

What could explain the low regret rate reported by the study? One possible factor is that all the survey respondents were adults. There are examples of women who regretted top surgery that they underwent later in life. It seems reasonable to suppose that when the same surgery is performed on children as young as twelve, incidence of regret would be much higher. Nonetheless, this practice has been advocated by, amongst others, an article in the same scientific journal that published this recent study: “waiting for chest surgery until age 18 years induces harm and undue suffering for many patients.”

Another possibility is the fairly low level of response: 41 per cent of the patients contacted for the study did not provide answers. We can’t know for sure that there was anything different about those who didn’t respond — it’s possible that if they were included, there would still have been extremely low regret. One should be careful about assuming that the people who respond to a survey truly are a random subsection of the population of interest, though. There’s a cartoon that illustrates this nicely: an office worker is proudly demonstrating the outcome of a poll, which shows a landslide in favour of “yes, I love filling out surveys” over “no, I toss them in the bin”.

Almost by definition, people who undergo transition surgeries will have been motivated by an ideology that idealises these procedures as part of a brave journey of self-discovery. As Grace Lidinsky-Smith writes, “I’d hyped myself up to believe that this was going to be a beautiful turning point to becoming the real me.” This denies the existence of regret. Moving away from this framing can be very difficult: one detransitioner has described herself as a “survivor of a body modification cult”. These surgeries are not viewed in a matter-of-fact way, like a hip replacement. It is very difficult, therefore, for a believer in gender ideology to express a degree of ambivalence and stay a believer — it’s all or nothing.

Just like the idea that you can’t lose weight through exercise, the idea that it is good to surgically remove the breasts of young women to alleviate psychological distress feels intuitively wrong. If stories of regret are not being picked up by a particular study, then it seems fair to conclude that it cannot be giving the full picture. Medical professionals have a duty of care, a duty to exercise their own personal judgement instead of unquestioningly accepting dogma. The rest of us have a duty not to close our ears to these cries of pain.

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