Tuesday, July 30, 2013

Book Review: Sex Change - It's Suicide by Walt Heyer

I have spent the last few days wading through Walt Heyer's latest self-publish book entitled "Sex Change - It's Suicide".

I'd like to say that it brings something new to the table.  It doesn't.

Frankly, this book is a mess.  It consists largely of the author pounding on the table and blaming the high suicide ideation/attempt rate identified in the 2010 NTEC study on the treatment community.

He doesn't really make any new arguments relative to what he argued in "Paper Genders".

Heyer has tried to make the case that the current treatment for transsexuals is horribly flawed.  This is largely predicated on his own disastrous attempt to transition in the early 1980s.  More or less, his claim is that because he transitioned while suffering from an undiagnosed dissociative disorder that everybody else who attempts transition is suffering from something other than what they think.

Unfortunately, Heyer makes enormous leaps of inference and asserts his position as fact without substantiating his position.  The majority of his evidence is anecdotal, or it is made in reference to deeply flawed research which has been largely debunked.

Heyer is no friend of the transgender community.  Although he speaks the words of compassion and advocacy for appropriate treatment, his underlying agenda is to prevent transgender people from having access to the treatment programs that are known to be effective.

[Update 16/08/13]
Heyer seems to have pulled the original Sex Change - It's Suicide title, and re-released under the title "Gender Lies and Suicide"

The summary of the book appears to be more or less identical to "Sex Change - It's Suicide" version, so I doubt there's anything particularly new other than a change of title.
[/Update]

[More after the jump]

In "Sex Change - It's Suicide", Heyer fundamental assertion is that the suicide rate among the transgender population is a function of unrealistic expectations of the available treatment combined with a collective failure on the part of the treatment community to deal with comorbid conditions that may be present in the transgender patient.

Heyer draws his 41% attempt suicide statistic from NTEC’s 2010 study.



Heyer’s interpretation of this statistic is that 41% of transgender people attempt suicide as a result of unsatisfactory treatment outcomes.  

When asked “have you ever attempted suicide?” 41% of respondents answered yes. According to government health estimates, five million, or 1.6%, of currently living Americans have attempted suicide in the course of their lives. Our study asked if respondents had ever attempted suicide while most federal studies refer to suicide attempts within the last year; accordingly it is difficult to compare our numbers with other studies. Regardless, our findings show a shockingly high rate of suicidality. ( http://transequality.org/PDFs/NTDSReportonHealth_final.pdf p. 14)

Here is the first of the misrepresentations that Heyer slips in to build his distorted picture.  The NTEC study does not provide us with that level of information.  It does not in any way tell us whether those suicide attempts happen before treatment, during or after treatment.  Anecdotally, I would suspect that sizable number of the suicide attempts take place before meaningful treatment has begun.
A study published in Metabolism states: “The number of deaths in male-to-female transsexuals was five times the number expected due to increased numbers of suicide and death of unknown cause.”

A long-term follow-up (over 30 years) of 324 transsexual persons undergoing sex reassignment surgery in Sweden reported that surgically sex-reassigned persons have considerably higher risks for mortality and suicidal behaviour.  

An international review of studies that followed over 2,000 persons in 13 countries who had undergone gender reassignment surgery identified 16 possible suicide deaths which, if confirmed, translates to rate of suicide that is seven times the national average. [1. Sex Change - It's Suicide location 101]
Let’s take a close look at those numbers in full context, shall we?  First, we have the NTEC study, which shows an 41% attempted suicide rate among transgender people.  Let me be clear here, this includes all shades of transgender people, not just transsexuals.  Transsexuals (those who transition, and often pursue GRS) are a minority within that population.

I am going to go a step or two further here, and point out what Mr. Heyer seems unwilling to raise because it doesn’t suit his political agenda:
  1. Let us recognize that in general, transsexuals experience much higher rates of discrimination than other population groups do.  This, in itself, creates significant stressors in life that are often overlooked. 
  2. Transsexualism is unique among medical conditions in that its treatment is almost entirely predicated on the patient's word.  In other words, the therapist making an assessment is almost exclusively dependent upon the patient being absolutely honest with them.  If the patient is deceiving the therapist at all, then the outcomes of treatment are much more likely to be questionable.
It would be folly indeed if we were to believe that the consequences of all of these problems magically go away because someone has surgery.  Surgery addresses but one part of the picture, not the entire picture - different people will have suffered different degrees of consequences from their experiences.

The second point that I put forward is very important when interpreting Mr. Heyer's complaints.  As I point out in a prior post, Heyer admits to lying to treatment providers in his attempt to get gender surgery.  So, while Heyer is perhaps somewhat correct to be urging the treatment community to be cautious when providing treatment to transsexuals, his criticisms must be understood in the context that he does not seem willing to take responsibility for his own role in what happened to him.

Dr. Money, the sexologist, and Dr. Walker, the social psychologist, were promoting gender surgery and the idea that gender could be changed and artificially fashioned by surgery.  They were not about to embrace the American Psychiatric Association causal factors nor were they going to accept a diagnosis that included the word disorder.  They were aware that the DSM would promote psychotherapy as the recommended treatment for the psychological condition called GID, not surgery.  The logical outcome would be the marginalization of sex change surgery. [Sex Change - It's Suicide: Location 240]
Money and his reputation were about to take a hit at his home base, Johns Hopkins Hospital.  After twelve years of asserting gender was learned and backing it up with falsified research results, Money found himself on the losing side.  Results from a 1978 follow-up study of the patients treated at Hopkins were being gathered.  They showed no improvement from surgery, reinforcing the view that gender issues were psychologically based and surgery was not helpful.  That study would lead to the end of sex change surgery at Hopkins. [ Sex Change - It's Suicide: Location 256 ]

The study that Heyer refers to has been thoroughly debunked for methodological problems, as well as contradictory evidence from a lot of other sources.  The only person who took it seriously was Paul McHugh, who unquestionably had an axe to grind when he took over as head of psychiatry at Johns Hopkins.  




Heyer goes on to claim that the WPATH Standards of Care are "meaningless" because they contain clauses which make it clear that a degree of clinical judgment is needed in order for a clinician to be able to handle individual cases in the most appropriate way.

The standards of are are as effective in prevent regret and suicide as a speed limit sign is in curtailing speeding. 
At this point in the discussion people with some familiarity with the transgender community will usually say, “But what about the standards of care?”  What about the two year trial period of living as the desired gender before being approved for surgery?”  In reply I use the analogy of a speed limit sign, based on my experience and from the experiences of those who write to me. 
The standards of care make good window dressing, nothing more.  One thing to know about the original standards of care, as well as their successor, is that they are merely suggestions to consider, not requirements.  Nowhere in the US will you find any enforcement of the approval process for gender surgery:  not for the transgenders or for the medical professionals who provide their care.  No enforcement of the standards, not at all.  [ Sex Change - It's Suicide: Location 400 ]

Really?  I find Heyer’s arguments here highly problematic.  First of all, he is arguing that the Standards of Care are not “enforced”.  I’m not sure what he means by “enforcement” in this situation.  He seems to overlook that in most medical professions, the notion of “standards of care” are enforced - primarily through practice ethical guidelines and professional licensing.  In short, if the professionals that Heyer is so critical of are in fact acting outside of a standards of care guideline, they can be accused of malpractice or at the very least ethical breaches.  

I will point out that only a handful of surgeons provide GRS services, and most of them have been at it for a very long time.  I would imagine that if their practices were that far out of line with the SOC and the ethical guidelines of their respective professional associations that they would have long since been accused of malpractice in a very public way.  The only case I can think of this happening is the highly dubious practices of Dr. John Brown, who had a deservedly horrible reputation among the trans community.

Heyer seems to think that the SOC should be a rigid process, forgetting the problems that rigid, inflexible programs that the 'gender clinic' era imposed on transsexuals and ignoring the steadily changing scope that practical treatment programs.

The WPATH standards will not prevent the approval of an individual for surgery nor do they prevent regret or suicide, no matter how rigorously they are applied. 
No punishments, loss of license, or consequences apply to those in the medical community who contribute to the failures. [Sex Change - It's Suicide: location 435]

Here is a key aspect of where Heyer’s argument falls off the rails, in my opinion.  He fails to acknowledge that unlike just about every other medical condition, Gender Dysphoria depends on the patient being an active participant in the process of healing.  It is not just a matter of getting approval for surgery and undergoing surgery, but rather part of a much larger gestalt process that includes enormous amounts of psychosocial adaptation on the part of the client.

Heyer seems to conveniently forget that there are penalties for professional misconduct in these situations.  That is why the surgeons are insistent on receiving not one, but two letters of reference before they will provide surgery.  

Psychologists keep reams of notes about their clients.  Why?  Because if they are ever accused of malpractice, they rely on those notes as a key part of their defense. 

While a psychologist is probably better equipped than most people to pick up on when they are being lied to, we should recognize that they can be deceived just like anybody else.

No tracking of outcomes is required.  The standards of care do not even suggest that surgeons and psychologists track outcomes over time, so no one has any objective idea of how many are failures.  That works to the advantage of those who want the surgery to continue.  [Sex Change - It's Suicide: location 435]

This is blatantly false.  Section XII of the 7th edition of the SOC states:

Long term postoperative care and follow-up after surgical treatments for gender dysphoria are associated with good surgical and psychosocial outcomes.  (Monstrey et al. 2009).  Follow-up is important to a patient’s subsequent physical and mental health and to a surgeons knowledge about the benefits and limitations of surgery.  Surgeons who operate on patients coming from long distances should include personal follow-up in their care plan and attempt to ensure affordable local long-term aftercare in their patients’ geographic region. 
Postoperative patients may sometimes exclude themselves from follow-up by specialty providers, including the hormone-prescribing physician (for patients receiving hormones), not recognizing that these providers are often best able to prevent, diagnose, and treat medical conditions that are unique to hormonally and surgically treated patients.  The need for follow-up equally extends to mental health professionals who may have spent a longer period of time with the patient than any other professional and therefore are in an excellent position to assist in any postoperative adjustment difficulties.  Health professionals should stress the importance of postoperative follow-up care with their patients and offer continuity of care.  [WPATH SOC v7 pp 64-65]

If you heard me go “Argh!”, it’s because Heyer has chosen to quite blatantly ignore what the SOC actually does say.

The flexibility built into the standards of care is meant to protect the medical providers, not the patients.  The standards of care give medical practitioners the flexibility to ignore, dismiss and not treat other serious disorders.  Nowhere in the standards of care will you find any rigid guidelines for the prevention of suicide.  In my view that is reckless.  [Sex Change - It's Suicide: location 454]

What Heyer doesn’t seem to understand here is that those other conditions all have standards of care associated with them.  It would be ridiculous for the SOC related to Gender Dysphoria to try and address the cornucopia of possible combinations of conditions that can arise.  Further, with respect to suicide, there are specific rules and guidelines that psychologists and other professionals follow.  Preventing suicide can go as far as committing a patient to a psychiatric institution for a period of time if needed.  

Heyer’s stance is unnecessarily rigid, and takes a very legalistic view of how the SOC should be implemented.  Those who are familiar with the evolution of treatment for transgender people as a whole will recognize that the guidelines of the SOC have changed dramatically as it has become more visible and clear that transgender people are part of a broad spectrum of people who benefit from treatment in varying degrees.  

The clinical flexibility is required for one simple reason:  treating Gender Dysphoria is much more than providing treatment for people who are heading towards gender surgery.

Sadly, Heyer's arguments in this book are no better than what he has served up in the past.  The unfortunate thing is that there will be those who take Heyer seriously, and will point to him and his claims as an example of why transgender people should be held to second class citizen status.

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