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Saturday, October 26, 2019

The era of dangerous medical fads is not over

A prominent website has drawn interesting connections between sex reassignment surgery and lobotomy.

T his week an interesting new idea came up that had never occurred to me. (Yes, it happens.) Here's the idea: sexual reassignment surgery is a medical fad, just as lobotomization was in the 1940s and 50s.

I first heard it in an article by Megan Fox at Pjmedia that directed me to an calm and thoughtful article by Renee Gardner (a pseudonym) at The Federalist. The author finds ten similarities between lobotomies and “transitioning,” which is the current euphemism for sex reassignment surgery or SRS, in cases of gender dysphoria. SRS amounts to destruction of healthy tissue, usually leaving the patient sterile, and it is being performed on children as well as adults. That makes it, like a lobotomy, an involuntary procedure: no child has the independence of mind to push back against a parent who decides that they think the child has gender dysphoria.

The similarities, as Gardner points out, are many: in both cases, the motivation was to eliminate behavioral disorders and prevent suicide. In both cases, the press championed the procedures with biased, uncritical reporting. And in both cases, people in the medical profession were pressured by their peers who claimed the surgery to be safe and effective.

Blue caterpillar
Blue caterpillar

Comparing SRS to lobotomies may sound controversial or even cruel. Nowadays, we regard lobotomies as barbaric. But in the 1940s and 1950s, there was enormous pressure to accept lobotomization as an enlightened, lifesaving procedure. Rosemary Kennedy, Evita Peron, and American actor Warner Baxter all had them. Egas Moniz, the doctor who did the first lobotomies in humans, was awarded the Nobel Prize in Physiology or Medicine for it in 1949. For doctors to criticize it would have been to admit that the highest honor in their profession was faulty.

Walter Freeman, who performed the first lobotomies in the USA, claimed that lobotomization was necessary to reduce the incidence of suicide. And it probably did, for those who survived the surgery. But what a cost. Lobotomies turned people into living zombies (as a neurology resident friend of mine once called them), and they're now widely recognized as a clear violation of the Hippocratic oath. They also played a role in the movement to close down involuntary treatment of mental patients.

Up to 60% of the survivors developed troublesome personality changes that rendered them docile, flat, childlike, aimless, and apathetic or emotionally incontinent. About 4% developed what was called the “cabbage” personality. At autopsy they showed massive gliosis and demyelination in areas surrounding the former frontal lobes, such as the thalamic nuclei, indicating widespread damage and Wallerian degeneration in areas once connected to the frontal lobes.

The same caterpillar a bit later
The same caterpillar a bit later

Alternatives to the infamous transorbital “ice pick” technique were equally troubling: mental patients were infected with malaria to induce fever, put into insulin shock, and injected intracerebrally with cocaine deriv­atives. Later, some lobotomies were performed by electrocoagulation or by injecting radioactive iridium-194 transorbitally. Lobotomies were performed for ulcerative colitis and peptic ulcer, which were thought to be psychosomatic disorders, and for intractable pain such as from bone cancer. They had no effect on the pain, but the patients no longer cared about it.

To call this a fad is misleading. Lobotomies were a way of treating the symptoms of mental illness in the most radical possible way: by removing the mind. Practitioners often claimed that lobotomization did not lead to any intellectual deficits, and even if it did, it was worth the cost of staying alive.

Practicing physicians are not free to decide whether a given procedure is ethical. They must abide by the current practice. If current practice demands it, and it is legal, they can get in trouble for denying it to patients. In today's authoritarian environment, it's worse: they can get in trouble for saying something critical of SRS, or even discussing it with students.

There are three questions here that are relevant to us: (1) When does a child have a right to refuse medical experimentation done on them? (2) Is gender dysphoria a psychiatric disorder or just an emotional feeling? and (3) What should doctors do when the Hippocratic oath conflicts with preventing suicide?

The Federalist article cites a website (4thwavenow.com) whose author links to an American Foundation for Suicide Prevention study that questions the widely cited figure that 41% of patients with GD attempt suicide. As Gardner points out, a study published in the scientific journal PLoS One found that SRS actually considerably increases the rate of suicide attempts. It cites an adjusted hazards ratio of 4.9, CI 2.9–8.5, which is statistically highly significant.

Even if we accept that the 41% figure is not inflated, we have to ask: how does one know if a child really has gender dysphoria? Who makes the diagnosis, and on what basis? A study in the BMJ found that patient self-diagnoses obtained on online symptom checkers are only correct 34% of the time, even when the input is a set of precise classic symptoms entered by a physician. Patients come in thinking they have cancer when they actually have something trivial, or vice versa. Clearly, a surgeon would be remiss in removing the suspect organ in such cases. Psychiatric disorders should be held to at least the same standard as somatic diseases, especially when the treatment is radical surgery.

Doing medicine on the basis of wild guesses is something I have consistently argued against. I've witnessed (and even been dragged into helping carry out) clinical trials of drugs that affect biochemical processes whose connection to the disease they're supposed to treat is tenuous at best. If nothing else, SRS entails a risk of treating a disorder without understanding its cause. Such treatments can lead to a cure only by random chance.

My philosophy is: if an adult of sound mind thinks SRS will make them happy, and they can pay for it, fine: hack away! In these cases, the ethics of mutilating healthy tissue are on the conscience of the doctor. But these days, it seems even little children have to pay attention to the political winds, lest their parents (or step-parents, in a case currently receiving wide attention) pressure them into making a permanent change in their anatomy that they might not really want.

Children will say whatever elicits the most praise from their parent. Teenagers are pawns in the face of peer pressure. So neither can give informed consent. If anything, the likelihood of irreversible sterilization should alert physicians that more discussion is warranted about how and whether to accommodate a parent's demands, until a way is found to diagnose GD by objective means. States should consider keeping the procedure illegal until the scientific doubts can be resolved.

oct 26 2019, 4:28 am. last edited nov 04 2019, 4:51 pm

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