SIO428: Regret After Gender-Affirming Surgery Is Virtually Nonexistent

Transcript

This transcript was generated automatically and may contain errors — the audio is the record.

0:00:16 Thomas: Hello and welcome to Serious Inquiries Only. This is episode 428. I'm your host, Thomas Smith, and I've got a great one for you today. This is a topic that I care very much about and I know so many of you do too. Lydia and I ran into a study out of Johns Hopkins how minuscule regret is after gender-affirming surgery. And top line is less than 1% receive gender-affirming surgery report regret, which is dramatically lower than rates of surgical regret among, you know, everybody else. So I'm so excited to have one of the researchers on Dr. Harry Barbee, PhD, assistant professor interdisciplinary social scientist at Johns Hopkins. This is really important stuff and we need to get the word out about this.

0:01:01 Thomas: So I'm excited for this interview. In other exciting news, hey, the monthly patron hangout that's for the top tier patrons, top two tiers, that's on the 27th. So that's Tuesday, the 27th at 3 PM Pacific. And that's a Zoom hangout. It's gotten bigger every month. It's been really fun. We play games and stuff like that. So, hey, good reason to hop on to patreon.com/seriouspod maybe pledge one of those top two tiers or edit your pledge up. And another great reason is you don't have to hear the audio ads, including the one that's going to go right in between me talking and the interview. Patreon.com/seriouspod. Thanks so much for supporting the show. It is vital and you are helping put out episodes like this, which I think you'll agree is so important, and I really hope people share this around as well. Dr. Harry Barbee, how are you doing today?

0:01:48 Harry: I'm doing great. Thank you so much for having me.

0:01:50 Thomas: Oh, no, the pleasure is all mine. Seriously, I am so excited to speak to you about this. This is something that I've definitely covered in the past, but. It seems like such valuable research to be doing. And I'm sure it gets a lot of reaction, I imagine, out there.

0:02:06 Harry: To say the very least, yes.

0:02:09 Thomas: Yeah, I can't wait to get into it. Do you mind at all giving some background for listeners? Like, how'd you get into this? What's what's your educational background? How'd you get here.

0:02:17 Harry: So I received my PhD in 2020 in sociology. And I'm currently an assistant professor in the Bloomberg School of Public Health at Johns Hopkins. Although I guess I should also just say from the outset that I do not speak on their behalf at all. That being said, yeah, I mean, I've been studying LGBTQ plus populations and their health for over 10 years at this point. And broadly, I am interested in understanding how LGBTQ plus people's life experiences influence their health over the life course.

And so on the one hand, been really interested in understanding how negative experiences like discrimination, harassment, violence, impact health throughout people's lives, but also how positive experiences influence LGBT people's health. Like, for instance, having co-workers who support your LGBTQ plus identity And of course, in the last, I don't know, like three-ish years in particular, I'd say really since like 2020, since we've seen this huge boom in policies across the United States that are targeting trans populations, I've been really focused on thinking about policy as a social determinant of health or something that influences people's health. That interest has sort of set the stage for the work that I recently published.

0:02:33 Thomas: Sure. Right.

0:03:45 Thomas: Yeah. Yeah, let's talk about that. How much was this study kind of a reaction to some of that, awful, you know, the attacks you're talking about, and how much do you think is just, oh, this is genuinely something you'd study anyway, separate from, you know, that negative reaction, that negative kind of, it's even a reaction, I guess it's just that going after trans people, essentially.

0:04:07 Harry: I suppose, you know, as I said, I've been interested in sort of just how a policy influences LGBTQ plus people's health in many different ways. But, you know, particularly with regard to policies that have been targeting access to gender-affirming care, when you look at the sort of rhetoric behind policies, I noticed that, you know, a lot of these proponents of, you these discriminatory policies were saying things like, oh, you know, we need to restrict people's access, particularly youth's access.

Because if we allow them access to gender-affirming care, particularly hormone therapy or surgical procedures, then they're going to regret it later on. And so, you know, or the thing that sort of arose in my head was, okay, well, this concern of whether or not people are going to regret gender-affirming surgery, well, that's an empirical question, right? We can actually study the issue. We don't have to, you know, sit around and speculate and wonder. Like, we can actually study it. And in fact, there are studies that have been done on this topic. And so, you know, when I looked at that literature, you know, my colleagues and I, we found that, you the current studies on surgical regret among trans people who have received these procedures, it's less than 1%, less than 1%

0:04:56 Thomas: Yeah. Yeah.

0:05:24 Harry: Of trans people who receive gender-affirming surgeries report regret. But even more interestingly, was that, Not only is that degree of regret dramatically low based on the evidence we have, but this level of regret is actually much lower than levels of surgical regret among the general population, which is around 14% based on current data. Data.

0:05:45 Thomas: Sure. Sure. Yeah. Well, before we get into that, maybe let's step back a little bit and cover a lot of basics for people who might not be familiar. First of all, I love this idea. Of course, it's like, yeah, that's an empirical question. And I have to imagine that all the people yelling about this will hear that and be like, oh, okay, we'll wait for science's answer to that before we form our opinion. Our apologies, we will be quiet now.

0:05:54 Harry: Yeah. Right.

0:06:11 Thomas: I imagine that'll be their reaction to your research. But anyway, what scares me so much about this issue is how much even of center left, and I don't know, even parts of the left have bought into some of what I think is very inaccurate rhetoric about this. So what are the kinds of procedures we're talking about? I mean, you hear people talk about like, well, all you have to do is you take your eight-year-old into the doctor and your eight year old says, well, I'm a boy instead of a girl. And then bam, surgery that day. And that's kind of the straw man of how this is presented. Um, what are some of the realities of this care that you're talking about that you researching?

0:06:46 Harry: Yeah, I mean, this is such an important point. I mean, so I guess first, even more broadly, so, you know, away from surgery a little bit, we could talk about what is gender affirming care, okay? So now gender affirming is a very, very broad umbrella that comprises many different medical and non-medical services that ultimately are geared towards supporting people's desire to live authentically in their gender. And again, this can take many different forms.

It can include counseling or various mental health services, but it can also include things like hormone therapy and surgical procedures. Now, if we're talking about gender affirming surgery specifically, well, that's also like an entirely different umbrella under the umbrella of gender-affirming care, which also comprises different procedures, the most common being top surgeries, which would be like breast or chest reconstruction, bottom surgeries, genital reconstruction, but also procedures to reconstruct the face, such that it can appear more conventionally masculine or feminine. And yeah, and you're absolutely right about sort of the sort of process that leads up up to these procedures. There's an organization called the World Professional Association for Trans Health, which is an international authority in trans health and medicine. And they have outlined extensive evidence-based guidelines that are interdisciplinary, that again, provide guidelines for healthcare providers to follow as trans people and their families approach them seeking various services. And it's also important to note that, you know, these procedures and access to them have been endorsed by nearly every major medical association in the U.S., including the American Academy of Pediatrics, the American Medical Association,

0:08:37 Harry: The American Academy of Child and Adolescent Psychiatry. And so, you know, they are recognized as safe, effective and beneficial and medically necessary for those who desire them.

0:08:47 Thomas: Yeah. But of course they're all in on the conspiracy. No. Uh, yeah, yeah, all that super important to know. And what is the process of getting some of this care, because my impression, I have a lot of, you trans friends and friends with trans kids. And my impression is that it's far from super easy, like, rubber stamp process, you know, to just like get whatever gender affirming care you want for your, you trans minor. Um, can you talk about some of those realities? Yeah.

0:09:19 Harry: So it's absolutely a long process. Um, and so, I mean, the first step in terms of engaging with a medical provider is like actually just gaining access to one, right? There are often, you know, wait lists that people, you know, you can't just, like, call up your provider and be like, hey, I want surgery and come in the next day. There's often, you know, wait lists to even see a provider. But once you, you know, gain access to a provider, as I said, there are extensive guidelines and recommendations for the sort of regulate this process. And so, for instance, if we're talking about gender-affirming surgery, there are a few things that patients would need to meet, criteria that they would need to meet. So things like having a persistent and well-documented history of gender dysphoria. They would need to have the ability, of course, to provide informed consent or assent if they're a minor, of course be at the age of majority. And if they have any kind of medical or mental health conditions, those must be well controlled.

0:09:29 Thomas: Yeah. Yeah.

0:10:20 Harry: So that's what the guidelines say, just baseline across the board. Now, there are also surgical procedures, which can be things like hysterectomy, phalloplasty, vaginoplasty. And those involve additional criteria, such as you have to complete at least 12 continuous months of being on hormone therapy. And you also have to demonstrate knowledge of the procedure that you're seeking. So you have to understand what the costs are, the potential complications, what rehabilitation is going to look like, What are the, you know, potential risks and benefits, essentially? And so, all that together is going to create, significant hoops that you have to jump through in order to ultimately get the procedure that you desire.

0:11:03 Thomas: I I remember, I don't know if this will be a comparison that makes any sense, and if it doesn't, feel free to tell me, but I remember, so I got a diagnosis for ADHD, and that was a lot of work. And one of the things that was was really frustrating about it was, um, because I've also had depression at times, they were like, well, you can't, you're not going to get anything else until you figure out that depression thing. And I was like, yeah, but I think that might be maybe caused by the ADHD sometimes where it's like, I can't, you know, it, it means I can't focus on the right things.

It means I focus too much on negative things. And so it honestly ended up that I had to just kind of like, you know, take some meds and say, okay, depression, all better. Now can we do this thing? And it's like, is that a similar situation at all here where it's, like, well, we need to fix every other mental health issue. And sometimes thought would be, well I feel like gender dysphoria would cause a lot of mental health issues. Is that a challenge to getting care?

0:11:34 Harry: Right.

0:12:02 Harry: Yeah, I mean, I think the literature certainly suggests that is the case. You know, folks who are not able to live in the gender that they identify with could certainly be more at risk for having a variety of mental health concerns like depression, like anxiety. And so, you know, it's certainly reasonable that that could pose a barrier for them, which is why, when it comes to, you know, surgery, guidelines recommend that, that they are seeing some kind of mental-health professional to sort of cope with the sort of mental health dimensions of gender affirming care prior to moving into surgery. And so again, this is sort of part of the sort of caution that is built into the larger, process. But to your point, there have been, medical professionals and scholars who have written about how this can be a form of gatekeeping in a way, right?

0:12:55 Thomas: Yeah, yeah, yeah.

0:12:56 Harry: Because if you do have these intense psychological distress because you're not able to live authentically, well, it's going to be really difficult to fully manage that until you are able to live authentically, right? Um, and so I think that is certainly a challenge, but, know, part of the process is to try to manage that as best as possible along the way. Absolutely.

0:13:17 Thomas: Right. Recognizing that even in the best of circumstances, you know, not all medical care is going to be easy, you know, or decisions are going to be made with perfect confidence, even just in any medical case. It's just so important. I know there's probably some basic stuff, but it is so important to me because I care a lot about this issue. I worry so much about trans people, especially in our country. And I just know that in kind of tracking the politics that I do, these- These arguments are just, they are appealing to a broad group of people in this country. And it's scary because they just aren't true. Like, a lot of what you'll hear is that the left wants it to be super easy for your eight-year-old to go get all, and it's just like, no, the process you just described is my understanding of it. No, it is a considered, science-based process that is not easy to do and probably is too, too hard to do a lot of the time.

0:13:25 Harry: Right.

0:14:13 Thomas: And so apologies for getting on a soapbox, but I just think it's so important because misinformation the just feels so rampant to me and it's being used to hurt people, I think.

0:14:24 Harry: It Yes, and, you know, as a scholar who studies disabilities, you LGBTQ plus issues. And as a queer person myself, it's really not surprising to me because, you know, we've seen this over and over throughout history. I mean, you know, just before this we've seen, we, you know, in 2016 we had the bathroom bills which of course are emerging again.

0:14:42 Harry: And of course we've Seen this decades ago sort Labeling queer people as you threats to children, right? That's sort of a common trope we see in our culture because LGBTQ plus people are easy targets as a minority group. And so, yeah, I'm not entirely surprised, but, you know, as someone who studies the issue very closely and really understands the consequences of discourse like this and to the policies like this, it does concern me because the research is pretty clear and growing that, you know, these policies are going to do real harm. In fact, if they have not already done real harm, yeah.

0:14:33 Thomas: Yeah. Yeah, yeah, Yeah. Well, okay, let's come back to the study. So if you don't mind for the non-science people, can you talk about, you've referenced and I've already talked about in years past, some of the other studies that exist. Can you talk to us about some of the scientific history, some of the studies that went into your analysis and what your analysis found.

0:15:37 Harry: I guess first it is important to say that although, um, there have been, you know, numerous studies that study the issue of regret, it is still very much a burgeoning area, and of course we can, you know, we can talk about sort of the future of research later, but, but yeah. And so essentially what we did is we looked at, um, what is the existing, um, consensus on this topic, what are different studies saying. And particularly, not just for trans people who are receiving gender-affirming surgeries, but also, like, what does regret look like in the broader population? What is sort of the disparity, if there is one, between the broader population and trans people? And what does that mean? And so what we found is that, based on current evidence, that approximately 1% of all trans people who access gender-affirming surgeries report regret.

0:16:34 Harry: And you can compare that to about 14% among the general population. Now, it is important, I think, to note that given that we are making a comparison between the general population, gender affirming surgery is different in many ways from surgeries that, an you average person might seek out. And so what we did was we sort of took a specific example of mastectomy. And so what the literature shows is that about 1% of trans people who receive mastectomies report regret. And for cis people, it's sort of a large range, but about 5 to 14%. Now, in that particular study that looked at mastectomies among the general population, and, you know, when they found, okay, it's you know, the regret is about 14%, the authors of that study actually noted that 14% is not, it is relatively low, believe it or not.

0:17:31 Harry: And so So, mastectomy is just a useful example because, you know, obviously trans people could seek out mastectomies as a gender-affirming procedure. But, of course, there's going to be really important differences in motivation for mastectomy, for seeking out a mastectomy for trans people versus cisgender people. And that motivation could potentially influence regret.

0:17:54 Thomas: Of course, you know, I remember a time previously I've talked about this. Not all regret is the same. I think to differentiate, it's and I don't know if this is something, you know, how the data was what in you looked at, but regret, I think a lot of people may just assume in the context of trans care that it's like, wow, they totally regret transitioning and they wish they never did. But it's like, no, regret could mean, you know, if I get a knee surgery and I'm like, oh, my knee is still, it's not working. Like, you Know, I have more pain because of something. Maybe it just happened to not go well or whatever. Can did you further like subdivide what kind of regret it was?

0:18:31 Harry: Yes, that's a really great point. Right. And it's actually a major limitation in the literature, not just for trans people, but just for the literature that examines regret broadly, because you're right. There are many different ways that we can assess regret. It could be, for instance, oh, I wish I had a different outcome, I don't like the way I look now, or perhaps there was sort of a cascading effect. You know, I had a procedure that on one part of my body, but it had, you latent consequences for another part of my body that I didn't like. Maybe I just regret the provider I had, because if I chose a different provider, I could have had a better outcome. Maybe I don't like that the procedure put me into debt, right? There's a lot of different reasons why we can have regret. And one of the important things about that is not only are there different types of regret, but that can change over time. You know, when people initially come out of surgery, probably not going to feel too great because they're

0:18:51 Thomas: Mm-hmm. Mm-Hmm. Yeah. Yes, that's the worst

0:19:34 Harry: In pain, right.

0:19:35 Thomas: Time to ask him.

0:19:35 Harry: It's The worst time to ask someone how they feel, I mean, and the research suggests that people could even feel differently about their surgical procedures a year out to eight years out. And so, there are many different social demographic characteristics that could influence that. And, you know, all that to say, it makes regret a complicated issue to study where you can't just ask people, do you regret this or do you not regret it, um, because people actually have much more nuanced views of their procedures than just that dichotomous assessment.

0:19:35 Thomas: Yeah.

0:20:10 Thomas: Exactly. Exactly. Especially because, and again, it's it's such a different context, because it's so politicized, I think people put it into a framework that we wouldn't really do with anything else. I mean, maybe there are a few procedures, but for the most part, you know, if we're talking, I don't know, a knee surgery, it's not usually going to be like, OK, if it doesn't work perfectly and cure whatever was wrong with my knee, I therefore believe the entire project of knee surgery is wrong. You know what I mean? Where it's like, they do do that with trans care. And I think it's

0:20:10 Harry: Right. Right. That's

0:20:44 Thomas: Important. I mean, I could think of all kinds, this is just hypotheticals, but I could think of all kinds of things like, I could imagine you get some gender affirming care of some kind, some surgery, whatever it is, and you regret it, maybe your surgeon wasn't particularly good. And what that would mean is not Oh, people shouldn't do that. No, maybe we need more highly trained surgeons in that area. It would be the opposite of the conclusion that I think people would try to draw from that regret. So I do think there's, there's so much nuance there.

0:20:58 Harry: Right. Yeah.

0:21:13 Harry: Yes. So there are sort of degrees of regret, as you could be saying, right? Instead, even if we were just asking, do you regret it or not, like, we could put that in like a scale, like on a scale of one to ten, how Do, much do you regret or not, right? And so, like, there's just so many, as you're saying, there's so many Different ways to measure and investigate that Question. I mean, our publication was meant to really start a conversation about what we know, but more importantly, what does this mean for research going forward? What does it mean for practice going forward? What does that mean for policy going forward, because, You know, particularly with regard to research. As I said before, studies are not without limitation. And so since publishing this article, I've received some pushback saying, oh, well, we don't have this full, robust understanding of regret among trans and cisgender populations. But part of the reason for writing this article was to say, well, here's all the studies that we do have, um, here's

0:21:23 Thomas: Yeah. Yeah, so Yeah, right, right.

0:22:13 Harry: What they say, and so let's like build on this, let's try to improve, no like, like, our goal is not to say, oh, only one percent, less than one percent of trans people report regret, point, like, end of story, no more questions asked. It's sort of intended, tended to sort of raise questions about, like, what are the implications if that were true, um, and sort of how can we improve our, our, our processes of studying this issue moving forward.

0:22:37 Thomas: Absolutely. Yeah, I mean, that's just one of those, appeals to ignorance where it's like, well, we don't know literally everything about this. Therefore, you should believe my conclusion. And it's, like, no, I mean – I like the approach of let's look at the research we do have. And, hey, if you want to do more, anyone, knock yourselves out, right? I mean we could always use more information. I imagine queer people in general are, you probably not well represented enough in medical science. I mean, I've read about how like often medical science and interventions are just geared toward like men and leave women out a lot. You know, there's all kinds of inequities. If you want to do more studying, anyone, hey, knock yourselves out, right?

0:23:16 Harry: Absolutely, and I think, um, you know, one of the things we raise is that I sort of mentioned the many sort of hoops that trans folks have to move through in order to access these procedures. But one of the things we write in our article is that these hoops may actually be a leading reason for why levels of regret are actually so low, because, in effect, the patients who move through that whole process, they are highly, highly motivated and they're highly, highly educated. They really understand and know what are the potential risks?

0:24:01 Harry: What are the potentially benefits? They've grappled with it. They've talked with their family. They talked with mental health providers. They talk with their surgeons, right? Right. And so they're going through this long process, really weighing the pros and cons. So when you pair that with the fact that their ability to live just more authentically, I think, you know, those things together really big contributors, potential contributors to why the regret rates are so low among trans people. People.

0:24:33 Harry: Whereas, You know, whereas with sort of mastectomy case that we looked at, right, these mastectomies are being done, cisgender people are receiving them for risk reduction, right? So these are largely folks who have risk of cancer. And so they're receiving mastectomy in order to prevent that risk of cancer. And so you could imagine, you, you know, your doctor's, oh, you're at a very high risk of, you know, developing breast cancer, you know, your best option here is to have a mastectomy. I mean, no one wants breast cancer, but like, do you also want a mastectomy if you don't know, like, okay, so, like, so, say,

0:24:32 Thomas: That's a great point.

0:25:09 Thomas: Yeah,

0:25:09 Harry: You don't even have you, cancer, well, it's, I mean, that's a tough decision, right? I don't really know what the full consequence of this surgery is, but I do know I'm gonna be preventing the potential of cancer. Well, you know, when you get to the end of that procedure, yeah, surely you feel better that, you know, you've avoided that risk, hopefully. But that's a very different end point than someone who says, okay, I want a mastectomy because the end point is something I really, really want, and it's going to just like make me so much happier in my life, right? So whereas trans people are sort of gaining this ability to live authentically, the cis folks who are getting mastectomies, are really preventing something that could harm them in the future, a potential outcome,

0:25:10 Thomas: Right. Yeah, right, so this is all kind of an effort to explain why the regret rate is so low, surprisingly low perhaps.

0:25:59 Harry: Yeah. And it's, it's an important point because, you know, we make the comparison to show that there is a difference in regret. But we don't make the comparison to say, oh, haha, cis people, they're so much more regretful, right? But the goal is to really point out like, okay, there are different reasons why trans people are seeking out these kinds of procedures. And here's all these factors that could actually be leading to much lower levels of regret. And if we're talking about the guidelines, for instance, well, I mean, trans people are expected to go through all these guidelines that are evidence-based, interdisciplinary. And if it is true that those are leading to lower levels of regret, well I think that's a lesson, a potential lesson that could be applied to other surgical procedures that cisgender people are receiving. Not to say we should place all these barriers in front of people who even just want an elective surgery.

0:26:11 Thomas: Oh, sure. Yeah, yeah.

0:26:57 Harry: But the point is that patient education is good. It's good when patients are educated and knowledgeable and fully understand the risks and benefits of the procedures that they're going into. And that's just not always the case for many cisgender people, particularly when compared to sort of the hoops that trans trans folks have to jump through.

0:27:18 Thomas: Yeah. I mean, when I got my tonsils out, I mean I guarantee you I knew far less about that than your average trans child knows about trans care. It was like, well, these things kind of suck. I feel like I get sick more and they're big and bulky. Let's get them out. You know, like it's, we're putting quite a burden, possibly uh, an unfair burden, but also, maybe we can, um, take that as some reassurance for anyone who is concerned that this stuff happens too fast. It sounds like, no, there's so much education. There's so much, as you say, an interdisciplinary, uh, batch of knowledge that's, that's brought to bear. Uh and the regret rate is so low it's it's really impressive, so kind of you mentioned really the goal of this is to get the word out, right? I mean, policy to recommendations, what are some of the other takeaways from what you found?

0:28:05 Harry: Yeah. And so, as I said, you know, we really focus on sort of new directions for research, practice, and policies. So, you know, as I said with the research, I think this is a fruitful area of research to study, as we discussed before, the different types of regret, different degrees of regret. Not just for trans people, but for cisgender people also. And looking at that across different time points, I think, is a really important area to continue investigating. But I would also just say, though, it is a burgeoning area and that it is, you know, there are certainly limitations to our paper. I think I actually just saw this today that 2022 U.S.

0:28:05 Thomas: Sure.

0:28:51 Harry: Transgender Survey, they just published their initial findings. And this is just a huge survey of trans folks in the U. S. over 92,000 respondents. And what they found was that 97 percent of respondents who had gender-affirming surgeries reported greater life satisfaction. And so I just say that to underscore the fact that, yes, although the studies that I refer to in my article have limitations, right, we keep getting more and more data on this issue that suggests, okay, yes, access to these procedures is good for people who want them, right? When they get them, when they desire them, and when they want them they have dramatically better outcomes.

0:29:37 Harry: So that's just one thing I would say in terms of the research. But in terms of practice, I think, as I said, the body of research suggests that the current evidence base we have for gender-affirming care provides a really strong foundation for supporting trans people in their transition journeys. And I think that more healthcare providers need to be educated about best practices, even if they're not providing surgical gender-affirming surgeries, right? Because even if they're just a general practitioner, it's not unreasonable that they would have a trans patient someday, and that practitioner should know what it means to support them. They should know how to interact with them in a way that affirms their gender, provide helpful health and medical information, and knowing other providers who could offer specialized support if that was necessary. And so that sort of fits into this broader or sort of conversation about the importance of gender affirming care. Surgery is one type of that, but it's just, part of that process.

But even before that, trans folks are interacting with many other general practitioners along the way. And some of my previous research that I've done has actually shown that when, not just trans people, but LGBTQ people broadly, when they have access to an affirming provider, a provider who affirms their sexual or gender identity, they actually have dramatically better health outcomes, particularly engaging in preventative health behaviors.

0:30:16 Thomas: Yeah.

0:31:12 Harry: And so we know that that's facilitated by, you know, looking to the current evidence base we have, right? We have research on this topic. Increasingly we're understanding what it means to affirm and support trans people. So it's important that we put that into practice with medical providers. Policy was sort of the final bit that we addressed in our article. And again, if we recognize that the evidence, the overwhelming consensus suggests that access to gender affirming care among those who desire that treatment, if we recognize that is effective and beneficial, then why are we passing all these policies that deny people access to gender-affirming care? My point is, these policies completely lack an evidence base, so, right, I just to give you an illustration, the bill in Ohio that denies adolescents access to gender-affirming care. It's called Saving Adolescents from Experimentation Act, okay?

0:32:00 Thomas: Oh. Oh, my God.

0:32:12 Harry: They're calling gender-affirming care experimentation, when in fact, it is a robust and growing field that is based on, you interdisciplinary research. And so I would like to see policies that actually implement or are grounded in scientific consensus and evidence-based and best practices. And so this could mean, you know, expanding access to gender-affirming care and devoting more resources to improving it, not denying people access.

0:32:41 Thomas: Absolutely. It is so frustrating. At a certain point, you know, you kind of mentioned that one of the goals was to get the conversation going. And it reminded me of the Onion headline they put out every time there's a shooting. That's just no way to stop. This says only nation on Earth where this happens. And at a certainpoint, does this become that where it's like, yeah, OK, we could keep studying it and sure, go keep ahead and study it. But I feel like we all should just really be as much as we can, people on the left, people who care about this issue, and I would urge people to care about this issue, at a certain point we all just need to be saying, hey, this is sound science, this is sound science, fight back against it, it's just misinformation, to call it experimentation is just so dishonest,

0:32:54 Harry: Oh, yeah. Right. It It is. And unfortunately, I mean, we've learned this lesson in other contexts when it comes to misinformation, just how powerful it is. Um, it's just a very powerful form of distraction for people. Even in the face of scientific evidence. I mean we learned this, of course, during COVID as well. And I'm not confident in some politicians or folks' ability to become enlightened when presented with scientific evidence. I mean, again, policymakers claim that they are doing this to protect children, okay? Well, the evidence says they're not just not protecting them, the evidence suggests they're actually harming them, okay.

0:33:51 Thomas: Harming

0:34:04 Harry: So either they do not know what the science says, or they know and they're ignoring it. So okay, let's just give them the benefit of the doubt that they don't know it, well if they don't know it, why are they making policies that they haven't investigated? Like they shouldn't they be doing like some research when they're, you know, and so either way it's just not a good situation. Um, but not, as I said, I'm not optimistic that some of these policymakers are going to come around to the scientific evidence. Um, and so I think ultimately what's going to happen is, um, there'll probably eventually have to be some kind of court ruling, Supreme Court ruling, um, as

0:34:03 Thomas: Them yeah, you would hope oof

0:34:42 Harry: You know, which is not promising either.

0:34:43 Thomas: They're even worse at, yeah, I

0:34:45 Harry: And yeah. And so, I guess it's hard to be optimistic. You know, I've done some other writing, I recently published another article in JAMA Health Forum, where I sort of make the case for why more cities and states need to be passing some of these sanctuary policies that we've seen. You know, some, some folks have criticized them as symbolic, but in my publication, I actually sort of walked through, like, okay, well, they could be symbolic if we can actually make them effective, if, if we, you know, do these certain things. And so these sanctuary policies can actually provide important protections and resources and support for trans people who live in states that ban their access. And so I think that although it's not a fundamental change, it's, you know, something that could help a lot of people in a difficult time. But again, there are states like doing some really useful things too.

0:34:45 Thomas: Wouldn't rely on that hmm

0:35:36 Harry: Like, I currently live in Washington, D.C., but I, you know, I work at Johns Hopkins in Maryland, and Maryland just expanded Medicaid to cover gender affirming services. Policies could also try to ensure that insurance companies are not denying trans people access to gender affirming care because it's not quote-unquote medically necessary, right. And so, so there are things that states could be doing, unfortunately, given the broader political landscape at the federal level, it's just unclear what's going to happen sort of long term.

0:36:09 Thomas: Absolutely, and I just want to echo that, I really, yeah, I mean, we gotta do what we can. I don't think we're convincing some people, but why I think this is so urgent is because I do think there's a segment of persuadable people who just don't know any better. Like, I think I think there are center right and center left people in this country who are genuinely just ignorant on the issue and think that the science isn't there.

And I do think that's a persuadable group of people. And I just hope that we do everything we can to keep that message out there. But like, if they took in the information and trusted it, that this, this gender affirming care is good science and it is, best, the best way to save kids' lives, I think they would be persuaded and would change their minds. I think that the right has done a good job.

They often hide really toxic views in kind of plausible sounding, you know, hooks, you know, like, oh, trans people in sports, you know, or should a seven-year-old get, you know, like they hide much more reactionary views behind what seems like, oh, they're just kind of asking questions. And I think we need to do everything we can information-wise to fight against that.

0:37:16 Harry: I completely agree. I do think there are people who, whether it's because they lack any information or they're just bombarded with misinformation, I do think there is a significant swath who could be convinced. And I think it's important to engage with those folks. It's a big part of what I do as a public scholar. I try to engage with the public as much as possible. I always tell people that science for the sake of science is not interesting to me.

I want to ask questions that have potential to, to make the world a better place, to decrease suffering. And um, I think that, um, that kind of engagement is really important. I think, you know, maybe a useful analog would be people who identify as gay or lesbian. I think there used to be, it used to being much easier um, to discriminate against particularly gay and lesbian people at the policy level, especially when it came to marriage. But you know, I think once people actually sort of realize, like, oh, like, I know this gay couple and I know this gay person and they're great, I love them, and um, or I have a child who's gay, and so, like, that's the issue, like, I think, is a useful analog. As more and more people come out, as more and more people are integrated into society and have representation, I think that does have potential to make a meaningful difference. Whereas when you, think you don't know a trans person, it's easy to just buy into the misinformation about them, like, oh, they're just, you know, these

0:38:47 Harry: Creepy, like mentally unstable people. Yeah, that's a long term effort.

0:38:47 Thomas: Yeah, absolutely. Yeah. Great. Well, I have a couple listener questions. Now, you may have already answered them, but do you mind taking a stab or just kind of reiterating the answer for these? Okay, so someone with the username Waffle Priest asks, question for the gender affirmation surgery topic. What is the interviewee's take on Ohio's executive order requiring adults to consult with multiple professionals? I know one is a bioethicist, in parentheses. Are there any actual benefits to this approach, or does it just place barriers to care?

0:39:00 Harry: Absolutely.

0:39:22 Harry: Answer is, it depends. That's sort of already built into the framework that exists through the World Professional Association for Trans Health. So, one thing that's really important to understand about people's trajectories to surgical procedures is that there's not a one-size-fits-all sort of, "Here's the guidelines for everyone no matter what," right? Right. Like, people start at different times. Their life circumstances are different. They have different needs. And so some people may, in fact, need to consult with different medical providers. Others may not. Right. And so I think it really depends on the individual. I don't like a blanket statement, I don't think it would necessarily be appropriate for every person seeking a particular type of procedure, but it does depend.

0:40:09 Harry: Again, and this is just my opinion, it seems to me that if that right sort of process already exists to be sensitive to sort of what particular a patient might need, it just seems to me like the goal is to add an additional barrier. So hopefully that answers the question in some way, but ultimately, it depends. It really depends on what the specific needs of a patient is. Some may require more interaction, some may require less.

0:40:29 Thomas: Sure. Yeah, and this, this strikes me, the first thing that came to my mind, and I don't know if this is an appropriate comparison. So let me know what you think. But this strikes me as how a lot of what Republicans used to do is say, hey, we're not banning abortion. We're just saying any place that offers abortion needs an onboard hospital and a helicopter to fly someone to, you know, just adding something that I'm exaggerating, but adding things that, you know, hospital admitting privileges. That's like, oh, that sounds reasonable. But it's just another thing that you really don't need. That'S just there to make it a little bit harder.

0:41:09 Harry: That's, I think that's a really useful comparison. I mean, right, again, like whether it's reproductive health or trans health, right, we, like, let the actual experts, like these policymakers are not experts.

0:41:18 Thomas: Yeah. Hey, there's people whose job it is actually to do this.

0:41:23 Harry: Right, right, if we have this robust, you know, set of guidelines, why not just follow the guide? Like, why, why is it that policymakers say, oh, no, actually, I'm an expert in this, even though I've, you know, only read about it for five minutes. Like, I don't understand that we already have medical professional scholars who have been studying these procedures for decades. So let's, let's differ to them.

0:41:30 Thomas: Yeah. Yeah. Yeah. You're in luck, Republicans. We already know all this. One more question. And this is, again, it might have been a little bit answered, but just in case. Brett, is patriotism, Hatch asks. The paper abstract mentioned an overall 14.4% regret rate for surgeries. Within that population, I'm interested to know how much variation there is on on the type of surgery, life-saving surgery, surgery that offers a trade-off between some positive health benefit and some negative health side effect, reconstructive surgery, and purely cosmetic cosmetic surgery. So yeah, we touched on that, but maybe expanding a little bit or at least reiterating.

0:41:50 Harry: Sure.

0:42:19 Harry: There's absolutely going to be variation in the type of surgery. I mean the type of the surgery, I'm not just the type of surgery but sort of the motivation for it as well, like, because you could, you could take one type of surgery, as I said, like mastectomy, and you could have two different motivations.

0:42:35 Thomas: Right. Well, are they asking what, ones are represented in that 14.4%

0:42:37 Harry: Um, So I think, um, I have to go back and look, but most of them are, uh, risk reducing procedures. So in that study, you're not going to see things represented like, I don't know what would be a good example, like, more cosmetic related things. You're, you're not, not going to see that. But, don't know, I, don't, I I would imagine that if you did look at the more cosmetic related surgeries, again, this is just speculation, I would have actually imagined that regret rates for those would be much higher, much higher.

0:42:52 Thomas: Cosmetic kind of thing?

0:43:12 Harry: Yeah, I for things that are more geared toward risk reduction, I mean, again, the authors described the 14% number as relatively low. So, I hard to say, put myself in the shoes of someone who just had a, mastectomy for risk reduction purposes. But, know, as we talked about before, knowing that you're preventing, you potential death from cancer is a good thing, of course. And so like, as We said, you Know, feelings of regret are really complex, you can hold sort of these two ideas in your head at once, you know, if I just received a risk reducing this segment, I think, oh, well, you know, I'm glad that I'm not gonna have cancer, but I don't like how I look now. Right. And

0:43:08 Thomas: Oh yeah. Higher. Yeah. I would think. Yeah, yeah.

0:43:56 Harry: So you can hold those two ideas and, you know, at once. But it also just goes back to some of the limitations of this research and why we need better ways to measure regret across, you know, different types of procedures and different different populations.

0:44:12 Thomas: Excellent. Well, Dr. Barbee, thank you so much for taking the time and for doing this very valuable work. Is there any place you'd like to send listeners? Any, I always let people plug stuff, stuff, whatever you want, social media, whatever, anything you would like, them, you know, a call to action, what can they do?

0:44:27 Harry: Yeah. I mean, I think if you're interested in a call for action, I think it's always good to, number one, be knowledgeable. So as I said, if you're interested in reading more on this issue, particularly with regard to sort of what is involved in the process of seeking gender reform and care, the World Professional Association for Trans Health, this is the leading international authority on the issue. So if you're wanting to educate yourself more on that, if you are really interested in sort of some journalism around this issue, Aaron Reed is a fantastic journalist.

0:45:00 Thomas: Aaron Reed, yeah.

0:45:01 Harry: Yep, does a lot of really important work. So I would encourage you to look Aaron up on social media and follow their work. And, yeah, if you're interested in sort of getting involved in policy, I mean, I think, as I said, I'm not sort of optimistic about some policymakers' desire to change their course, but we can try. So, you know, if you want to write your policymaker and encourage them to support, you policies that are evidence-based and that happen and that have scientific consensus, I think that's a great place to start.

0:45:01 Thomas: Excellent.

0:45:35 Thomas: And apologies, but I'm gonna tack on, you don't, you don't have to endorse it or anything, but I'm gonna tack on, I, I really just from my personal view, I think this issue is so worth talking about because it's so important, and to say for a third time, I really think there's some persuadable people who have been told the wrong thing on this. So I would put a call to action to talk to your friends and family about this. Like, even if you're just a cis boy like me, just at least, you know, it's an awkward thing to just bring up. But if it comes up or if you can, you knows, manage a way to bring it up, just talk to your family about the fact that this is settled science. That's a message that in my view is just not out there enough. And I really think it will have an impact on changing at least some people's minds.

0:46:01 Harry: Yeah, and if I can just say just really quickly on that, you know, I was, I won't say who, but I was recently having a conversation with a very close family member, um, who was talking about some politicians who have endorsed anti-LGBTQ plus policies. And I said, oh, well, how do you feel about the fact that, I am a queer person and I could be harmed by some of these policies? And my family member said, well, it really bothers me. And would love to talk to you more about it. And so that was just a nice way to sort of raise this with my family number. And, I don't know where that's going to go with them, but the conversation started.

0:46:40 Thomas: Yeah.

0:46:50 Thomas: Get the conversation going. Yeah, no. Yeah for sure. And that's it. That is a huge first step. Thank you again so much for coming on the show. It was a pleasure and keep up the good work.

0:47:04 Harry: Thank you. I appreciate it. That.