ColbyCosh.com

Mr. Cosh: when the inevitable case against you from irate transgender persons arrives, you will be interested to know there is ample parking on the south side of the building.

There was some controversial points in the piece, but it contained a fair bit of balance on the technical side, and was pretty clear (I thought) at driving home it's main point, which was the objection to the basis on which this funding decision is and will be made.

As such: the headline writers for both the print edition and Full Comment need a fucking slap.

"Colby Cosh: Mutilating the body to correct a delusion" is sort of amusing in that it looks like Colby Cosh's personal slogan. That aside, it's a nasty bit of trolling.

With regards to the other headline,"Dude looks like a lady", I don't see why a (male-to-female) transgendered person can't chuckle along with the rest of us. But that's probably because I've never been a male-to-female transgendered person.

I think the first commenter on the story makes a pretty fair point: surgery is the medically approved treatment for severe forms of the condition. In lieu of better research, it's hard to justify walking back the status-quo funding.

"Mutilation" is just plain hysterical. Is a vasectomy, which may or may not be reversible, mutilation? How about hysterectomies, which are most often performed to correct non-life-threatening conditions? Where's the hand-wringing over coverage for those? I imagine recipients report satisfaction with having undergone that procedure; should we discount their opinions too?

A strong point in theory, but if vasectomies and hysterectomies imposed the continuing health burdens that gender reassignment surgeries do, and were as poorly studied, then yes, there'd be a lot of handwringing from evidence-based medicine practitioners. In fact, there's been handwringing already over the markedly different rates of hysterectomy in different provinces.

Interesting column. It amazes me that advocates for covering things like sex reassignment surgery get away with neglecting the aspect of allocating limited resources. Does this surgery honestly convey more benefit than hip replacements and organ transplants - surgeries with a demonstrable benefit for quality and/or quantity of life? Also some curious posts from a bioethicist on the Full Comment blog. Sometimes I wonder whether bioethicists pick the conclusion they want to arrive at and work backwards...

But that sounds like handwringing over practice. Not funding.

Once upon a time tonsillectomies were common and now they're rare. It's easy to look back and say that in light of further research, most of those procedures were unnecessary or even detrimental. It's much harder to look back and say the recipients ought to pay back the cost.

I'm all for evidence-based medicine (in fact, I think that's redundant, like equation-based math); but I don't see the case for de-listing a procedure that doctors recommend. Efficacy of mental illness therapies is often difficult to assess. If you have evidence that the continuing health burdens of gender reassignment surgery outweigh the mental health burden they relieve, have at 'er.

I'm open to the argument that the procedure never should have been covered in the first place (taking you at your word that the evidence is weak.) But I'm not for delisting a procedure that experts recommend just because the evidence is not as compelling as I would like.

I don't understand why you speak of anyone being required to "pay back" the cost of procedures already performed. (Alberta Health is in fact going ahead with fully-funded surgeries for patients already in the process of qualifying for gender reassignment.) Your approach might be more in the spirit of fairness than mine, but let's keep in mind that if "gender reassignment" came in pill form, it would never have been allowed onto the shelves at all on the existing evidence, let alone publicly funded.

That was just my awkward way of distinguishing between good practice and good funding. Or more to the point, arguing that there shouldn't be a distinction. The latter follows from the former.

If gender reassignment came in pill form, the drug company would fund human trials--and we would know whether it worked or not.

Maybe the solution is more surgeries--not fewer--so we can get a larger sample. There are appear to be some very willing volunteers.

The lack of scientific trials for efficacy of surgical procedures is a longstanding problem. A good example would be a recent study of knee surgery that compared the results of surgery, drug therapy, and a placebo consisting of an incision on the knee. The surgery demonstrated no significant benefits compared to the other treatments. Still, the fact that a lot of surgical therapies haven't been subjected to strict scientific scrutiny is a poor argument for funding an expensive therapy without life-and-limb consequences.

George, you're assuming acute sufferers of gender identity disorder aren't already at risk of losing life or, um, limb. One of the data points apparently missing from this debate is suicide rates among those who want the surgery but don't get it, compared to rates for post-op patients. And as Colby points out, the cost of ongoing cognitive therapy may be higher than the cost of surgery.

And then, of course, there are risks associated with do-it-yourself home surgery. Visit eunuch.org sometime for instructions. (I'm being mostly facetious; those folks suffer from something else, maybe a body dysmorphic disorder or maybe just a dark sense of humour.)

Why the government is in the business of paying for a surgery that corrects a purely psychological issue is beyond me. We have enough tangible medical problems putting a burden on our healthcare system, with wait times for surgeries to replace hips, repair rotator cuffs and various other demonstrable maladies going on for months. Furthermore, practically speaking if the government is unwilling to pay for you to have a root cannal, which certainly causes those who need one a great deal of anguish and the performance of that operation is demonstrably beneficial but expects the Canadian public to pay for that out of pocket, why the hell should they pay for what amounts to an elaborate drag costume.

Yes, SRS is mutilation. Honest transsexuals acknowledge this. They know that what they are getting is going to be problematic for the rest of their lives, at best.

However, I'm not sure that "delusion" is accurate. The question is "Where is gender identity?"

Is it within the mind, a creation of the mind, and therefore malleable by purely psychological means? That comes close to the "Gender is a social construct" rubbish peddled by postmodernists.

Does it derive from perception of the body? One would think so - and yet there are people who have bodies that are clearly of one gender, yet from somewhere get the feeling that they are "really" of a different gender. The physical reality of the body does not establish gender identity in the mind.

Something else does. If that something else is a neurological structure, then it is not delusional for the mind to receive that signal: the feeling of "wrong gender" is real. The optimal solution would be to fix that neurological error. But no one knows how to do that; the only answer seems to be SRS.

It may well be that gender identity is a secondary sex characteristic, like facial hair, breast development, and genital anatomy. If other secondary characteristics are mismatched, surgery or drugs to bring them into conformity is an obvious choice. These days, mental qualities outrank everything else. Thus, SRS, if gender identity mismatches the body.

If that something else is a neurological structure, then it is not delusional for the mind to receive that signal: the feeling of "wrong gender" is real.

Not buying it. Your argument is careful, but the archetypal syndromes traditionally described as delusions—Capgras, Fregoli, Cotard—have, on the whole, relatively stronger cases for having resulted from neurological impairments, and being genuine in the sense you describe. So in a technical sense you seem to be arguing, "It is not delusional... because it meets the definition of a delusion."

Colby - any response to the studies cited by Zoe Brain in the FC thread?

Well, at some point I have to trust interested readers to figure this stuff out for themselves, but the Pfäfflin-Junge review is, as its title suggests, effectively almost 20 years old; it contained the same anecdotal case reports as the ink-still-wet study I cited (the new one actually uses more inclusive criteria); and it is off-point, since it is a review of gender reassignment as opposed to gender reassignment surgery specifically. "Zoe" also cites something called the "World Professional Association Standards of Care", which I suggest Googling for in quotes if you're up for a laugh.

Assuming you find the claim that "The reason why there have been no double-blind experiments is for the same reason there have been none on other surgical procedures, such as appendectomy" convincing, I'll point out that (a) appendectomy is the removal of an inflamed organ, not the destruction of a healthy one, and (b) when laparoscopic appendectomies were introduced as an alternative to open ones, you'd better believe doctors conducted a fuckload of RCTs to find out which approach was less harmful. Double-blinding has nothing to do with anything here, and is not mentioned in my column.

The idea that "we can detect [transsexuality] from MRI scans" is a favourite red herring from discussions of almost all mental illness; unless you can DIAGNOSE IT PROSPECTIVELY from those scans, you are telling just-so stories about pretty pictures. If we could detect intractable gender identity disorder in an MRI, as if it were a hematoma, I suppose we could save everybody a lot of trouble and perform SRS without subjecting the applicants to years of testing and behavioural scrutiny.

Well, at some point I have to trust interested readers to figure this stuff out for themselves

Stuff I'm interested in, I do; stuff I don't care about, I ignore; in between, I contract out.

In the interest of strict accuracy, if you google "World Professional Association" "Standards of Care" (just like that), you end up with a lobby group called the World Professional Association for Transgender Health, so that's okay then.

Questions I'd like to see answered:

1) As of March 31, 2009, how many provinces in Canada were offering sex-change surgery as part of the public health care system?

2) If the answer is, "Ontario and Alberta" then the next question should be, "Why isn't the GLBT community launching lawsuits in all the other provinces where it's not covered, as doesn't that violate one or more conditions of the Canada Health Act, i.e, portability and comprehensiveness?"

3) If the answer is "Ontario and Alberta" it begs the question of why it's not covered in Quebec, seeing as Alberta is paying for these surgeries to be done in Montreal.

4) If Quebec does not cover, are these surgeries being done at a private clinic in Montreal and being paid for with taxpayers dollars?

(NOTE: Q 3 and maybe 4 are void if Quebec does cover.)

Quebec covers in principle, but the clinic in Montreal that performs the procedure (the Centre Métropolitain de Chirurgie Plastique) is private and they won't pay. (They will pay for partial sex reassignments in public hospitals.) Saskatchewan will pay for SRS to be performed at the CMCP, but at a hypothetical "Saskatchewan rate" that covers about one-third of the cost. Until de-listing, Alberta was happy to pay the CMCP at its own rates.

Alberta taxpayer dollars were subsidizing a private clinic in Quebec then. Quick, someone alert Brian Mason so he can change his mind on this subject!