One of the bigger scandals surrounding gender treatment concerns the long term effects of both hormone use and surgery. A particular aspect of it was brought home this week at the Clinical Advisory Network on Sex and Gender (CAN-SG) conference by Elaine Miller – a self-described “fanny physio”.
Miller has a nice sideline in pelvic floor-based stand-up comedy and is also the woman who famously flashed her merkin at Nicola Sturgeon in the Scottish parliament’s debating chamber in 2022. Her account of the stunt and the planning which went into it is my favourite chapter in The Women Who Wouldn’t Wheesht.
There is a serious side to Miller, as befits a Fellow of the Chartered Society of Physiotherapists . She has just finished an academic paper with Professor Ruth Parry from Loughborough University called the “Unwanted Effects of Transgender Related Hormones and Gender Surgery on Urinary and Sexual Functioning”. Miller presented this for the first time at the CAN-SG conference.
Miller’s initial interest in the subject was piqued by a spike in referrals in young female people presenting with incontinence at her clinic. They had symptoms which would have been “familiar with menopausal women” but they were happening “thirty years earlier”. All the young women were on cross-sex hormones, specifically testosterone.
Miller reminded the conference that continence problems can be devastating. “If you worry that you are going to wet yourself in public, it affects everything that you do, and everything that you think”.
People who suffer from incontinence tend to “stop exercising, stop being intimate with their partners and become very worried about odour control. They change what they wear… and their sense of self is impacted.”
After vaginoplasty (an operation not for the faint-hearted), up to 15% of males reported incontinence with a further 5% reporting urinary problems (eg desperately needing a wee and having to drop everything to do so). 75% reported sexual dysfunction.
“That’s not a good outcome of surgery”, said Miller. “These are things which reduce somebody’s quality of life”.
For males who had not undergone surgery, 55% on prolonged oestrogen use reported “urinary leakage”.
For females, the outcomes are worse. Up to 50% of women who undergo phalloplasty (an even more gruesome process than vaginoplasty) are left with urinary incontinence. 54% reported sexual dysfunction. “This data is shocking”, said Miller. “But they’re carrying on. Chelsea and Westminster [NHS Hospital Trust] are training up new surgeons.”
25% of females who elect for metoidioplasty (in which clitoral tissue is detached from the labia and ligaments around it are cut so it protrudes forward) along with urethroplasty (in which the urethra is rerouted through the clitoris to allow urinating whilst standing) report difficulty urinating. Some require help from “continence nurses” and end up “self-cathetising” because the surgery has caused strictures in the urethra, which means the bladder can’t be emptied efficiently.
Miller said their research found that gender clinics were largely “ignoring” the continence problems reported by their patients or weren’t accurately recording them. Miller felt there were parallels with the NHS mesh scandal where patients reporting pain were ignored by their doctors.
After dealing with pelvic matters, Miller touched briefly on other rehabilitative failures after gender surgery. She noted that most women who received bilateral mastectomies due to cancer were routinely offered physiotherapy to prevent “post-operative shoulder dysfunction” – eg a frozen shoulder. There is, however, no NHS physio provision for women having their breasts removed for gender-related reasons. In fact, the surgical protocols say the arms should not be lifted above 90˚ for “anything between six weeks and six months” after surgery. Miller said this was because the protocols were written by plastic surgeons who are basically just interested in the scar – “they’re concerned that if [patients] move an arm too much, the scar will widen and be less aesthetically pleasing”.
Miller said a disproportionate number of trans-identifying people seem to have persistent pain and chronic fatigue, but we don’t know why. A feature of any trans gathering is multiple mobility aids. Miller said “from a physio point of view, if you give somebody a mobility aid, you should have an exit strategy”.
And they should fit. “You don’t give them a wheelchair that you’ve bought off Argos that they’re all slumped in, that doesn’t fit their leg length.”
Miller said there were wider problem with gender patients in possession of physio referrals. Clinics can and do often refuse to take patients on the basis that – and Miller says she was told this directly – “we don’t treat gender here”. This, according to Miller, is because health professionals are “nervous” about taking on gender patients. “They don’t understand them, they’re worried about using the wrong words, and upsetting the person or being accused of a micro-aggression or worse.” This, said Miller, was not good enough. “If we wouldn’t reject a referral for a woman [with] pelvic floor disorder who’s been de-oestrogenised because she’s menopausal, we should not be rejecting young people who are de-oestrogenised because they’re on cross-sex hormones.”