The other Olson's research

On consumer satisfaction surveys in gender medicine

It is perhaps a sign of the times that in a Medical News brief from the premier JAMA Network, we got this headline, “Most transgender youth who received medical interventions including puberty blockers or hormones expressed satisfaction with their treatment, according to a study published in JAMA Pediatrics.” And sure enough, the link takes us to a study titled “Levels of Satisfaction and Regret With Gender-Affirming Medical Care in Adolescence.”

Its lead author is the good Olson. The one who does not hide results from NIH-funded studies if their conclusions are inconvenient to their cause (at least, not that we know of), or does not claim that if you want breasts at a later point in your life, you can go and get them. No, this Olson is the one who received the MacArthur Foundation grant in 2018 for her Trans Youth project while we, especially those in some English-speaking countries, were at or nearing Peak Trans. She subsequently moved to Princeton University in 2020.

Predictably enough, the irrepressible Selena Simmons-Duffin at NPR covered the study within two days of its publication. (In contrast, NPR never covered the Cass Review—only Meghna Chakrabarti at WBUR did two (excellent) interviews with Dr. Cass in May 2024.) NPR quoted Olson at the start of the piece, “Regret was very rare.”

How rare was it, though? There are 317 youth enrolled in the Trans Youth Project, out of which 269 are on puberty blockers and/or cross-sex hormones. The survey about medical interventions received no response from over 18% of the 269 youth, which included 49 individuals whose parents also did not respond, which is close to the 20% mark when the loss to follow-up starts becoming a significant threat to the validity of the study (to understand why, consider the worst-case scenario: all the 49 non-respondents regretted the interventions—not a far-fetched conclusion because people want to cut their losses and usually do not want to discuss past events which they regret with third-party researchers—along with the 9 that did respond. The regret rate then would be 21.6%, leading to a very different conclusion).

There is also the issue of short follow-up times. The median time to surgical regret has been recorded at 8 years. The time to regret other gender medical interventions is possibly shorter, but reliable estimates are hard to find. In the Olson study, among those who responded to the survey, the average time since starting puberty blockers was 4 years and 10 months, while the average time since beginning hormone treatments was 3 years and 5 months. As it has been pointed out elsewhere, “Transition may be associated with a “honeymoon period,” with quality of life and satisfaction rising at 1-year post-transition compared to baseline, but then starting to fall at 3 years and falling even more precipitously at 5 years post-transition.”

The issue of satisfaction and regret is even more fraught with uncertainty if you pose such questions to children, whose parts of the brain that control insight and judgment are yet to develop. If puberty blockers effectively stop puberty from taking place, children who feel distressed about it will obviously like that outcome—at that time. They are children, after all!

But what about the Regret—the one with an upper-case R—later? As the psychoanalyst Marcus Evans put it across so elegantly: “Asking about regret [from children] two years later is meaningless—they are still in the euphoria of escape. The real reckoning comes decades later when the chance to have children is lost [emphasis mine]. By then, what can they say? They have no choice but to make peace with decisions made for them as children.”

But let’s keep aside such thorny philosophical questions for the time being and ask a simpler question instead—what has patient satisfaction got to do with the quality of healthcare? Preciously little, as it so happens.

In the aftermath of the opioid crisis, it was found that physicians, whose pay and bonuses are often tied to patient satisfaction ratings, “feel pressured to prescribe opioids when patients request/demand them, despite their reservations about the need for opioid medications.”¹ In fact, a 2019 study found that striving for high patient satisfaction scores for a hospital is usually bad for the patients, as it correlates with higher expenditures, higher rates of hospitalization, and a higher risk of death. Another nationwide prospective cohort study (from JAMA!) found that respondents in the highest patient satisfaction quartile had lower odds of any emergency department visit, higher odds of any inpatient admission, greater total expenditures, greater prescription drug expenditures, and higher mortality relative to those in the lowest patient satisfaction quartile.

(As a parenthesized aside, the above-mentioned perspective article on the aftermath of the opioid crisis mentions several culprits, some of whom you will recognize in their current avatars. One of them is the American Pain Society, which introduced the “Pain as the 5th Vital Sign” campaign. “This declaration was not accompanied by the release of any device which could objectively measure pain, as was done with all previous vital signs, blood pressure, pulse, respiratory rate, and temperature, making it the first and only subjective vital sign” (p. 83). Does that ring any bells in the present context of gender medicine?

Another culprit in the opioid crisis (from the same article) was the Joint Commission, which is a non-profit that published a guide in which it blamed some clinicians for having “inaccurate and exaggerated concerns about addiction, tolerance, and risk of death. This attitude prevails despite the fact there is no evidence that addiction is a significant issue when persons are given opioids for pain control.” They also “framed pain management as a patient’s rights issue” (p. 83). Does that ring any bells in the present context of gender medicine—non-profits berating any sign of skepticism or advocates framing access to medication as a patient-rights issue?)

“…this entire field has avoided medical ethics. Ethics are meant to curb medical omnipotence—the ‘god complex.’ When it comes to children, agreeing to medicalize a healthy body for a psychological issue is a folie à deux—a shared delusion between distressed children and the adults meant to help them.”

And so the tamasha goes on. Even as a multitude of systematic reviews—from 2023, 2024, and now in 2025 (1, 2)—fail to show any evidence of benefits, even as the risk signals from medicalization continue to mount, we continue to rate the success of medical interventions from consumer satisfaction surveys. Which then gets published in premier medical journals! And it is 2025! I could go on ranting, but it gets frighteningly depressing after some time.

When all the while, we know what should have been done. To quote Dr. Evans once again:

“The logical next step would be to collect data from adult services—but this entire field has avoided medical ethics [emphasis mine]. Ethics are meant to curb medical omnipotence—the ‘god complex.’ When it comes to children, agreeing to medicalize a healthy body for a psychological issue is a folie à deux—a shared delusion between distressed children and the adults meant to help them. Instead of rushing to irreversible interventions, mental health professionals should say: We understand your distress. Let’s not take drastic medical action—let’s explore why you feel this way.”

Ethics? Understand and explore a child’s distress? Ha!

The good doctor must be crazy.

1. A similar thing happens in higher education, too—instead of handing out prescriptions, instructors hand out easy grades, even at the best of universities.