What Michael Laidlaw gets wrong about transgender youth

This month, endocrinologist Michael Laidlaw posted a lengthy review of the book I Am Jazz by Jessica Herthel and trans teenager Jazz Jennings at the Witherspoon Institute’s Public Discourse blog, alleging that the book includes “a number of factual accuracies and very significant omissions”. Unfortunately, Laidlaw’s review is shot through with misrepresentations of the evidence regarding gender dysphoria and its treatment, and contains a panoply of unsubstantiated claims with no sound basis in science. His article thus presents a highly distorted view of the lives and experiences of trans youth and the known benefits of a gender-affirming approach.

Persistence of gender dysphoria in children

Laidlaw asserts that “about 90 percent of biologically male children who believe they are female as young children, when allowed to go through normal puberty and enter adulthood as men, will identify as biological males.” This vague statement omits crucial details about these findings, depicting gender-dysphoric children as a homogeneous group, any member of which is overwhelmingly likely to desist in their gender dysphoria during adolescence.

This is not the case. Not only have various studies found different rates of desistance, some as low as 45% (Newhook et al., 2018), but there are factors known to be associated with a greater likelihood of persistence of gender dysphoria into adolescence. These include having undergone a transition of social gender role in childhood, explicit identification of themselves as their desired sex (“I am” as opposed to “I wish I was”), more intense gender dysphoric symptoms, and greater dissatisfaction with their body’s primary and secondary sexual characteristics (Steensma et al., 2013). Some gender-dysphoric youth are more likely to persist into adolescence than others; treating all of them as if they are overwhelmingly likely to desist is simply inaccurate. Laidlaw has little to offer the 10-55% of these youth who will persist in their gender dysphoria and will likely find experiencing the wrong puberty to be highly distressing.

Evidence from twin studies

Laidlaw claims that identical twin studies show that the genetic contribution to transgender identity is minimal:

If gender identity is determined only by genes, then we would expect that identical twins would profess having the same gender identity nearly 100 percent of the time. This is not the case. In fact, the largest transexual twin study ever conducted included seventy-four pairs of identical twins. They were studied to determine in how many cases both twins would grow up to identify as transgender. In only twenty-one of the seventy-four pairs (28 percent) did both identical twins identify as transgender. This is consistent with the fact that multiple factors play a role in determining gender identity, including psychological and social factors.

The claim that genetic aspects of gender identity must be insubstantial because identical twin studies fall short of showing 100% concordance in gender identity is not accurate. Instead, Laidlaw should be comparing concordance in transgender identity among identical twins to concordance among fraternal twins. In this context, concordance among identical twins is highly elevated, while concordance among fraternal twins is nearly zero. This is an indication of a significant genetic component of transgender identity (Polderman et al., 2018).

Positive effect of transitioning on psychiatric symptoms

Laidlaw states:

At least 70 percent of people with gender dysphoria suffer from mental illness currently or in their lifetime. The most common comorbid mental illnesses include depression, anxiety, bipolar disorder, and dissociative disorder.

On this basis, he raises the possibility that trans people may instead be cis people who are experiencing apparent gender dysphoria arising as a symptom of another condition, as seen in the case of Walt Heyer. However, gender-affirming treatment such as hormone therapy and surgery is associated with a reduction in rates of depression, anxiety, substance use, and suicidality. Conversely, there is no evidence that only treating a trans person’s depression, anxiety, or other comorbid psychiatric conditions can successfully alleviate their gender dysphoria or diminish their cross-gender identification. Presenting a single case of regret such as Walt Heyer as a representative example is particularly misleading, given that rates of regret following transition treatment are minimal, ranging from 0.3-3.8%.

Impact of puberty blockers on gender identity development

Laidlaw claims that Jennings and other trans youth on puberty blockers have “not been allowed to go through puberty”:

Jazz is currently being given hormone blockers to stop him from going through normal pubertal development. These powerful hormones arrest the normal development of boys into fully developed men and of girls into fully developed women. In other words, Jazz is now a teenager who has not been allowed to go through puberty.

However, Jennings herself already began taking estrogen several years ago, and Endocrine Society clinical guidelines provide protocols for the induction of puberty using cross-sex hormones (Hembree et al., 2017). It is not accurate to state that these youth have not gone through puberty when their puberty has already been induced by use of these hormones. Laidlaw further alleges that administering puberty blockers itself interferes with the development of a cisgender identity, and that withholding puberty blockers can produce desistance in gender dysphoric youth:

By current protocol, children with gender dysphoria are given these powerful hormones at around age eleven. This is too young for them to understand the implications of what will happen to their minds and bodies. Time is required for maturity of the developing adolescent mind, and hormones play an important role in this development. For Jazz, allowing normal production of testosterone would further the development of his adolescent brain and very likely lead him to different conclusions regarding his gender.

Such a possibility is not supported by evidence. Clinicians involved in the treatment of trans youth generally do not hold the position that puberty blockers alter the course of a child’s gender identity development, particularly given that a large number of cisgender youth are given these same medications to treat precocious puberty without producing any apparent shift toward a transgender identity (Vrouenraets et al., 2015).

Vaginoplasty and sexual function after use of puberty blockers

Laidlaw misrepresents the current state of genital surgery for trans girls, falsely presenting it as highly complex and risky:

But Jazz has a problem. Since he still has a small child-sized penis (because of puberty blockers), he does not have enough skin to line the false vagina. Potential remedies include sewing in a section of intestine along with the penis skin to make the false vagina. In one episode, Jazz is actually offered two different surgeries: one surgery to create the false vagina and a second surgery two months later to attempt to form the labia. The need for two dangerous surgeries instead of one is directly related to the effects of puberty blockers.

In reality, many surgeons operating on adult trans women already perform a two-stage procedure of vaginoplasty followed by labiaplasty, meaning that this objection would not be specific to trans youth only. The implication that operating on trans girls who’ve used puberty blockers is uniquely challenging or dissatisfying in its results is also not supported. In a survey of 20 vaginoplasty surgeons, 11 of whom had performed the procedure on minors, most felt that any shortage of tissue could be adequately managed using skin grafts, which are also sometimes used in adult trans women without sufficient genital tissue (Milrod & Karasic, 2017).

Laidlaw further claims that trans girls undergoing treatment with puberty blockers and surgery will experience an “almost certain loss of sexual function”:

The effects of puberty-blocking agents (started in early adolescent development) on long-term sexual function seem to be largely unstudied. However, from interviews with Jazz’s surgeons, one can deduce the almost certain loss of sexual function. Or more accurately, the sexual development of the genitalia has not been allowed to occur in Jazz and never will occur under the current circumstances.

However, in a followup study of trans youth who had been treated with puberty blockers, trans women who had undergone genital surgery reported improved levels of satisfaction with their primary sex characteristics (de Vries et al., 2014), and stated that they were “very or fairly satisfied with their surgeries”. None experienced regret. Laidlaw’s unfamiliarity with the subject matter is evident here. Transition using puberty blockers is not a recent development; the use of GnRH agonists in the treatment of trans youth began in the early 1990s, and it is unlikely that such treatments would continue to be in widespread use if they commonly produced unsatisfying results in terms of sexual function.

Ethics of puberty blockers and impact on fertility: “Do no harm”?

Laidlaw claims that treatment with puberty blockers and surgery is “highly unethical” because it can result in infertility:

Once he has surgery to remove his testicles, Jazz will be forever infertile, with no chance to produce biological offspring. …

Is this a decision that any adolescent child has the maturity and insight to make? I do not believe so. This is another reason that the use of puberty blocking agents in adolescents is highly unethical.

His ethical stance is not shared by clinicians and others working with trans youth, who recognize that fertility is not the only relevant consideration here. Refusing to provide this treatment to gender-dysphoric youth can result in a worsening of their dysphoria, along with elevated rates of depression, anxiety, self-harm, and suicidality (Crall & Jackson, 2016; Radix & Silva, 2014). Many trans youth, as well as their families and clinicians, will find that the benefits of gender-affirming treatment ultimately outweigh the harm of fertility loss (Shumer et al., 2016).

Laidlaw appeals to the medical maxim of “first, do no harm” as a basis for withholding treatment with puberty blockers from trans youth:

Primum non nocere is the Latin phrase for “first, do no harm” and is an admonition to physicians to seriously consider the risks of any treatment before applying it. Given the multitude of health risks, potential infertility, and sexual dysfunction associated with the hormonal and surgical treatment of gender dysphoria, I could not in good conscience recommend these treatments to any child or adolescent.

He instead proposes some poorly-articulated alternative treatment that would supposedly alleviate gender dysphoria without affirming care: “It is possible that with proper therapy the child’s gender dysphoria could be alleviated.” But Laidlaw presents nothing to support why this would be possible, and does not explain what form this alternative treatment would take. The simple refusal to provide treatment cannot be usefully characterized as “doing no harm” when withholding that treatment would result in harm and providing treatment would prevent harm. As clinicians working with these youth have noted, refusing to act is far from a neutral or harmless choice (Cohen-Kettenis et al., 2008):

Finally, in judging the desirability of hormonal pubertal suppression as a first but reversible phase in the sex reassignment procedure, one should not only take consequences of the intervention into account. Rather, one should also consider the consequences of nontreatment. Nonintervention is not a neutral option, but has clear negative lifelong consequences for the quality of life of those individuals who had to wait for treatment until after puberty.