Short letters to the editor of peer-reviewed journals are generally not held to the same stringent editorial scrutiny as, say, a systematic review or a clinical study presenting new findings. But most lay readers, and particularly certain motivated readers such as anti-trans advocates among the general public, will not recognize that distinction – they will likely regard even such a brief opinion piece published in a refereed journal as constituting solid scientific evidence. The letter’s extensive references cultivate an appearance of credibility even as the text fails to make good on that promise; indeed, the cited sources contradict the claims of the authors at numerous points.
So who decided to put their name to this?
- Dr. Michael K. Laidlaw, an endocrinologist currently practicing in California. Laidlaw’s previous highlights include entirely misunderstanding the timing of protocols for puberty blockers in trans youth; misrepresenting findings on gender dysphoria in twins as evidence against a genetic component when this is actually evidence for it; claiming that trans women who’ve used puberty blockers will only be able to access ineffective or risky methods of vaginoplasty, when in fact these surgical methods are highly effective and utilized even in trans women who haven’t used puberty blockers; broadly spreading misconceptions about trans-affirming care in countless conservative outlets; and at one point describing me as a “porn saturated trans psychopath” for bringing my criticisms of the “rapid onset gender dysphoria” study to the attention of PLOS One and Brown University.
- Pediatric endocrinologist Dr. Quentin L. Van Meter. Van Meter is the current president of the anti-gay, anti-trans “American College of Pediatricians”, a hoax group so named as to cause confusion with the American Academy of Pediatrics, a much larger non-homophobic professional organization. He previously co-signed a position statement of the hoax group, which described transitioning as “chemical and surgical impersonation of the opposite sex” and acceptance of trans youth as “child abuse”, and made the astonishingly flimsy claim that “psychodynamic and social learning theories of [gender dysphoria] have never been disproved”. Van Meter has incorrectly termed being trans a “delusional disorder”, and was interviewed by Breitbart regarding his belief that transness was invented in a 1950s university laboratory.
- Pediatric endocrinologist Dr. Paul W. Hruz. Hruz previously co-authored a heavily biased review article of affirming treatment for trans youth with arch-transphobe Paul McHugh for the conservative Christian journal The New Atlantis. He’s also published a paper on cross-sex hormone therapy for National Catholic Bioethics Quarterly in which he claims that this treatment “distorts a proper view of human nature and violates bodily integrity”, and is a member of the St. Louis Catholic Medical Association.
- Family physician Dr. Andre Van Mol. Van Mol is a longtime advocate for anti-gay conversion therapy, and has written several articles defending this harmful practice for the Christian Medical & Dental Associations. He’s previously claimed that “homosexual practice itself leads to loss of 25 to 40 percent of life expectancy” and that “simply put, gay sex is bad for people”, and has testified against bills banning conversion therapy. Van Mol’s Twitter currently features retweets of individuals alleging that “paedophiles have infiltrated the trans movement”.
- Endocrinologist William J. Malone. Little information is available on Malone’s history of any other engagement with issues of transness or trans healthcare, so all we can say about him is that he willingly chose to affiliate himself with the previous four individuals.
An auspicious lineup, to be sure. Let’s dive into this fun-size disasterpiece.
“Not an endocrine condition”? On the health effects of transitioning
Childhood gender dysphoria (GD) is not an endocrine condition, but it becomes one through iatrogenic puberty blockade (PB) and high-dose cross-sex (HDCS) hormones. The consequences of this gender-affirmative therapy (GAT) are not trivial and include potential sterility, sexual dysfunction, thromboembolic and cardiovascular disease, and malignancy (1, 2).
If a person is experiencing a clinically distressing syndrome, and an endocrine approach to treatment is not only known to mitigate the condition and its symptoms but is indeed part of the most effective known treatment and endorsed by dozens of major medical organizations, it is hardly accurate to say this is “not an endocrine condition”. Notably, the article to which Laidlaw et al. are responding – the Endocrine Society’s 2017 clinical practice guideline for treating gender dysphoria (Hembree et al., 2017) – recognizes the role of endocrinology in gender identity and emphasizes the shortcomings of a solely psychological model of transness:
Normative psychological literature, however, does not address if and when gender identity becomes crystallized and what factors contribute to the development of a gender identity that is not congruent with the gender of rearing. Results of studies from a variety of biomedical disciplines—genetic, endocrine, and neuroanatomic—support the concept that gender identity and/or gender expression likely reflect a complex interplay of biological, environmental, and cultural factors.
It is simply misleading to assert that there aren’t endocrine factors deeply involved in both the origins and effective treatment of the condition of gender dysphoria.
And what of the authors’ claims of “thromboembolic and cardiovascular disease” and “sexual dysfunction” resulting from transition treatment? The article cited in support of this, Irwig (2018), itself notes that trans men may only “possibly” be at an increased risk of acute cardiovascular events, while also observing:
It is likely that some forms of estrogen (i.e. transdermal estradiol) carry less risk for venous thromboembolism.
Laidlaw et al.’s cursory citation also fails to acknowledge a number of other published findings on trans people, hormone therapy, and cardiovascular health risks. For instance, a systematic literature review and meta-analysis by Khan et al. (2019) found that the incidence of venous thromboembolism (VTE) among trans women on estrogen was elevated compared to the general population, but still lower than the incidence of VTE among cisgender women taking oral contraception. As the authors point out:
Although significance would need to be supported by statistical analyses, our data support the risk of thrombotic events in transgender women taking estrogen therapy being roughly comparable with the risk of thrombotic risks associated with oral contraceptives in premenopausal women. Given the widespread use of oral contraception, this level of risk appears to be broadly accepted.
Khan et al. further disclaim that their meta-analysis “found statistically significant heterogeneity, and for that reason, the overall point estimate of the incidence rate cannot be reliably applied to transgender women as a group”, and note that their review “may overestimate the risk of thrombosis because we included several older studies (i.e., before year 2000) with data before the introduction of estradiol valerate.” Meanwhile, Streed et al. (2017) explain that the medical ethics of this treatment are far different from the bleak picture presented by Laidlaw et al.:
Although a randomized trial of CSHT in transgender patients might be ideal to evaluate CSHT’s effects on various outcomes, including CVD, the psychological benefits of CSHT in transgender persons render a placebo group unethical. . . . Providers caring for transgender patients should understand that although CSHT is associated with potential risks, providing gender-affirming care has important psychosocial benefits.
Additionally, Laidlaw et al.’s one-sided depiction of “sexual dysfunction” is wholly excised from even the most obvious context of untreated gender dysphoria, its alienating and isolating impact on body image and sexual relationships, and distress at one’s own incongruent primary and secondary sex characteristics (Holmberg, Arver, & Dhejne, 2018):
Qualitative studies describe difficulties among individuals with gender dysphoria to be nude alone or with a partner and difficulties of touching one’s own body or letting somebody else touch it, with a greater focus on satisfying a partner. Body satisfaction is dependent on the degree of body and genital dysphoria, but also on coping strategies to handle the dysphoria. Thus, some individuals use coping strategies such as imagining a different body, reinterpreting gendered body parts, or applying a gender role during sex congruent with their gender identity. . . . A vast majority (80–92%) of persons applying for gender-affirming treatment or those who had unmet gender-affirming treatment needs have, in the past, been sexually active with a partner. However, only half of this group engaged their genitals in sexual activity, and only 12% of transgender women and 15% of transgender men in this group derived pleasure from involving their genitals in sexual activity.
In essence, untreated gender dysphoria itself can be a cause of actual sexual dysfunction. And more than that, transition treatments are associated with improvements in trans people’s sexual functioning, sexual health, sexual desire, and satisfaction with their sex lives.
Also, we’re only one paragraph into this letter.
Next: Desistance, persistence, and “objective tests” for gender dysphoria.