Previously in Part 1: Endocrine aspects, cardiovascular risk, and sexual functioning.
Previously in Part 2: Desistance, persistence, and “objective tests” for gender dysphoria.
Is untreated gender dysphoria “healthy”?
GnRH agonists are used in precocious puberty to delay the abnormally early onset of puberty to a physiologically normal age. The goal of PB in the healthy child, however, is to induce hypogonadotropic hypogonadism to “buy time” to confirm gender incongruence. In a study of PB in adolescents aged 11 to 17 years, 100% desired to continue GAT. They simply “bought” themselves lower bone density and the need for lifelong medical therapy (5).
It is a shameless elision for Laidlaw et al. to describe medical interventions for gender dysphoria in youth as being used on “the healthy child” – suffering from untreated gender dysphoria and its many comorbidities is not a state of health. As Radix & Silva (2014) point out:
For these transgender adolescents, forcing them to undergo puberty in their natal sex can result in severe dysphoria, depression, suicidality, and self-harming behaviors.
Or we can just look to the very study the authors cited, which found that use of puberty blockers in trans adolescents, even before cross-sex hormones, led to an improvement in general functioning and psychological health and well-being (de Vries et al., 2011):
This is the first prospective study showing that psychological functioning of adolescents diagnosed with GID had improved in many respects after an average of nearly 2 years of GnRHa use. Adolescents showed fewer behavioral and emotional problems, reported fewer depressive symptoms, feelings of anxiety and anger remained stable, and their general functioning improved.
While Laidlaw et al. may have found that all trans youth in a study chose to continue medically transitioning, this is far from the case in all studies. Several cases of previously dysphoric adolescents choosing to discontinue puberty blockers and resume their natal puberty have been reported in the literature, and a study of thousands of patients at the largest Dutch gender identity clinic found that 4.1% of AMABs and 0.7% of AFABs on puberty blockers went on to discontinue this without any further treatment (Wiepjes et al., 2018).
Bone health in trans adolescents during and after use of puberty blockers is another area in which the authors demonstrate their unfamiliarity. Studies of bone mass in these youth have found that these changes are slight and transient, and measures of bone health are once again normalized after treatment with cross-sex hormones is added, with researchers concluding that “halting puberty in gender-dysphoric adolescents is a responsible practice that will not harm bone health.” And, once more, having gender dysphoria is not a matter of choice any more than other health conditions. To describe these youth as having “‘bought’ themselves lower bone density and the need for lifelong medical therapy”, as if requiring treatment for a condition is something they had a say in and opted into, is insensitive and dismissive – to trans people and to reality.
Trans youth, fertility, and medical ethics
Studies show that <5% of adolescents receiving GAT even attempt fertility preservation (6). Those started on PB at Tanner stage II, as recommended by current guidelines, will be blocked prior to sperm maturation and ovum release. They will have no prospect of biological offspring while on HDCS hormones and continuing on to gonadectomy.
First, Laidlaw et al. conspicuously neglect to weigh any ethical dimensions of puberty-blocking treatment other than future fertility, or even consider the possibility that there could be relevant concerns here that are more significant than fertility preservation. Affirming care for trans youth is a matter of medically necessary treatment, not some capricious undertaking whose outcomes can be wholly summarized as “sterility”.
Cohen-Kettenis, Delemarre-van de Waal, & Gooren (2008) rightly point out that withholding this treatment from youth who are in need of it, whether to preserve fertility or for any other reason, would mean sacrificing other significant benefits and incurring significant harm: “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.” Giordano (2008) similarly notes that there is a much wider array of potential costs and benefits to be weighed here, and that this does not tilt in favor of withholding treatment:
Whether or not the administration of puberty suppressant drugs is ethical depends not only on the net balance of clinical risks and benefits of treatment, but also on what is likely to happen to the child if s/he is not treated at the early stages of puberty. On balance, healthcare providers should include future physical risks (invasiveness of future surgery), and the psychological and relational/social risks (disgust for the self; social integration; risk of suicide). Healthcare providers are ethically (and to some extent legally) responsible for what is likely to happen to the applicant as a consequence of the fact that treatment has been withheld.
Second, and more absurdly, the authors choose to highlight the case of trans youth who are started on puberty blockers early enough that they have no opportunity to produce viable gametes – immediately after citing a study in which 91% of trans girls and 96% of trans boys had matured sufficiently for gamete preservation to be a possibility (Nahata et al., 2017):
Seventy-two of 73 subjects (98.6%) had documented fertility counseling provided by the pediatric endocrinologist prior to initiation of any therapy; 91% of transgender females had progressed beyond Tanner stage 2 and were offered an opportunity to bank sperm; 96% of transgender males were postmenarchal and were offered a referral to a reproductive endocrinologist at a nearby fertility practice.
This same study goes on to note that fertility preservation simply may not be as much of a priority or interest for trans youth, potentially due to factors such as dysphoria about one’s body and its sexed features:
Transgender youth and AYA have self-reported some of these same barriers as well (such as cost), but given the significantly lower FP rates in this transgender cohort compared to FP rates in AYA with cancer, other factors such as dysphoria about one’s body and/or mental health morbidities may contribute to lower rates of FP utilization among transgender youth. Notably, nearly one-fourth of the subjects with a documented reason for declining FP stated that they “never wanted to have children.” This was noted more frequently in those identifying as female, which is interesting and a topic for further investigation. Despite the fact that youth in general may have difficulty envisioning future parenthood, it is uncommon to see reports of adolescents in other populations commenting that they know they “do not ever want to have children.” In fact, a study about perceptions of fertility among healthy, cisgender, and teen girls (in a similar age range to our cohort) showed they already had strong thoughts about having children in their future. This discrepancy raises questions about differences between transgender and cisgender youth with regard to parenthood desires. . . .
In conclusion, although recent editorials and guidelines make statements that transgender adults have the same desire for biological children as cisgender adults, there is little evidence to support this assertion, and the available data are mixed.
It is especially inconsistent for Laidlaw et al. to argue that infertility constitutes an unacceptable degree of harm to a given group when a strong majority of this group appears to be explicitly uninterested in voluntary exercising the viable option of fertility preservation.
Trans men, testosterone, and ovarian pathology
The Endocrine Society’s guidelines recommend elevating females’ testosterone levels from a normal of 10 to 50 ng/dL to 300 to 1000 ng/dL, values typically found with androgen-secreting tumors. The ovaries of women given testosterone correspond to those found in PCOS, which itself is associated with increased ovarian cancer risk and metabolic abnormalities (1). Venous thromboembolism risk is elevated fivefold in males taking estrogen (2).
The authors’ reference to testosterone levels at “values typically found with androgen-secreting tumors” is entirely irrelevant, and serves only the purpose of scaremongering. These levels could be described as those of a tumor – or, as in the Endocrine Society guideline cited here, they can be described as “normal male range” (Hembree et al., 2017). The circumstance of testosterone replacement therapy used for trans men is rather different from that of an androgen-secreting tumor, as the effects of normal male levels of testosterone are typically desired by the trans men taking it, and crucially, this is not the result of an uncontrolled abnormal growth or indicative of the presence of such a concerning pathology.
As for whether trans men’s ovaries “correspond to those found in PCOS”, the Endocrine Society guideline cited by the authors paints a much more mixed picture. Namely, many of the included studies referred to an elevated prevalence of PCOS in trans men before starting hormone therapy (Baba et al., 2007), another study found that the ovaries of trans men on testosterone did not show changes consistent with PCOS (Ikeda et al., 2013), and the guidelines refer to a grand total of three cases of ovarian cancer in trans men reported in the literature:
In females with GD/gender incongruence, the effect of prolonged treatment with exogenous testosterone on ovarian function is uncertain. There have been reports of an increased incidence of polycystic ovaries in transgender males, both prior to and as a result of androgen treatment (74–77), although these reports were not confirmed by others (78). . . .
Although aromatization of testosterone to estradiol in transgender males has been suggested as a risk factor for endometrial cancer (216), no cases have been reported. When transgender males undergo hysterectomy, the uterus is small and there is endometrial atrophy (217, 218). Studies have reported cases of ovarian cancer (219, 220). Although there is limited evidence for increased risk of reproductive tract cancers in transgender males, health care providers should determine the medical necessity of a laparoscopic total hysterectomy as part of a gender-affirming surgery to prevent reproductive tract cancer (221).
Next: Misusing Dhejne et al. (2011), anti-trans conversion therapy, and ideology in activism.