Previously in Part 1: Endocrine aspects, cardiovascular risk, and sexual functioning.
Previously in Part 2: Desistance, persistence, and “objective tests” for gender dysphoria.
Previously in Part 3: Medical ethics, fertility preservation, and ovarian pathology.
Dhejne et al. (2011) and the “health consequences” of transitioning
The health consequences of GAT are highly detrimental, the stated quality of evidence in the guidelines is low, and diagnostic certainty is poor. Furthermore, limited long-term outcome data fail to demonstrate long-term success in suicide prevention (7). How can a child, adolescent, or even parent provide genuine consent to such a treatment? How can the physician ethically administer GAT knowing that a significant number of patients will be irreversibly harmed?
Are the health “consequences” of medical transition really “highly detrimental”? Laidlaw et al. seem content to depict transition treatment as something being provided for no actual reason, which does nothing of any benefit and then kills you in six different ways. Contrary to the authors’ opposite-day take on the existing body of medical evidence, transitioning has repeatedly been shown to result in reduction of gender-dysphoric symptoms, improvements in body image and sexual functioning, better quality of life, reductions in depression and anxiety, reduction of dissociative symptoms, and lower rates of substance abuse and suicidality.
Are we to regard these as the alarming and calamitous consequences of an obviously ill-advised treatment that no patient could rationally choose to undergo, and no physician in their right mind would possibly provide? Or is it possible that Laidlaw et al. are just way, way off base here?
The authors’ choice to cite Dhejne et al. (2011), in the context of arguing that transition is not beneficial or does not reduce suicidality in trans people, is a classic red flag among transphobes. It’s the kind of red flag that makes you stop and say, “Wow, that flag is red! How did you get it so red? Did you use Tide ColorGuard on that red flag?” This paper has been selectively quoted and misused since its publication, with lead author Cecilia Dhejne now spending the better part of a decade trying to get people like Michael Laidlaw to stop twisting and misrepresenting its findings. Dhejne explained the crucial details of the study’s findings on trans people, transition, and suicidality in an interview with The TransAdvocate:
“The study as a whole covers the period between 1973 and 2003. If one divides the cohort into two groups, 1973 to 1988 and 1989 to 2003, one observes that for the latter group (1989 – 2003), differences in mortality, suicide attempts, and crime disappear. . . . The difference we observed between the 1989 to 2003 cohort and the control group is that the trans cohort group accessed more mental health care, which is appropriate given the level of ongoing discrimination the group faces. What the data tells us is that things are getting measurably better and the issues we found affecting the 1973 to 1988 cohort group likely reflects a time when trans health and psychological care was less effective and social stigma was far worse.”
As Dhejne states in the interview: “Of course trans medical and psychological care is efficacious.” Alternately, Laidlaw et al. could once again find some clarity in the text of the very study they cited:
It is therefore important to note that the current study is only informative with respect to transsexuals persons health after sex reassignment; no inferences can be drawn as to the effectiveness of sex reassignment as a treatment for transsexualism. In other words, the results should not be interpreted such as sex reassignment per se increases morbidity and mortality. Things might have been even worse without sex reassignment. As an analogy, similar studies have found increased somatic morbidity, suicide rate, and overall mortality for patients treated for bipolar disorder and schizophrenia. This is important information, but it does not follow that mood stabilizing treatment or antipsychotic treatment is the culprit.
Disaffirming treatment: an “obvious and preferred therapy”?
Hypothesis-driven randomized controlled clinical trials are needed to establish and validate the safety and efficacy of alternate treatment approaches for this vulnerable patient population. Existing care models based on psychological therapy have been shown to alleviate GD in children, thus avoiding the radical changes and health risks of GAT (8). This is an obvious and preferred therapy, as it does the least harm with the most benefit.
Indeed, why can’t we just conduct randomized controlled trials where people with untreated gender dysphoria are made to try some other kind of Laidlaw-recommended therapy in place of the trans-affirming care that we know works? Because transition treatment is so effective it is actually unethical to deny it to a group of patients who need it, even for the sake of research:
An inherent limitation in the field of transgender health research is that it is difficult to conduct prospective studies or randomized control trials of treatments for gender dysphoria because of the individualized nature of treatment, the varying and unequal circumstances of population members, the small size of the known transgender population, and the ethical issues involved in withholding an effective treatment from those who need it.
Laidlaw et al. particularly overstate their case when claiming that certain forms of psychotherapy alone “have been shown” to make gender-dysphoric children stop being gender-dysphoric. Their cited article by Zucker et al. (2012) certainly shows no such thing. Instead, the authors of this publication openly admit to lacking data showing that a disaffirming approach reliably produces remission of dysphoria in children, and even acknowledge that they are unsure of what forms a metric for “successful” treatment in this manner could take.
Their paper concludes with a handful of case vignettes whose outcomes are summed up as “Success? Failure?” or “Success? Failure? In between?” Suffice it to say that most clinical studies of affirming treatment in trans youth report measurable outcomes that are somewhat more well-defined than “in between”. More than that, at least two cases are known of adolescent trans girls under the care of Zucker et al. who lied to these clinicans about desisting in their dysphoria after being subjected to this disaffirming and potentially coercive “treatment”, before once more coming out as trans later in adolescence. This is the approach, and the result, that Laidlaw et al. have chosen to describe as a “preferred therapy” that conclusively provides “the least harm with the most benefit”. Success? Failure? In between?
What does ideologically slanted activism really look like?
In our opinion, physicians need to start examining GAT through the objective eye of the scientist-clinician rather than the ideological lens of the social activist. Far more children with gender dysphoria will ultimately be helped by this approach.
“The ideological lens of the social activist” is perhaps the best way to describe how such a brief communication by a ragtag band of conversion therapists and public liars managed to distort nearly every aspect of what’s known about transgender health. If someone were to read the sources cited, they would come away with a distinctly different impression of the subject matter and the state of the science in these areas than someone who only read the letter itself. That makes it a bad summary of the research and a bad attempt at answering research-based questions.
Between its sweeping, grandiose claims and its wholesale dismissal of reams of existing evidence, this letter displays all the professional integrity and restraint of a Christian doctor calling a woman a porn-saturated psychopath for talking about science. The sheer scope of wrongness compacted into this one brief article at least offers an opportunity for someone to respond to these misrepresentations in press – it would just take a lot longer than half a page. ■