Michael Laidlaw and friends still misunderstand the basics of affirming care for trans youth

Zinnia JonesI’ve previously covered Dr. Michael K. Laidlaw et al.’s (2019) remarkable feat of fitting so many inaccuracies and distortions about trans youth treatments into an eight-paragraph letter to the editor in the Journal of Clinical Endocrinology & Metabolism, it took several thousand words to dissect these errors thoroughly. These included:

  • Claims that gender-affirming medical care causes “sexual dysfunction”, without acknowledgment that untreated gender dysphoria can itself be a significant source of sexual dysfunction and gender-affirming care is associated with improvements in sexual function.
  • Asserting that youth with untreated gender dysphoria are “healthy”, omitting any recognition of the many severe comorbidities that can accompany these.
  • Asserting the existence of new “rapid onset” form of gender dysphoria developing “suddenly” in teenagers through “social contagion”, supported by a single study that examined only parental reports and perceptions without including a single transgender, gender-nonconforming, or gender dysphoric youth.
  • Incorrectly claiming that all transgender adolescents who take puberty blockers will continue on to take cross-sex hormones as well.
  • And the utterly groundless assertion that use of puberty blockers induces persistence of adolescent gender dysphoria that would supposedly otherwise remit spontaneously.

As it turns out, that last item appears to be a persistent point of confusion for Laidlaw and his coauthors. In their letter to the editor, Laidlaw et al. stated that most “children” would “outgrow” their gender dysphoria “by adulthood”, inaccurately suggesting that adulthood rather than the onset of adolescence is the point at which gender dysphoria is observed to persist or desist. This is not the case: statistics about “desistance”, which are themselves often questionable and highly variable, are about whether or not childhood gender dysphoria persists beyond the onset of adolescence. Past that point, these dysphoric youth are unlikely to experience spontaneous remission of their dysphoria upon reaching adulthood – but Laidlaw et al.’s misrepresentation makes it seem as though this is the case. This is an attempt to provide a pretext for the continued denial of medically necessary care to gender-dysphoric adolescents, based on the false belief that it will simply go away within a few years and any affirming care would be unnecessary and inappropriate.

Astonishingly, it turns out that Michael Laidlaw, Michelle Cretella, and G. Kevin Donovan (2019) made a very similar error in an article published earlier this year in the American Journal of Bioethics. In “The Right to Best Care for Children Does Not Include the Right to Medical Transition”, Laidlaw et al. draw a false distinction between (their misunderstanding of) “watchful waiting” as opposed to “gender affirming therapy” with puberty blockers, and on this basis, argue that the “current standard of care” of watchful waiting entails withholding any medical treatment, including puberty blockers, until the age of 16. This is a complete misunderstanding of the literature and the very definitions of these terms. Bioethicist Florence Ashley (2019) explains in a response article:

It is false that the watchful waiting approach does not prescribe any transition-related intervention prior to 16 years old. On the contrary, the watchful waiting approach, also known as the Dutch approach, is known for traditionally initiating puberty blockers beginning at 12 years old.

Moreover, “watchful waiting” refers to an approach to childhood gender dysphoria and evaluation of the suitability of childhood social gender transition for these youth with an eye toward the possibility that their dysphoria may either persist or desist at the onset of adolescence. It does not refer to an approach to adolescent gender dysphoria and medical transition treatment:

The main difference between the watchful waiting approach and the gender-affirmative approach is not whether they allow puberty blockers in tween years— both do—but rather their attitudes toward prepubertal social transition and the extent of assessment required to initiate puberty blockers.

It’s rather disappointing – to put it mildly! – that such absolutely glaring errors were allowed to slip through in a paper published in a peer-reviewed journal of bioethical arguments. This isn’t a difference of opinion, it’s an ignorance of facts. How can Laidlaw and his associates, or this journal for that matter, claim to offer meaningful ethical arguments when it turns out those arguments are rooted in empirical falsehoods?

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About Zinnia Jones

My work focuses on insights to be found across transgender sociology, public health, psychiatry, history of medicine, cognitive science, the social processes of science, transgender feminism, and human rights, taking an analytic approach that intersects these many perspectives and is guided by the lived experiences of transgender people. I live in Orlando with my family, and work mainly in technical writing.
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