Florida Department of Health Guidance Against Transgender Youth Healthcare Contains False Statements and Misrepresentations and Should Not Be Used by Anyone (part 3)

The FLDOH guide to parenting: Ignore a child’s issues, and just hope it all goes away

Previously: FLDOH anti-trans guidance attacks “low-quality evidence” for gender-affirming care, citing low-quality evidence for conversion therapy

The Florida Department of Health states in their 2022 guidance:

Based on the currently available evidence, “encouraging mastectomy, ovariectomy, uterine extirpation, penile disablement, tracheal shave, the prescription of hormones which are out of line with the genetic make-up of the child, or puberty blockers, are all clinical practices which run an unacceptably high risk of doing harm.”

In this bullet point, FLDOH cites a brief article by psychoanalytic psychologist David Schwartz (2021) outlining his personal history in clinical practice and his opinions on gender-affirming care. Like Hruz (2019), this is not any kind of systematic review of evidence. Large swathes of Schwartz’s assessment of the “currently available evidence” are merely his own assertions without any supporting references, or the most cursory sprinkling of tangentially relevant sources, and none of it constitutes an adequate summary of that evidence.

Schwartz (2021) on Mahfouda et al. (2017) on Klink et al. (2015) on bone health

Schwartz makes the following statement about possible harms of puberty blockers:

First, we do not have certainty about the harmful effects of puberty blockers as we do have for cross-sex hormone administration, because we do not have good longitudinal data on their effects in general. But we do know that puberty blockers adversely affect bone density, can instigate excessive height and adversely affect fertility. (Mahfouda et al., 2017).

The cited source, Mahfouda et al. (2017), highlights the delayed accrual of bone mass during treatment with puberty blockers and the question of whether this reaches normal levels during subsequent cross-sex hormone therapy. This source notably suggests that this should be addressed with higher doses of estrogen for adolescent trans girls:

Preliminary results of the first 21 patients (n=11 female-to-male transgender patients) with gender identity disorder to be given GnRH agonist treatment (triptorelin, 3.75 mg given subcutaneously or intramuscularly every 4 weeks) showed a significant decrease in bone accretion during puberty suppression, although bone accretion normalised during CSH treatment. Klink and colleagues retrospectively assessed BMD in a cohort of patients with gender identity disorder (n=34) who had received triptorelin monotherapy during adolescence, followed by CSH therapy in combination with triptorelin, and then surgical gonadectomy and CSH therapy as adults. . . . In female-to-male patients, areal BMD Z scores of both the lumbar spine and femoral region significantly decreased with triptorelin monotherapy, although these scores improved substantially with CSH treatment. The researchers surmised that this improvement was probably due to the rapid increase in dose increments of testosterone. By contrast, BMD Z scores did not significantly decrease during triptorelin monotherapy in male-to-female patients, although a rise in these scores was not seen following low-dose oestrogen administration. Similar results have led to the proposition that higher doses of oestrogen might be warranted in male-to-female patients.

Klink et al. (2015), cited by Mahfouda et al., offer additional caveats: “The relevance of these findings with respect to fracture risk is not clear”, and “The contribution of GnRHa treatment is at best tentative”:

Most patients were late pubertal at start and therefore part of their bone mass development had already occurred and GnRHa monotherapy therapy was relatively short before start of CSH therapy.

Mahfouda et al. go on to recommend, not that puberty blockers or hormone therapy be withheld until age 18 as the FLDOH recommends, but that bone health be monitored during this treatment:

Therefore, regular monitoring of BMD in transgender patients receiving medical treatment is recommended, in accordance with Endocrine Society guidelines. This recommended monitoring includes an examination of BMD before treatment initiation. Encouraging young transgender patients to maintain optimal bone health with adequate calcium intake, vitamin D supplementation (if indicated), and weightbearing exercise is also important.

Additionally, Mahfouda et al. describe an approach to minimize risks to bone health by shortening the time spent on puberty blockers before progressing to hormone therapy:

By contrast, some institutions have been studying the effect of adding CSH therapy to puberty-suppression treatment at age 14 years. This approach is based on the premise that keeping adolescents in a prepubertal state until age 16 years might not only compromise bone health, but also further isolate these adolescents developmentally from their peers. Similarly, in Japan, CSH therapy can be started at age 15 years.

The FLDOH’s source has relied on a publication that clearly contradicts the department’s recommendations against puberty blockers or hormone therapy for anyone under 18, and in fact recommends that hormone therapy may need to be given at even earlier ages.

Does Schwartz know what puberty blockers and hormones are?

The FLDOH’s quote of Schwartz is taken from a longer paragraph:

So my narrow purpose today is to persuade you that in the treatment of children and adolescents, no matter what the diagnosis, encouraging mastectomy, ovariectomy, uterine extirpation, penile disablement, tracheal shave, the prescription of hormones which are out of line with the genetic makeup of the child, or puberty blockers, are all clinical practices which run an unacceptably high risk of doing harm.

In this passage, Schwartz has asserted that treatments such as puberty blockers “run an unacceptably high risk of doing harm” in children and adolescents no matter what the diagnosis. This would present an issue for cisgender children with precocious puberty, which is treated with the same puberty blockers used off-label for trans adolescents (Guaraldi et al., 2016). Schwartz does not cite any supporting material pertaining to the safety of puberty blockers in cis youth, and this paragraph leaves it unclear whether Schwartz is aware of basic information about puberty blockers.

Similarly, the description “hormones which are out of line with the genetic makeup of the child” appears to be based on a misunderstanding of the roles of both sex hormones and the genome in both cis and trans people. Those assigned female and those assigned male both have estrogen and testosterone present at higher or lower levels, because both hormones play important biological roles for everyone (Cooke et al., 2017), and everyone is capable of responding to those sex hormones without respect to their individual “genetic makeup”. This is the very essence of how hormone therapy works: it is not out of line with anyone’s genetic makeup, but works with the instructions coded in our DNA to cause the expression of the desired secondary sexual characteristics. Treatment with testosterone or estrogen is simply the switch – the necessary machinery was already present. Schwartz’s phrasing is needlessly confusing and possibly revealing of his lack of familiarity with this field.

Schwartz conflates childhood-onset and adolescent/adult-onset gender dysphoria

Schwartz says of treatment with puberty blockers:

In fact, the clinical articles in Drescher and Byne’s volume (2013), assert that most adolescents who undergo puberty suppression do tend to proceed to transition away from their natal sex (Stein, 2013), in contrast to the fact that the large majority of gender dysphoric children in general do not (Singh et al., 2021). It would seem that the use of puberty blockers promotes transition.

However, gender dysphoria in childhood and gender dysphoria in adolescence are two distinct entities. Childhood-onset gender dysphoria may persist into adolescent gender dysphoria or desist around the onset of puberty; adolescent/adult gender dysphoria, whether persisting from childhood gender dysphoria or appearing in adolescence for the first time, is very unlikely to desist. The cited source Stein (2012) explains exactly this:

A majority of children with GID turn out to be desisters. As adults, a majority will turn out to identify as gay men, lesbians, or bisexuals, with a significant portion of the rest becoming heterosexuals without gender dysphoria. In only a small proportion of children with GID does the condition persist from childhood and into adulthood. . . .

Second, the clinical articles in this special issue support the practice of using puberty suppression drugs for persisting gender variant adolescents, although they seem to have different thresholds for recommending or offering this course of treatment. Ehrensaft (this issue), for example, says that “children who are approaching puberty and are faced with a sudden trauma that forces to consciousness the horror that they are living in a body that is totally at odds with the gender they know themselves to be … are in gender crisis and need to be attended to immediately with an evaluation for puberty blockers … ” (p. 345). De Vries and Cohen-Kettenis (this issue) consider adolescents “eligible for puberty suppression when they are [i] diagnosed with GID [specifically “very early onset gender dysphoria that has increased around puberty”], [ii] live in a supportive environment and [iii] have no serious psychosocial problems interfering with the diagnostic assessment or treatment.” (pp. 310–311). Edwards-Leeper and Spack (this issue) consider an individual in “early or mid puberty” to be a candidate for puberty suppression when i) a clinical evaluation “indicates strong and persistent gender dysphoria and a desire [for] medical intervention,” ii) there is “no evidence of severe, untreated psychiatric conditions,” iii) his or her parents support use of puberty suppression, and iv) the individual will continue mental health counseling during treatment (p. 325). . . .

Despite the seemingly varied tests described by the clinical articles for when puberty suppression is appropriate, they seem to share the same rationale for this treatment regimen, namely to allow for a wait-and-see approach, giving gender dysphoric individuals time to experience additional emotional and cognitive maturation before they decide how they wish to deal with their gender variance. The onset of puberty seems to be a critical phase for gender dysphoric adolescents. At that stage in their physical development, some of them experience increasing distress about the development of secondary sex characteristics typically associated with their natal sex (e.g., natal males may experience distress about getting spontaneous erections and deeper voices and natal females may experience distress about developing larger breasts and the start of menstruation). Puberty suppression drugs will halt such physical developments, often relieving the distress that apparently comes from the emergence of undesired secondary sex characteristics.

This is not a contrast and it does not show that “the use of puberty blockers promotes transition”. It shows that puberty blockers are being used, not in that large majority of children, but in the smaller group of adolescents with persisting gender dysphoria that is very unlikely to remit.

“I am aware of at least one”

Citing his solo “incomplete reading of the literature”, Schwartz tells us:

Besides the obvious losses, costs and risks of these procedures, there are problems that are less immediately apparent and insufficiently emphasized in the literature of those who promote them: the surgeries are not uncomplicated. I am not aware of any tabulation of the frequency of serious complications, including fatalities; but I am aware of at least one documented fatality from my incomplete reading of the literature (de Vries et al., 2014). Testosterone is associated with significant acne (Braun et al., 2021; Thoreson et al., 2021; Turrion-Merino et al., 2015) and much more ominously, may exacerbate preexisting affective illness (Elboga & Sayiner, 2018) (a not uncommon condition in the relevant population), both of which I have observed clinically, sometimes with serious consequences; and estrogen administration to genetic males significantly increases their chances of getting breast cancer (de Blok et al., 2019).

The fatality noted by de Vries et al. (2014) was reported in greater detail by Negenborn et al. (2017) and describes a hospital-acquired infection with ESBL-producing E. coli, a type of antibiotic-resistant infection that is especially likely to be fatal (Melzer & Petersen, 2007). Because the risk of this kind of infection is not specific to gender-affirming surgery, any argument against gender-affirming surgery on this basis would require arguing against receiving surgery or going into hospitals for any purpose.

Elboga & Sayiner (2018) did not address trans patients or gender-affirming care, but was a single case report on one 17-year-old cis boy with late puberty and a history of inpatient hospitalization and treatment with antipsychotics and mood stabilizers. His case was complicated by several conditions and it is not clear why any features of this case would be broadly applicable to transmasculine adolescents. It says nothing about the nature or scale of the alleged risk to that population, and it certainly does not offer sufficient grounds to declare that gender-affirming care is firmly unacceptable for transmasculine adolescents.

While de Blok et al. (2019) reported that trans women using hormone therapy experienced a higher likelihood of breast cancer than cis men, the same study estimated that their risk is only 30% that of cis women. (This same clinic has also reported data showing that trans women on HRT have a risk of prostate cancer only 20% that of cis men (de Nie et al., 2020).)

Braun et al. (2021) state that “Isotretinoin has been used to treat moderate-to-severe acne effectively in transgender persons” and recommend “screening and treatment for acne and mental health morbidity” for transmasculine patients with acne. Thoreson et al. (2021) conclude that trans men considering testosterone “should be counseled on the increased risk of acne and the treatments available”, and Turrion-Merino et al. (2015) report on two cases of successful treatment of acne in trans men, stating: “We believe that personal susceptibility plays a crucial role in the acne development after cross-sex hormone therapy.” None of these sources conclude, however, that the risk of acne associated with HRT constitutes “an unacceptably high risk of doing harm”.

“I am telling them to be like me”: Schwartz’s parenting by “punting”

What does Schwartz recommend as an alternative approach to addressing gender dysphoria in children and adolescents? Citing his “almost ten years of experience with transgendered and gender dysphoric youth”, he describes his treatment:

I began by recognizing that the preoccupation with gender that these children and their parents were manifesting was only that, a preoccupation, and often, an obsessional preoccupation, which means that the patient felt compelled to return to it, anticipating intense anxiety if he or she didn’t, unconsciously anticipating relief when they did. Gender, an ideational configuration only, was being centralized and reified (with cultural cooperation) to function as a defense against other, unspoken dreads. This means that in each case the preoccupation with gender conceals something different, something idiosyncratic. There is no common underlying meaning to gender dysphoria. The therapeutic move I had to make was to open a space of relatedness outside of gender. In my interactions with patients I would never bring gender up, nor would I talk about it more than absolutely necessary. If the patient wanted to talk about gender I would welcome it, listen and respond enough so I didn’t seem to be evasive, but spend very little time with it in my own my mind, thinking all the while of what might really be going on for that patient. In addition I actually made an effort to experience the patient as having no gender, which I guess really meant trying to effect a kind of gender neutralizing in the way I paid attention. This is, of course, impossible, but turns out to be an excellent way of paying better attention to the aspects of a, trans child that he or she is neglecting in his or her hypercathexis of gender: intelligence, creativity, unspoken emotions, friendships. I became deeply involved with all the details of each child’s interests – TV shows, movies, songs, other kids, etc.

Schwartz has begun with the assumption that apparent gender dysphoria is always a manifestation of an “obsessional preoccupation”, and rather than being a distinct clinical syndrome, reports of gender dysphoria have “no common underlying meaning”. From the outset, this framing does not permit even the possibility that a transgender adult was once a transgender child – on the basis of Schwartz’s mere assertions, we are expected to accept that transgender youth’s identities are universally invalid because they must always originate in something other than the direct experience of gender dysphoria. In keeping with this assumption, Schwartz obliviously labels a young adult gender patient’s symptoms as due to “preoccupations” and “obsessionality”:

Interestingly, the unanticipated material that has come up has at times been marked by a high frequency of body preoccupations: a young woman is distressed at the feeling of her breasts tugged by gravity when she lies on her side; another is disturbed by the feel of her thighs touching one another while walking; a young woman hates her vagina and feels the face she sees in the mirror does not belong to her. My speculation about the role of obsessionality is receiving confirmation: I am repeatedly seeing significant obsessive-compulsive symptoms in these patients, e.g., needing to sit perfectly centered on a couch.

However, these symptoms align with criteria of the DSM-5 diagnosis of gender dysphoria in adolescents and adults, including “A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics” and “A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender” (American Psychiatric Association, 2013). What Schwartz labels as “obsessive-compulsive symptoms” have already been recognized as gender-dysphoric symptoms – the very subject he studiously avoids discussing with the patients seeing him for exactly those symptoms. He goes on to recommend parents of trans or gender-questioning youth adopt his approach of consistently avoiding this one issue, other than ignoring their child’s chosen name and pronouns:

To the parents, with whom I meet when they feel the need, and which I always encourage, I gave the emphatic advice to give intense and plentiful attention to their child, but not speak about gender at all. Listen to whatever your child has to say on the subject if they bring it up, be interested, but make no contribution of your own and never initiate it. (I am telling them to be like me.) They have found this surprisingly hard to do. I was somewhat surprised to learn how preoccupied with gender some of these parents were – wanting to bombard their children with e-mails about the negative effects of surgery and hormones, among other things. I would receive late night phone calls begging my permission to send such destructive missives. On the question of pronouns and names, my advice was to avoid them as much as possible. There is rarely a need for the noun of address when the child is in the room, and artful dodging can elide gendered pronouns more often than you think. I do not favor explicitly agreeing to a, trans child’s requests to modify language and naming. Such agreements are usually infested with dishonesty – parents have not really agreed to a name or gender change, they are just succumbing to pressure – and the unconscious meanings behind the linguistic surrender are very hard to disentangle. Punting and honesty are usually better.

Sources other than Schwartz do not recommend “punting” or avoiding conversations about gender with your gender-diverse child. Instead, the UK’s NSPCC emphasizes the importance of engaging in these conversations with a child:

It can help to listen actively and respectfully to show them you’re truly involved. Try to ask open questions that don’t have yes or no answers and not to interrupt them. It’s important to keep the conversation about their feelings, and to avoid offering opinions or advice. . . . Some children or young people may find it difficult to talk about how they’re feeling about their gender identity. It can take a lot of courage for them to start the conversation and sometimes they may not feel comfortable sharing everything straightaway. Be patient and try not to rush them. Instead let them know that you’re there if they want to continue the conversation at a different time.

The Mayo Clinic similarly recommends:

If your child is persistent about gender identity feelings, listen. Talk to your child and ask questions without judgment. . . . Speak positively about your child to your child and to others. Show your admiration for your child’s identity and expression of it. By allowing your child to demonstrate preferences and share them, you’ll encourage a positive sense of self and keep the lines of communication open. . . . Whatever your child’s gender identity, do your homework and seek appropriate care. Showing your love and acceptance will also help your child feel comfortable in his or her body and in the world.

And the American Academy of Pediatrics recommends:

When your child discloses their identity to you, respond in an affirming, supportive way. Understand that although gender identity is not able to be changed, it often is revealed over time as people discover more about themselves. Accept and love your child as they are. Try to understand what they are feeling and experiencing. Even if there are disagreements, they will need your support and validation to develop into healthy teens and adults. . . . Celebrate diversity in all forms. Provide access to a variety of books, movies, and materials—including those that positively represent gender diverse individuals. Point out LGBTQ celebrities and role models who stand up for the LGBTQ community, and people in general who demonstrate bravery in the face of social stigma. Support your child’s self-expression. Engage in conversations with them around their choices of clothing, jewelry, hairstyle, friends, and room decorations.

Schwartz’s recommendation of “punting” also appears to contradict FLDOH’s own position that “Children and adolescents should be provided social support by peers and family and seek counseling from a licensed provider.” Instead, Schwartz has maintained that families should almost entirely withhold support from their trans and gender-questioning children. The public deserves clarification of the FLDOH’s position on whether parents should support their kids, or opt for “punting” this basic parental responsibility.

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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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