Watchful waiting doesn’t mean no puberty blockers: Anti-trans researchers misrepresent academic literature in recent article

In the latest issue of the American Journal of Bioethics, a peer commentary by Michael Laidlaw, Michelle Cretella, and G. Kevin Donovan was published. In it, the authors argue against access to puberty blockers for trans youth, arguing that the best approach is to wait until at least 16 years old before allowing transition-related interventions, claiming that allowing puberty blockers “would constitute an unmonitored, experimental intervention in children without sufficient evidence of efficacy or safety.” In so arguing, they grossly mischaracterise the very academic literature they cite.

For those in trans health, the argument is unsurprising coming from those authors. Michael Laidlaw and Michelle Cretella are known for their opposition to gender affirmative care for trans youth. Laidlaw has appeared before the California Senate Judiciary Policy to argue against a bill which would allow trans youth in foster care to access transition-related care. Cretella has come to infamy as director of the American College of Pediatricians, an anti-LGBT association which is classified as a hate group by the Southern Poverty Law Center. Neither, to the best of my knowledge, engages in clinical work with trans youth.

According to them, the current standards of care are as follows:

As stated, watchful waiting with support for GD children and adolescents is the current standard of care worldwide until the age of 16 years, not GAT (de Vries and Cohen-Kettenis 2012). Children referred for psychological therapy or simple watchful waiting have been able to alleviate their GD without the damaging health consequences of GAT. These methods are the obvious and preferred therapy for GD, as they do the least harm with the most benefit for the greatest number.

Here, GAT refers to gender affirmative treatment which they claim offers puberty blockers, unlike the watchful waiting approach.

The watchful waiting approach is also known as the Dutch protocol, after the team which theorised it. The article which Laidlaw, Cretella and Donovan cite is the first authoritative statement of that approach, a paper titled “Clinical Management of Gender Dysphoria in Children and Adolescents: The Dutch Approach”. The paper is written by Annelou L. C. de Vries and Peggy T. Cohen-Kettenis, both of the VU University Medical Center in Amsterdam. This is how they describe their approach to puberty blockers:

If the eligibility criteria are met, gonadotropin releasing hormone analogues (GnRHa) to suppress puberty are prescribed when the youth has reached Tanner stage 2–3 of puberty; this means that puberty has just begun. […] Because the protocol for young adolescents had started in a period when there were no studies on the effects of puberty suppression, the age limit was set at 12 years because some cognitive and emotional maturation is desirable when starting these physical medical interventions. […] It is, however, conceivable that when more information about the safety of early hormone treatment becomes available, the age limit may be further adjusted.

Notice the massive discrepancy between what is claimed to be the watchful waiting approach by Laidlaw, Cretella and Donovan, and how the authors they cite describe the approach. According to the former, the watchful waiting approach means no intervention before 16 years old. According to the later, the watchful waiting approach means waiting until 12 and then, if assessment conditions are met, initiating puberty blockers. For the Dutch team, 16 years old is the line for hormonal treatment, i.e. estrogen and testosterone.

In other words, Laidlaw, Cretella and Donovan published a paper in a serious journal in which they falsely claim that the watchful waiting approach, which they claim to be the worldwide standard of care, doesn’t allow any intervention until 16 years old, when in fact it already allowed puberty blockers starting at 12 years old back in 2012, and at the time acknowledged that this limit might be revised downwards. Recent publications by that team indeed suggests that they are now applying a more flexible approach, though I do continue to consider the Dutch protocol very conservative notably when it comes to pre-pubertal social transition.

I’m still struggling to wrap my head around how three people working together couldn’t even correctly characterise one of the most seminal papers in trans health history, a paper which they actually cite and heavily rely on for their argument. In so doing, they demonstrate a lack of basic familiarity with the academic literature on therapeutic approaches to trans youth care, and completely undermine their credibility.

This is not a minor mistake. It’s a massive, massive one. It’s baffling to think that people who claim expertise on trans health and who write about it in scientific publications could get something this wrong. This is a beyond beginner’s mistake. It’s very hard not to conclude that they either simply didn’t read the paper they cited or maliciously mischaracterised it.

It is plainly false that the wait-and-see approach asks kids to wait until they’re 16 for puberty blockers. The Dutch protocol, which as evolved since the 2012 paper, used 12 years old as its minimum. The ‘watchful waiting’ part of the name refers primarily to pre-pubertal social transition: the main difference between the Dutch protocol and the gender-affirmative approach is that the former advises against socially transitioning prior to puberty, whereas the latter allows it if the child desires it.

Saying the Dutch protocol is the standard of care is false, in my opinion. While it is true that consensus is still emerging, more and more groups are coming out in strong favour of the affirmative approach. The Australian Standards of Care and Treatment Guidelines of ANZPATH supports it, the American Academy of Pediatrics supports it, and so does a recent Position Statement by a specialised group on trans health of the Pediatric Endocrine Society. And with the data coming out of Kristina Olson’s team at the University of Washington, more and more practitioners are turning to the affirmative approach.

Differences in opinions are bound to occur in academic literature. I don’t fault Laidlaw, Cretella, and Donovan for claiming that the Dutch protocol remains the standard approach. I disagree and think that even had that been the case it would have been worth noting that the affirmative approach enjoys very wide acceptance in trans health and is supported by an increasingly strong evidence base. But that disagreement is well within the bounds of what is to be expected in academia.

However, their mischaracterisation of a paper they cite in the very first sentence of their commentary, falsely claiming that the worldwide standard of care requires waiting until 16 years old before initiating any medical intervention including puberty blockers is appalling. From an academic standpoint, this is an error that should have never made it to publication and seriously undermines the authors’ credibility in trans health. You simply can’t claim to have enlightened opinions on trans youth care and not know that the Dutch protocol allows puberty blockers starting around puberty.

I have contributed to that issue of the American Journal of Bioethics. You can read my contribution here or, if you don’t have institutional access, here.