The Laramee Filter: pseudorandom thoughts, subsequently put on the Internet.
Tom Laramee
Date Published:
April 21st, 2023
Word Count:
3,167 (20:00 read time)
Filed Under:

Compare and Contrast

(In Which We Compare the Requirements for Two Medical Treatments That Will Change the Course of Someone's Life, Oftentimes Irreversibly, and Find Out That the Requirements Are Radically Different)


To show how far away we are from a societally responsible response to rapid onset gender dysphoria (ROGD), one only needs to compare teenage GD "gender-affirming" medical care with teenage bariatric surgery.

Before I get too far, I'd like to describe (briefly anyways) what I mean by "a societally responsible response". To me, the adults supporting teen and pre-teen kids who are contemplating medical decisions that have long-term consequences need to be good stewards of the health (both physical and mental) of these young people. To that end, the adults need to meet them where they are: begin by listening to them, make an effort to understand where each kid is coming from, and become educated about the current challenges they're facing. Then, help guide the teen in terms of understanding the pros and cons of their medical decisions, as well as the risks. Do your best to ensure the best possible overall outcome for your teen.

As adults, we're not here to tell kids what to do, unless we think they're making a medical decision that is (a) irreversible (b) has long-term implications that are either unknown or not well understood or (c) will ultimately cause them harm and/or (d) that they will deeply regret at another developmental stage during their lifetime.

We're not here to tell kids what to do, but we are here to try to ensure that they understand their decisions: risks, benefits, likely outcomes, possible outcomes, implications for long-term health/viability, alternative treatments, and the pros and cons of both probable and likely mental-health effects.

We're not likely to tell them "No [you can't do this]". Guidance for surgeries that are risky, have long-term health implications, and forever alter the body and life trajectory of a very young person will look more like "No [you can't do this yet, just wait until you're older]".

Some Background, Beginning Here in Washington State

Here in WA State, we give 13-year olds full HIPPA. It's a one size fits all based only on biological age. The laws don't allow for any nuance for kids who are developmentally delayed, emotionally immature, or have autism spectrum disorder (ASD).

We don't let our 13-year olds drive cars, or purchase alcohol or tobacco products, own guns, or vote, but we give them complete control of their healthcare decisions.

Want to know what your doctor and your 13-year old discussed at their last checkup? Too bad. Want to know why your 13-year old stopped (or started) counseling with a psychologist? Also too bad.

It is possible that, as a parent, you're fully aware of the mental-health challenges your 13-year old is facing, and said challenges are serious, but you are denied the right to exchange information with their counselor when your kid suddenly quits counseling for unexplained reasons? Absolutely. Is it possible that your 13-year old exhibits extremely avoidant behavior (avoiding change at any cost and trying to bury or ignore extreme psychological distress) and therefore will not seek medical care of their own volition, and therefore get themselves into a risky situation (say: self-harming), but WA State law prohibits your participation in the seeking of medical treatment due to HIPPA preventing an exchange of information with your 13-year olds MD? Yes, this happens all of the time.

This legislation really does have some unintended consequences, mainly: some teens need help, and are unable, or unwilling, to ask for it, and it's up to the "parent+counselor" or "parent+MD" to work together to help these kids out, and HIPPA is often used like a weapon to prohibit any exchange of information about the teen, thereby preventing necessary medical or psychological support.

It often acts as a barrier between parents and the people involved in providing healthcare to our teens (which is exactly what the law intends to do).

Bariatric Surgery (With A Focus on Teen and Adolescent Care)

There was a recent article on NPR on the pros, cons, and risks of teens seeking bariatric surgery[1]. It highlighted some very important aspects of the surgery, mainly: the evaluation process that happens prior to surgery to determine if a given teen is sufficiently mentally healthy to undergo the surgery (and understand, and be able to live with, it's long-term effects).

Here are four relevant excerpts from the audio, along with the related text from the article itself:

Excerpt #1:

[2:02] Skeptics like UCLA surgeon Edward Livingston worry kids can't understand the lifelong implications. He advises parents "let them wait until they can make their own decision".

Here's the corresponding text of the article:

"Skeptics like University of California, Los Angeles surgeon Edward Livingston worry that children aren't old enough to understand its lifelong implications. Livingston says he formed this view based on his own limited experience in the 1990s performing the surgery on teenagers."
"Only a small percentage of children, he says, are sick enough to require the surgery for dire medical reasons. And, he notes, new medications and others in development can be highly effective. So Livingston advises parents: "Let them wait until they can make their own decision.""

Excerpt #2:

[2:15] Complications are also a concern. Those can include infection or tearing, or malnutrition, or weight re-gain in the longer term.

And the corresponding text of the article:

"Medical complications are also a concern. Shorter-term problems like infection or tearing can prompt hospital readmission for between 5% and 7% of patients within a month of surgery. Long-term effects like malnutrition or weight regain must be managed with extensive dietary and lifestyle changes, including taking daily vitamins."

Excerpt #3:

[2:27] Harvard obesity specialist Fatima Cody Standford says surgery is typically a families last choice. For example, one boy she met at 13 faced liver failure from obesity. "The mom and him were adamant against any surgical intervention". For two years, her tried medications and exercise and made no progress. Only now are they open to surgery.

(The article text is exactly the same as the audio)

Excerpt #4: And last but not least, the most important excerpt:

[5:02] Rigorous mental health evaluations prior to surgery is the recommended standard. Teens must prove they can commit to the permanent changes and lifestyle and nutrition necessary after surgery. They must also be emotionally stable enough to handle such big life changes.

And the text is highly germane here:

"A child's mental health is a huge part of the pre-surgical evaluation, which usually lasts at least six months and is lengthier and more involved for teens than adults. Patients must prove they're mature enough to understand and commit to the permanent changes in lifestyle and nutrition necessary after surgery — as well as understand the health consequences of not abiding by those."

So What's the Point?

The point is that this all seems pretty reasonable to me, ethically and procedurally. It meets my definition of a "societally responsible response [to childhood obesity]". Note that the parents and medical professionals involved in these decisions:

Note that nobody is saying "No", they're more saying "This is risky, so let's try to do a good job as stewards of your physical and mental health".

(Note that I didn't agree with everything in the article[2].)

Now Compare This to Gender-Affirming Medical Care

The medical care I'm focused on here is both hormone therapy (puberty blockers and testosterone) as well as surgical interventions (e.g.: to reduce a person’s Adam’s Apple, or to align their chest or genitalia with their gender identity).

I think a quick examination of any potential barriers to this care, keeping in mind the barriers to bariatric surgery, will be illustrative of my point.


Is There Potential Parental Push-Back?

In short: No (see "Background" section above). In WA State, the age of medical consent is 13, and in Oregon, it's 15. The age of medical consent varies on a state by state basis (with no standard), but it's well understood that 13-year olds in WA State do not require parental permission to seek medical care (including gender-affirming care).


Is There Potential Psychiatrist Push-Back?

In short: No. In WA State, "conversion therapy" is strictly prohibited (as it probably should be), but the problem is that it's applied incredibly broadly, and includes self-diagnosed GD / ROGD.

E.g.: If a teen goes to a psychiatrist with a self-diagnosis of gender dysphoria, and the psychiatrist [quite ethically and quite rightfully] says something like:
"I can see you have a very high level of anxiety, and depression, and you mentioned possibly being on the autism spectrum (ASD) .. I have some mental-health concerns I would like to address, and so we're going to put gender dysphoria on the back-burner for now, as it's not the most likely explanation for what you're feeling"
... well, that doctor could lose their license (even if their diagnosis is correct).

The mere insinuation that a kid might not be experiencing gender dysphoria is enough for a medical professional to get into serious trouble here in WA State. I know for a fact that there are MDs and mental-health professionals that (a) do not believe a given teen is actually experiencing gender dysphoria while at the same time (b) is providing gender-affirming care to said teen.

I consider that to be highly unethical, but the WA State legislature appears to have tied the hands of the medical community (by effectively criminalizing the pursuit of an accurate diagnosis).


Is There Potential School Push-Back?

Not here in Seattle there isn't. Schools are tripping over themselves to broadcast their LGBTQ+/trans support systems. It's become standard practice for schools to change both the name and the pronouns of students who self-diagnose as having gender dysphoria without communication of any kind with the family[3].

I believe the schools hands are tied here too, but for vastly different reasons[4].


Is There Potential Psychologist Push-Back?

Nope. None here either. These folks are as limited in terms of exploring alternate diagnoses as the psychiatrists. Even when a counselor (a) has insufficient information to know whether a GD diagnosis is accurate or not or (b) doesn't believe their patient is suffering from GD, they are strictly prohibited from exploring alternative diagnoses (as well as strictly prohibited from measuring the veracity of the self-diagnosis)[5].


Is There Potential MD Push-Back?

Same story: not a chance. The medical community is similarly bound by the broadly applied conversion-therapy ban. Not even a whisper that GD is not an accurate diagnosis (while at the same time being obligated to provide gender-affirming care)[6].

I believe this is unethical, both due to the lost opportunity cost of helping treat a teens actual problems, as well as [potentially] applying treatment for a condition that a doctor doesn't believe a teen actually suffers from.

As I mentioned earlier: many doctors are well-aware what's happening, but "talking about it" is a total minefield (talking with the parents, or with the teen, or really with anyone), as it could accidentally articulate the very points I'm trying to make in this post.


So There's No Push-Back: Is There any Pull?

WA State is considered to be a "transgender safe haven state". Overall, this is a good thing. States like Florida are passing all kinds of hateful legislation (which IMO goes way too far in the opposite direction). WA State also recently passed a bill (Senate Bill 5599) that seeks to protect transgender and at-risk youth seeking gender-affirming or reproductive care in WA State.

So yes, there's an incentive to travel to a state like WA State for gender-affirming care[7] (having arrived from another state).

I'd be much more in support of this is we didn't remove any/all barriers to hormone therapy and gender reassignment surgery. In other words, if I thought we were actually being good stewards of the current generation of ROGD girls, instead of allowing them to be victimized. The removal of barriers (like an actual diagnosis) is, overall, harming the current generation of adolescent girls.

It's troubling: from a macro perspective, it seems like the "culture war" aspects of transgender care are the dominant force when states create legislation, and that's why the legislation is so unbelievably polarized (and why neither side is entirely right, and both sides have huge, obvious, systemic flaws). What's overlooked [paradoxically] is the actual healthcare of GD youth.

So Let's Compare and Contrast

In comparing gender-affirming medical interventions to bariatric surgery (both for teens), we now know:

Gender-Affirming Medical Interventions
Is a Diagnosis Required?
Medical Decisions Made By
Psych Eval Required Prior to Intervention
Do the Interventions Have Unknowns?
Are the Interventions Risky?
Do We Understand the Long-Term Effects?

I honestly wonder why we've carved out this exception for gender dysphoria that not only removes the barriers to "gender affirming care", but we've criminalized anyone who might push back on a GD diagnosis.

I also wonder why everyone seems so keen on pushing girls into hormone therapy when so many people are de-transitioning. Nobody who is progressive wants to run the following youtube query: detransition video, but the stories are real (and I suspect: the lawsuits are coming).

Even though the source of the following video is politically conservative (and therefore the video will summarily dismissed by anyone who is progressive), I highly recommend watching Detransition: The Wounds That Won't Heal, to hear that person's story.

If you hate that source, check out this one. It hits on all of my points: self-diagnosis, no prescription to begin hormone treatment, no mental health eval prior to hormone therapy, no doctor involvement, a pathetic eval prior to top surgery approval (30 minutes!!) [top surgery is a big deal], later regrets their transition when they hit their 20s, detransitioning now, etc.

Or check out Sweden's U-Turn on Trans Kids: The Trans Train (Part 1): The New Patient Group & Regretters. It's an incredibly informative video. Here's the summary from YouTube:

In May of 2021 Sweden announced a change of their policy regarding the medical and surgical transition of children. The change came in the wake of several bombshell documentaries which explored the issue of medicalization of children experiencing gender dysphoria in Sweden and Europe.
The controversial documentary series examined the evidence base of the protocols, the ethics of treating children who cannot consent and the degree of oversight and accountability that clinics held for their patients.

We're effectively allowing a whole generation of young women to be railroaded into [yet another[8]] grand social experiment that can have serious, long-term, unintended consequences, instead of being excellent stewards of their mental and physical health.

It's not transphobic to wish for the best possible health outcomes for our teens. As parents, we're ethically obligated to do so.


[1] Bariatric surgery, also called weight loss surgery, is a category of surgical operations intended to help people with obesity lose weight. It includes such procedures as gastric sleeve, gastric bypass surgery, and stomach intestinal pylorus sparing surgery.

[2] I found one part of the article to be particularly absurd in terms of how misleading it is. Here it is:

[3:30] She knows obesity is driven by factors like genetics or environment that are not in a child or parents control.

This seems breathtakingly disingenuous. As a parent of young kids, I was responsible for what they put into their bodies, and I made sure we never had soft drinks, or candy, or high-glycemic carbs available ... you know: the very things that are driving the obesity epidemic.
We know what's driving the obesity epidemic, and to say that obesity is wholly, if not entirely, out of the control of the people involved is both patronizing and misguided.

[3] Personally, I don't want anything to change here, other than being informed of the change. It feels very "us vs. them" to have this all going on while keeping families in the dark ... it's almost like we're (the parents) are assumed to be very bad, judgmental people and the school should therefore protect the students from us.

[4] I believe schools are under enormous pressure to "go with the flow" here, mostly due to the bullying and aggressive nature of the cancel culture that surrounds all things GD. Think about it for a moment: say a school doesn't get 100% behind in support of a kids self-diagnosis of GD, all it will take is one Twitter or Facebook callout to go viral for the school to suffer irreversible harm to it's reputation (similar to how nearly anyone and everyone who has been deemed "critical" or "unsupportive" of the TG zeitgeist has suffered great reputational harm).

[5] FWIW: The philosophy that's been adopted across vast swarths of the American medical system is called "Affirmative Care", which means your doctor is being persuaded to affirm your self-diagnosis. In the case of ROGD, your doctor is effectively your life coach, not your MD.

[6] And I'm not a doctor, but I can imagine it's a bit irritating to be relegated to the role of "life coach" after all of those years of med school.

[7] And to quote Kurt Cobain, if you are actually transgender "Come as you are", and we'll help you out. People who are legitimately transgender (estimated at approx 0.01% of the population, or 1 in 10,000) deserve ethical, skilled gender-affirming medical care and have a right to be free from persecution for their decision to transition. I'm glad WA State is a safe-haven in this area (and in others).

[8] Satanic panic, borne out of the misguided Recovered-Memory Therapy era of the 1980s.