From: Sent: To: Cc: Paul Hruz 1/28/2020 9:21:01 AM "Laidlaw Michael" <mike@drlaidlaw.com>, "Andre Van Mol" <95andrev@gmail.com> "Deutsch Fred" <fred.deutsch@sdlegislature.gov>, "Lappert Patrick" <patrick@lappertplasticsurgery.com>, "Bernard Hudson, MD" <loyolamd82@gmail.com>, "Shupe Jamie" <jamie.shupe@yahoo.com>, "QUENTIN VAN METER" <kidendo@comcast.net>, "Natasha Chart" <natasha.chart@gmail.com>, "Vernadette Broyles" <vbroyles@childparentrights.org>, "Mary McAlister" <mmcalister@childparentrights.org>, "Cretella Michelle" <drmcretella@gmail.com>, "Katherine Cave" <kelseycoalition@gmail.com>, "David Pickup" <davidpickuplmft@gmail.com>, "Eunie Smith" <alaeagle@charter.net>, "McCaleb Gary" <mccgsm@gmail.com>, "Glenn Ridder" <glenn.ridder@outlook.com>, "Horvath Hacsi" <birdcatcher9@yahoo.com>, "Robbins Jane" <rlrobb123@gmail.com>, "Margaret Clarke" <margaretclarke317@icloud.com>, "Sharp Matt" <msharp@adflegal.org>, "McHugh Paul" <pmchugh1@jhmi.edu>, "Monique Robles MD" <pamosa27@comcast.net>, "Mast Richard" <rmast@lc.org>, "Brooks Roger" <rbrooks@adflegal.org>, "Timothy Millea MD" <tmillea@qcora.com>, "Heyer Walt" <waltsbook@yahoo.com>, "William Malone" <malone.will@gmail.com>, "Shafer Jeff" <jshafer@adflegal.org>, "Chris Motz" <cmotz@sdcatholicconference.org>, "Jon Hansen" <jon.hansen@sdlegislature.gov> Subject: Re: Comment on Turban PB paper FYI: We submitted an online comment to Pediatrics a few days ago (necessary prelude to consideration for publishing "letter to editor") pointing out the problems with the most recent Turban et al study claiming Pubertal blockade saves lives. According to the journal, it will take up to 3 days for them to decide whether or not to post. Still waiting... Here is the text of our comments: Suicidality in Gender Dysphoric Youth Offered Pubertal Blockade Remains Alarmingly High Paul W. Hruz, Lawrence S. Mayer and Walter R. Schumm The article by Turban et al.1 is being widely interpreted as providing evidence that GnRH agonists are beneficial in preventing suicide in transgender youth. This includes an accompanying AAP news article2. This conclusion is not warranted from the article. While the authors acknowledge that, as a cross-sectional study, their data cannot establish causal relationship between pubertal blockade and suicidality, they fail to emphasize that those who received puberty blockade, and those that did not, both had alarmingly high rates of suicidal ideation (50% or higher) within the last year, rates strikingly similar to those previously reported for transgender adults3. There was no difference between the study groups when comparing a more robust measure of suicidal risk: ideation with a plan. Furthermore, those receiving GnRH agonists had higher rates of hospitalization for suicide attempts when compared to those not receiving this medication. The argument that there was a lack of statistical power is an assumed explanation for these effects, and is often used by scientists when their hypothesis is not supported by the data. An equally plausible explanation is that suicidal risk is almost independent of taking GnRH agonists because pubertal blockade fails to address important cooccurring psychological issues. The study has several methodological weaknesses. Community-based samples of patients identifying as transgender are rife with ascertainment biases. Gender dysphoric youth who do not identify as transgender later in life are not in the sample. The influence of pubertal blockade on their identity and suicidality are not considered. It is not surprising that patients who identify as transgender later in life value an intervention that supported their early identification and that patients that desired but did not receive that intervention over-estimate its value. The most meaningful comparison should be between patients that receive the intervention and those that do not regardless of whether the treatment was offered and regardless of whether they identify as transgender later in life. Secondly, since gender dysphoria experienced by these patients is influenced by a myriad of factors, it is misleading to base conclusions about the benefit of receiving GnRH agonist on any univariate analyses. To achieve reliable conclusions on suicide risk, more complex modeling assessing multiple interrelated contributors is required. Notably, all but one of the univariate results is non-significant when controlling for but a few background factors. Although the odds ratio for lifetime suicidality remains significant, the Pearson correlation is surprisingly small, < .08, yielding a very small effect size (Cohen's d < .20) and does not assess current or future suicide risk. Thus, from this survey it is an unjustifiable stretch to conclude, or even suggest, that for gender dysphoric youth, pubertal blockade is a lifesaving intervention. The observed outcomes for young adults who experience a gender identity that is discordant with biological sex leads to serious concerns about the long-term efficacy of puberty blockade. Further research into this complex and poorly understood population is needed. Until this research is published caution is required in recommending GnRH agonists to alter the natural course of puberty. 1. Turban et al. Pubertal Suppression for Transgender Youth and Risk of Suicidal Ideation. Pediatrics. Jan. 23, 2020, https://doi.org/10.1542/peds.2019-1725) 2. Jenco, Blocking puberty in transgender teens linked to lower likelihood of suicidal thoughts. AAP News January 23, 2020. https://www.aappublications.org/news/2020/01/23/pubertysuppression012320 3. Adams, Hitomi & Moody, Varied Reports of Adult Suicidality: Synthesizing and Describing the Peer-Reviewed and Gray Literature. Transgender Health 2.1:60-75, 2017 On Monday, January 27, 2020, 11:02:09 AM CST, Andre Van Mol <95andrev@gmail.com> wrote: For suicides attempts and hospitalization after hormonal therapy, the 2019 Branstrom study from Sweden (by way of Yale, naturally) also showed no improvement (they claimed it for SRS/GAS, but actually failed to show it credibly). Me, Mike, Miriam and Paul McHugh (lotta’ M’s there) have a letter to the editor of AJP criticizing the study that is going through peer review now. Mike pretty much hit it out of the park with his answer to the 7 Qs. Andre On Jan 27, 2020, at 6:21 AM, Michael Laidlaw <mike@drlaidlaw.com> wrote: Here are my thoughts on those items, Fred: 1. Suicide rates go up Kids who are suicidal need competent mental health care, not sterilization. The largest study tracking transgender people encompassed the entire population of Sweden over a 30 year period and showed that hormones and sex reassignment surgery still left people at a 19X higher risk of completed suicide compared to then general population. The U.K.'s Tavistock GIDS clinic showed that children on blockers reported GREATER self-harm. Girls reported MORE behavioral and emotional problems, greater dissatisfaction with body. The latest survey study being touted by the mainstream media [by J Turban] actually shows that puberty blocker use did NOT reduce the risk of inpatient hospitalization for suicide attempts. 2. Impact economy [I'll leave this to the econ people] 3. Interferes with doctor-patient relationship Not everything is permissible within a doctor-patient relationship. The doctor does not have a right to harm a patient. A proper doctor-patient relationship involves full disclosure of the risks and benefits of a therapy. If the child cannot fully understand the harms of therapy such as sterilization and removal of healthy body parts, then the child is a part of an unhealthy doctorpatient relationship and the state MUST intervene to prevent harms. 4. Interferes with parental rights The parent also does not have the right to participate in the harm of their child. The parent is relying on medical evidence that has been rated as low, very low and no quality evidence in the 2017 Endocrine Society guidelines. The Endocrine Society guidelines in their disclaimer on p. 3895 states clearly that these treatments are NOT standards of care. The state must intervene to prevent parents from inadvertently participating in the harm of their child because they have received incomplete information on a poorly researched subject. 5. Parents must give consent – therefore it should be the parent held responsible, not the doctor The parent provides consent based on a good faith assumption that the doctors are providing the best care possible and have properly weighed the risks and benefits of treatment. However, the harms that come to a child (e.g. sterilization, permanent disfiguration, heart disease risk, osteoporosis risk, etc.) are the primary result of physicians who have performed the surgeries or given these medications. Only the doctor can truly comprehend the potential scope of injury, and only they are licensed by the state to prescribe and perform these procedures. It is not the job of the parent to investigate any and all potential harms of a medication or procedure. It is the duty of a licensed physician. Therefore the culpability for harms to a patient, falls on the doctor. [Perhaps, similar to a medical malpractice suit]. 6. PB are reversible The effects of Puberty Blockers are NOT reversible. The important time lost for normal development can never be regained. A key period of bone strengthening is affected putting the child at risk for adult osteoporosis. A key period of brain development is affected, and many of the risks are unknown because they have not been studied. The U.K.'s Tavistock GIDS clinic showed that children on blockers reported GREATER self-harm. Girls reported MORE behavioral and emotional problems, greater dissatisfaction with body. Also a key time of growing together and interacting with peers and reaching important psychosocial milestones is lost forever. An analogy: Just imagine you've taken your child out of 6th grade for the entire year. Is the time lost reversible? If you put them back in sixth grade, are they not in class with a bunch of students who are developmentally younger than they? Can the time lost studying ever be regained? Will the child not be at a disadvantage trying to catch up to the next grade? Can the important sixth grade experiences with peers ever be the same? 7. Bill is unconstitutional [Will leave to attorneys and legislators] -Mike On 2020-01-27 03:55, patrick Lappert wrote: I think one has to be prepared to dismantle the validity of the WPATH guidelines: -Where WPATH came from -How the guidelines were crafted -How they are ignored, even by adherents. PWL On January 26, 2020 at 11:28 PM Andre Van Mol <95andrev@gmail.com> wrote: Those are the stats I've seen as well. So take away the medical students and residents, and the AMA really isn't the A-MA. As for it and the others, they are all professional guilds and susceptible to political/ideological/financial manipulation. They are not scientific organizations, and people don't seem to get that. Andre On Jan 26, 2020, at 6:50 PM, Bernard Hudson < loyolamd82@gmail.com> wrote: AMA membership hovers less than 20% of licensed physicians, actually about 17% of physicians and medical students. Decades ago, 3/4 of licensed doctors were members. The AMA movement towards accepting doctors killing patients, and infants are patients, has destroyed the membership over the decades. The issue will be that a physician is not a consensus doctor if not abiding by AMA affirmation guidelines. In Tampa, August 2019, the opposing attorneys wrote: "Dr. Hudson is not a consensus physician and clearly harms children." Although they lost the case, gutting all of Florida's affirmation guidelines, they included 13 medical and psychological organizations including, My God Yes!, the American High School Counselors Association! Accept this approach as typical. BH On Jan 26, 2020, at 6:44 PM, James Shupe (Formerly Jamie Shupe) < jamie.shupe@yahoo.com> wrote: That you're going against the advice of the American Medical Association and WPATH, etc. Note: This email chain had Kara Dansky and Greg Scott, please remove them if you respond. James On Sunday, January 26, 2020, 07:39:39 PM EST, Fred Deutsch < fred.deutsch@sdlegislature.gov> wrote: Brainstorming idea for objections to bill. Others that you think I should prepare for in addition claims that: Brainstorming idea for objections to bill. Others that you think I should prepare for in addition claims that: Suicide rates go up Impact economy Interferes with doctor-patient relationship Interferes with parental rights Parents must give consent – therefore it should be the parent held responsible, not the doctor PB are reversable Bill is unconstitutional Patrick W. Lappert, MD 8263 Madison Blvd. Suite E Madison, AL 35758