What's Going On In Florida: An Update And How To Speak Up

The Florida Board of Medicine and the Board of Osteopathic Medicine met on November 4, 2022 and formally approved the wording of rule changes that would prohibit providing gender affirming care to minors in the state. An open comment period is required from now until December 5, 2022. It is not clear when the next meeting of the joint boards where they will adopt the rules will be. We urge you to submit a comment in support of gender affirming care for youth. We have included a suggested template below.

The proposed changes are:

• Florida youth under age 18 will not be able to start gender affirming care, including blockers or hormones
• Any surgical procedures which alter primary or secondary sexual characteristics will be prohibited as treatment for gender dysphoria
• Florida youth already receiving blockers, hormones, or hormone antagonists at the time the rules are enacted will be able to continue care.
• Providers who violate these rules risk removal of their Florida medical license

The two boards diverged in allowing a research exemption.  The Florida Board of Medicine voted to exclude the research exemption.  This means that Florida MDs will not be able to start any minors on gender affirming care.

The Florida board of Osteopathic Medicine voted to retain the research exclusion.  Florida DOs will be able to provide gender affirming care to minors enrolled in an IRB-approved research study.

This discrepancy in rules may mean that an additional hearing will be required within the next 21 days.

We will update our blog and social media as we learn more. We’ll also be sharing the letter that our founder and CEO, Dr. Crystal Beal, is writing to the Florida Board of Medicine.

We are still treating youth in Florida.

You may submit a comment on the rules change here.

For people who like to see the link: https://www.flrules.org/Gateway/View_notice.asp?id=26536986

Below is our suggested comment text. You are welcome to use it as a template, and we encourage you to add personal details instead of the text that we’ve marked in lavender. If you choose to write your own text, it is important to keep comments direct, factual, courteous, specific, and constructive. Make sure your comment includes who you are, why this issue matters, how this ruling will impact you, and what you want them to do about it.

Know that if you submit a comment, it, and the identifying information that you provide (such as your name and email address) will become part of the public record. You can submit using a fake name.

To the Florida Boards of Medicine and Osteopathic Medicine,

I am a <describe your primary association with gender affirming care for youth and/or Florida (bonus points for being a Florida resident.>

I am writing to strongly condemn the Florida Board of Medicine’s proposed rule on practice standards for the treatment of gender dysphoria (64BS-9.019 Standards of Practice for the Treatment of Gender Dysphoria in Minors).

The rule draft as written is not based on the current standards of care for transgender youth as agreed upon by the majority of the relevant medical and professional organizations

• American Academy of Pediatrics
• The Endocrine Society
• The Pediatric Endocrine Society
• American Academy of Child and Adolescent Psychiatry
• American Academy of Family Physicians
• American College of Obstetricians and Gynecologists
• American College of Physicians
• American Medical Association
• American Osteopathic Association
• American Psychiatric Association
• American Public Health Association
• World Professional Association For Transgender Health

In addition, the body of evidence supporting gender affirming care for youth with gender dysphoria is strong and growing:

• Tordoff, D. M., Wanta, J. W., Collin, A., Stephney, C., Inwards-Breland, D. J., Ahrens, K. (2022) Mental Health Outcomes in Transgender and Nonbinary Youths Receiving iGender-Affirming Care. JAMA Network Open, 5(2), e220978.
• Turban, J. L., King, D., Kobe, J., Reisner, S. L., & Keuroghlian, A. S. (2022). Access to gender-affirming hormones during adolescence and mental health outcomes among transgender adults. PLOS ONE, 17(1), e0261039. https://doi.org/10.1371/journal.pone.0261039
• Carmichael, P., Butler, G., Masic, U., Cole, T. J., De Stavola, B. L., Davidson, S., Skageberg, E. M., Khadr, S., & Viner, R. M. (2021). Short-term outcomes of pubertal suppression in a selected cohort of 12 to 15 year old young people with persistent gender dysphoria in the UK. PLOS ONE, 16(2), e0243894. https://doi.org/10.1371/journal.pone.0243894
• Grannis C, Leibowitz SF, Gahn S, Nahata L, Morningstar M, Mattson WI, Chen D, Strang JF, Nelson EE. Testosterone treatment, internalizing symptoms, and body image dissatisfaction in transgender boys. Psychoneuroendocrinology. 2021 Oct;132:105358. doi: 10.1016/j.psyneuen.2021.105358. Epub 2021 Jul 17. PMID: 34333318.
• Green, A. E., DeChants, J. P., Price, M. N., & Davis, C. K. (2021). Association of gender-affirming hormone therapy with depression, thoughts of suicide, and attempted suicide among transgender and nonbinary youth. Journal of Adolescent Health.
• Nieder TO, Mayer TK, Hinz S, Fahrenkrug S, Herrmann L, Becker-Hebly I. Individual Treatment Progress Predicts Satisfaction With Transition-Related Care for Youth With Gender Dysphoria: A Prospective Clinical Cohort Study. J Sex Med. 2021 Mar;18(3):632-645. doi: 10.1016/j.jsxm.2020.12.010. Epub 2021 Feb 26. PMID: 33642235.
• Turban JL, King D, Carswell JM, Keuroghlian AS. Pubertal Suppression for Transgender Youth and Risk of Suicidal Ideation [published correction appears in Pediatrics. 2021 Apr;147(4):]. Pediatrics. 2020;145(2):e20191725. doi:10.1542/peds.2019-1725
• Achille, C., Taggart, T., Eaton, N. R., Osipoff, J., Tafuri, K., Lane, A., & Wilson, T. A. (2020). Longitudinal impact of gender-affirming endocrine intervention on the mental health and well-being of transgender youths: preliminary results. International Journal of Pediatric Endocrinology, 2020(1), 1-5.
• Becker-Hebly I, Fahrenkrug S, Campion F, Richter-Appelt H, Schulte-Markwort M, Barkmann C. Psychosocial health in adolescents and young adults with gender dysphoria before and after gender-affirming medical interventions: a descriptive study from the Hamburg Gender Identity Service. Eur Child Adolesc Psychiatry. 2021 Nov;30(11):1755-1767. doi: 10.1007/s00787-020-01640-2. Epub 2020 Sep 29. PMID: 32990772.
• de Lara, D. L., Rodríguez, O. P., Flores, I. C., Masa, J. L. P., Campos-Muñoz, L., Hernández, M. C., & Amador, J. T. R. (2020). Psychosocial assessment in transgender adolescents. Anales de Pediatría (English Edition), 93(1), 41-48.
• Anna I.R. van der Miesen, Thomas D. Steensma, Annelou L.C. de Vries, Henny Bos, Arne Popma,
• Psychological Functioning in Transgender Adolescents Before and After Gender-Affirmative Care Compared With Cisgender General Population Peers, Journal of Adolescent Health, Volume 66, Issue 6,
• 2020, Pages 699-704, ISSN 1054-139X, https://doi.org/10.1016/j.jadohealth.2019.12.018.
• Hodax JK, Wagner J, Sackett-Taylor AC, Rafferty J, Forcier M. Medical Options for Care of Gender Diverse and Transgender Youth. J Pediatr Adolesc Gynecol. 2020 Feb;33(1):3-9. doi: 10.1016/j.jpag.2019.05.010. Epub 2019 May 30. PMID: 31154017.
• Kaltiala, R., Heino, E., Työläjärvi, M., & Suomalainen, L. (2020). Adolescent development and psychosocial functioning after starting cross-sex hormones for gender dysphoria. Nordic Journal of Psychiatry, 74(3), 213-219.
• Kuper, L. , L. E., Stewart, S., Preston, S., Lau, M., & Lopez, X. (2020). Body dissatisfaction and mental health outcomes of youth on gender-affirming hormone therapy. Pediatrics, 145(4).
• Allen, L. R., Watson, L. B., Egan, A. M., & Moser, C. N. (2019). Well-being and suicidality among transgender youth after gender-affirming hormones. Clinical Practice in Pediatric Psychology, 7(3), 302.
• Kimberly LL, Folkers KM, Friesen P, Sultan D, Quinn GP, Bateman-House A, Parent B, Konnoth C, Janssen A, Shah LD, Bluebond-Langner R, Salas-Humara C. Ethical Issues in Gender-Affirming Care for Youth. Pediatrics. 2018 Dec;142(6):e20181537. doi: 10.1542/peds.2018-1537. Epub 2018 Nov 6. PMID: 30401789.
• Wiepjes CM, Nota NM, de Blok CJM, et al. The Amsterdam Cohort of Gender Dysphoria Study (1972-2015): trends in prevalence, treatment, and regrets. J Sex Med. 2018;15(4):582-590.
• Simone Mahfouda, Julia K Moore, Aris Siafarikas, Florian D Zepf, Ashleigh Lin, Puberty suppression in transgender children and adolescents, The Lancet Diabetes & Endocrinology, Volume 5, Issue 10, 2017, Pages 816-826, ISSN 2213-8587, https://doi.org/10.1016/S2213-8587(17)30099-2
• Costa R, Dunsford M, Skagerberg E, Holt V, Carmichael P, Colizzi M. Psychological Support, Puberty Suppression, and Psychosocial Functioning in Adolescents with Gender Dysphoria. J Sex Med. 2015 Nov;12(11):2206-14. doi: 10.1111/jsm.13034. Epub 2015 Nov 9. PMID: 26556015.
• De Vries, A. L., McGuire, J. K., Steensma, T. D., Wagenaar, E. C., Doreleijers, T. A., & Cohen-Kettenis, P. T. (2014). Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics, 134(4), 696-704.
• de Vries AL, Steensma TD, Doreleijers TA, Cohen-Kettenis PT. Puberty suppression in adolescents with gender identity disorder: a prospective follow-up study. J Sex Med. 2011 Aug;8(8):2276-83. doi: 10.1111/j.1743-6109.2010.01943.x. Epub 2010 Jul 14. PMID: 20646177.

The proposed rule changes to prohibit initiation of gender affirming care, including the use of blockers, hormones, and/or medical procedures will harm Florida youth. It is in opposition to existing guidelines and clinical knowledge. 29 major medical organizations have statements indicating gender affirming care is medically necessary.

< insert statement of your work or personal experience with gender affirming care for youth >

I urge you to vote against the adoption of Rules 64B8-9.019 & 64B15-14.014 at the December 2nd, 2022 meeting.

Thank you.

Below is Dr. Beal’s personal response:

This letter to the medical board has been submitted to their public commentary regarding rule 64BS-9.019 Standards of Practice for the Treatment of Gender Dysphoria in Minors

To the Florida Medical Board:

My name is Crystal. I was born and raised in Tallahassee, FL, and I had the privilege of attending medical school at Florida State University College of Medicine. At FSUCOM, I was taught the principles I was expected to uphold as a physician:

• Beneficence
• Non-maleficence   
• Autonomy
• Justice

I learned that beneficence was my duty to act for the benefit of the patient¹. I was taught that non-maleficence meant to do no harm to the patient, which includes not depriving others of the goods of life, that the practical application of non-maleficence is for me to weigh the benefits against burdens of all interventions and treatments, to eschew those that are inappropriately burdensome, and to choose the best course of action for the individual patient in front of me¹. FSUCOM taught me that all persons have intrinsic and unconditional worth and, therefore, should have the power to make rational decisions and moral choices, and each should be allowed to exercise their capacity for self-determination as the concept of autonomy¹. Lastly, FSUCOM helped me learn about justice as the fair, equitable, and appropriate treatment of all persons¹. FSUCOM also centered shared decision-making and patient-centered care, which are well-respected models of care supported by SAMSHA, CMS, AHRQ, and the AMA, to name a few.

FSUCOM trained me well. I am forever grateful for my time there and my education. I am now a Board Certified Family Medicine physician with four full state licenses and a Florida telemedicine license. I speak from a place of significant training and practice experience when I say how disappointed I am with you, the physicians of the Florida Medical Board. By drafting rule 64BS-9.019 Standards of Practice for the Treatment of Gender Dysphoria in Minors, you have violated your oath to do no harm and acted against the principles of medical ethics we all hold dear. You have removed the ability for physicians to center their patients in care and have disallowed shared decision-making.

In perusing the rules of the Florida Medical Board, the vast majority of them follow national standards of care or thorough clinical reasoning, so I am at a loss to understand how you arrived at 64BS-9.019 Standards of Practice for the Treatment of Gender Dysphoria in Minors–except that you were appointed by the Governor–which leads me to believe you have active personal political aspirations or ideological bias that have clouded your clinical judgment despite the statement that you are apolitical bodies who set aside personal feelings. This seems to be the only rationale that explains your choice to ignore the 29 major medical associations which have policy statements indicating the medical necessity of gender affirming care. These 29 associations are well-respected organizations with long histories and prolific memberships, including yourselves. They have published guidelines in other areas of care that constitute national standards of care, such as the Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents or Management of Newly Diagnosed Type 2 Diabetes Mellitus (T2DM) in Children and Adolescents. These organizations include, but are not limited to, the:

• American College of Physicians
  • Founded: January 8, 1915
  • Number of members: 160,000
• American Medical Association
  • Founded: May 7, 1847
  • Number of members: 240,359 as of 2016
• American Osteopathic Association
  • Founded: April 19, 1897
  • Number of members: more than 168,000
• American Psychiatric Association
  • Founded: October 16, 1844
  • Number of members: 37,400
• American Academy of Pediatrics
  • Founded: 1930
  • Number of members: 67,000
• The Endocrine Society
  • Founded: 1916
  • Number of members: over 18,000
• The Pediatric Endocrine Society
  • Founded: 1972
  • Number of members: 1,500
• American Public Health Association
  • Founded: 1872
  • Number of members: 25,000
• American Academy of Child and Adolescent Psychiatry
  • Founded: 1953
  • Number of members: more than 10,000
• American Academy of Family Physicians
  • Founded: 1947
  • Number of members: 127,600
• American Academy of Pediatrics
  • Founded: 1930
  • Number of members: 67,000
• American College of Obstetricians and Gynecologists
  • Founded: 1951
  • Number of members: 60,0000.

The medical organizations stating opposition to gender affirming care are small organizations with limited membership and history, including

• American College of Pediatricians
  • Founded: 2002
  • Number of members: 500
• American Association of Physicians and Surgeons
  • Founded: 1947
  • Number of members: 5,000.

They have no publications that are widely read nor treatment guidelines that have been adopted as national standards of care. 

Further, you have seemingly forgotten how to assess the evidence yourself. The current body of evidence indicates that the benefits of medical gender affirming care for youth who meet the criteria for gender dysphoria and desire medical intervention outweigh the risks. When you combine the numbers of individuals studied, it totals over 10s of thousands of subjects. Here is a summary of some of these studies to make the evidence easier to parse:

• A 2021 meta-analysis of 9 qualifying studies (one which was considered “excellent” quality, five considered “good”) on the effects of GnRHa found that the common benefits among them were decreased suicidality in adulthood, improved affect and psychological functioning, and improved social life³.
• A comprehensive literature review of 16 studies examining the benefits of puberty blockers and gender-affirming hormones in trans youth revealed that 13 of the 16 showed blockers and hormones resulted in statistically significant improvements in mental health, and none of them showed a decline. Two of these three studies found an improvement but did not reach the level of statistical significance due to small sample sizes⁴. 
• To be clear, the current literature suggests that access to gender affirming medical care is LIFE-SAVING. This is supported in many of the policy statements of the 29 aforementioned medical organizations.

The current evidence is so overwhelmingly positive that no Institutional Review Board is likely to allow randomized controlled studies in gender affirming care as mentioned in the proceedings. Almost, if not all, IRBs, would find non-treatment unethical based on the current body of existing literature in the field of youth gender affirming medical care, which was made clear by Dr. Meredithe McNamara, Assistant Professor of Pediatrics, Yale Medicine. As to the concern that youth gender affirming care is experimental, not even the district court of Alabama could find evidence of such. In May of this year, Judge Liles Burke enjoined a prohibition on puberty blockers, hormones, and hormone antagonists, stating, “Defendants produce no credible evidence to show that transitioning medications are ‘experimental.’ While Defendants offer some evidence that transitioning medications pose certain risks, the uncontradicted record evidence is that at least twenty-two major medical associations in the United States endorse transitioning medications as well-established, evidence-based treatments for gender dysphoria in minors.” Furthermore, Judge Burke stated that “there is a substantial likelihood that Section 4(a)(1)-(3) of the Act is unconstitutional.” (Eknes-Tucker v. Marshall, 2:22-cv-184-LCB: M.D. Ala. May. 13, 2022)

Dr. Patrick Hunter and other members of the board have referred to Dr. Micheal Biggs’ body of work in their rationale for removing youth access to gender affirming care in Florida. The studies cited for this reasoning have been misinterpreted, misquoted, or presented low-quality evidence. Dr. Micheal Biggs indicates that puberty blockers were first studied in 2010; however, they were first used in 1988 for treating gender dysphoria, and studies began before 2010. He also indicates that the Dutch trials did not publish any follow-up of their original cohort, which is again inaccurate. In 2014 they published “Young adult psychological outcome after puberty suppression and gender reassignment,” which indicates that “after gender reassignment, in young adulthood, the gender dysphoria was alleviated and psychological functioning had steadily improved. Well-being was similar to or better than same-age young adults from the general population. Improvements in psychological functioning were positively correlated with postsurgical subjective well-being.”⁵ Further, the Dutch clinic published a review of 6,793 patients seen at their clinic from 1972-2015 (95% of the gender care done in the Netherlands,) which found only 0.6% of transwomen and 0.3% of transmen who underwent gonadectomy were identified as experiencing regret⁶. 

Let it also be clear that Dr. Biggs has no co-authors on his work⁷ and his home institution is currently investigating complaints made against him, according to the Oxford student paper. He indicates risk to bone mineral density with GnRH agonists, which are not unsimilar to issues with BMD seen in the use of Depo-Provera. This contraceptive option is included in standard practice for adolescents in Florida. Similar to Depo-Provera treatment, BMD recovers after discontinuation of GnRH agonists or with the administration of hormones to levels appropriate for current gender identity (in this publication, they compare patients administered estradiol to cis boys scores which provides context for the lower zscores seen in transgirls)⁸. He indicates his concern for sexual satisfaction and orgasm in which there have been some published findings, despite his report that there have not. Early GAT (including puberty suppression, affirmative hormones, and surgeries) may provide young transgender adults with the opportunity to increase their romantic and sexual experiences^{9, 10}. Dr. Briggs states that no research has been completed on the cognitive effects of GnRH agonists in gender-diverse youth, which is an inaccurate statement. A study looking at Tower of London performance scores suggested that pubertal suppression with GnRH agonists is not associated with a detrimental effect to these scores describing higher-order cognitive process¹¹. A study in patients treated with GnRH agonists for precocious puberty indicated patients treated with GnRH agonists performed similarly in the domains examined, including auditory and visual memory, response inhibition, spatial ability, behavioral 

problems, and social competence¹². Lastly, Briggs indicates that gender care is only offered by the National Health Service as part of a formal study. This restriction to gender affirming care provided by the NHS has not actually been adopted.

Dr. Riittakerttu Kaltiala, who quoted that it is well known that 80-85% of children who experience gender dysphoria “change their mind” upon reaching puberty, misquoted this statistic. This statistic comes from four small studies^{13, 14, 15, 16} with a total study population of 254 youth who meet the now outdated criteria for Gender Identity Disorder from the DSM IV. To be clear, these children would not necessarily meet today’s actively used criteria for gender dysphoria in children. All that was required by the DSMIV was:

Manifestation by four (or more) of the following:

(1) repeatedly stated desire to be, or insistence that he or she is, the other sex

(2) in boys, preference for cross-dressing or simulating female attire; in girls, insistence on wearing only stereotypical masculine clothing

(3) strong and persistent preferences for cross-sex roles in make-believe play or persistent fantasies of being the other sex

(4) intense desire to participate in the stereotypical games and pastimes of the other sex

(5) strong preference for playmates of the other sex

Currently used is the DSM-5-TR defines gender dysphoria in children as a marked incongruence between one’s experienced/expressed gender and assigned gender, lasting at least 6 months, as manifested by at least six of the following (one of which must be the first criterion):

1. A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender)
2. In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing
3. A strong preference for cross-gender roles in make-believe play or fantasy play
4. A strong preference for the toys, games or activities stereotypically used or engaged in by the other gender
5. A strong preference for playmates of the other gender
6. In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities
7. A strong dislike of one’s sexual anatomy
8. A strong desire for the physical sex characteristics that match one’s experienced gender

As with the diagnostic criteria for adolescents and adults, the condition must also be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

These studies are misquoted as they no longer apply to today’s diagnostic criteria or standards of care. The bulk of the children in that study were not transgender but cisgender children who happened to like toys or clothes of the “opposite sex.” As some of your cis female board members have been photographed in pants, they may have been considered gender discordant by that study.

A further body of larger research has indicated that young people who have worsening dysphoria with the onset of puberty have persistence of their transness into adulthood at rates of 96-97.5%^{17, 18, 19, 20}. Further, UK GIC clinicians conducted a records review of 3,398 transgender patients at the Charing Cross, Tavistock, and Portman clinics. They found only two individuals (.06%) who had detransitioned due to regret or deciding that they were not actually transgender²¹. Similarly, a Dutch study of 6,793 patients who medically transitioned found only seven (.1%) regretted transition because they decided they were not transgender⁶. Among those few adolescents who detransition, including those who have undergone hormonal interventions, research indicates that most do not regret having been given the opportunity to explore their gender. A 2021 study of youth who ceased puberty suppression found that many were glad to have had puberty suppression available because it safely offered them time and space to explore their gender identity²². Conversely, approximately 5% of cisgender women who undergo breast reduction experience regret this procedure, and this is considered by plastic surgeons to be an extremely low rate of regret²³.

Additionally, none of our current guidelines or practicing clinicians recommend providing ANY medical interventions until patients are in puberty. There are NO recommended medical interventions for youth diagnosed with gender dysphoria while they are children. Puberty blockers are NOT administered until a patient is IN puberty. It is important to note that very few, if not NONE, of the children quoted 

in the 80-85% or the even higher number quoted by Dr. Laidlaw would have received medical treatment or intervention for their childhood gender exploration. 

Dr. Michael Laidlaw is an internal medicine physician and endocrinologist. Unlike Dr. Meredithe McNamara, Dr. Kristin Dayton, and Dr. Aron Jansen, he is NOT trained to work with a pediatric population. He does not have relevant training or experience in the medical care of patients under the age of 16. He states that the guidelines state to start puberty blockers at Tanner stage two – this is inaccurate. The guidelines state to start puberty blockers NO SOONER than Tanner stage two and that induction of puberty blocker therapy should be individualized past that to the needs of the patient and family seeking treatment. He misrepresents gender affirmative therapy as occurring in four stages. This is entirely inaccurate. According to WPATH SOC8 and the Endocrine Society, gender affirming care is neither universal nor occurs in stages. GAC for youth is a plethora of options available to youths and their families. Each family and youth, together with their care team, choose the options that are appropriate for that individual patient’s goals and values. It is exceedingly rare for a minor to undergo any form of gonadectomy, as most insurance companies and surgeons require an age of 18 for gonadectomy. Further, he states that there are two biological sexes which is surprisingly inaccurate for an endocrinologist to state, as somewhere around 1.5-2% of humans are born with a difference in sex development. Furthermore, hundreds of variations in Mullerian and Wolffian duct development have been documented. The increased rates of health complications and completed suicides in the Swedish study are by most experts in the field considered to be related to minority stress; however, despite those theories, it must be made clear that NO causation can be derived from the Swedish study. Dr. Laidlaw demonstrated charts of testosterone levels relevant to ADULT gender affirming care, not pediatric gender affirming care. He also states the testosterone levels recommended for adults are 6 to 100 times what is recommended for “females.” It is true that the adult cis male testosterone range is 6 to 100 times that of cis females. An expected treatment goal for ADULT transgender patients taking testosterone would be to target a testosterone level averagely seen in cis men, e.g., 6 to 100 times the average levels for cis women. These are not levels we initially target in youth care. Dr. Laidlaw is not trained in pediatric care. Additionally, his use of the term “females” when he means “cis females” is misleading and indicative of bias and his personal belief that trans people do not exist and that their inherent worth and our duty to care for them is to be dismissed.

His overstatement of side effect risks further elucidates this. For example, he indicates infertility as an outcome of treatment; however, we have multiple incidences of patients taking testosterone for gender care and achieving pregnancy²⁵. Further, rates of hepatic injury in people taking hormones for gender care with no other risk factors were found to be 0.6 and 0.4%²⁶. Additionally, the risk of VTE for patients on estradiol for gender affirming care is overstated as it has been found to be more in the range of 2 in 1000 patients treated. He indicates complications associated with gender affirming chest reconstruction with mastectomy, but he OMITS that it is considered a relatively safe procedure, with an all-cause complication rate of 4.7% and a similar risk profile to mastectomy in cisgender men and women²⁷. While some minor patients are able to access gender affirming chest reconstruction, the initial research indicates positive outcomes with self-reported regret near zero^28,29. Further, minor cisgender patients can also access gender affirming chest surgeries such as breast augmentation or gynecomastia chest tissue removal with parental consent. His claims that WPATHSOC8 is a document that is dangerous to youth are unfounded and based on no actual evidence. He then advises that youth be supported with a multidisciplinary approach, which is exactly what WPATHSOC8 recommends. Also, his response to the board member’s question about the permanency of short and long-term complications is erroneous as well. Bone mineral density can be recovered, emotional and cognitive maturity have been shown to be unaffected, and patients often desire body hair and vocal drop. Dr. Laidlaw paints a picture of patients with theoretical risk higher than actual, of side effects that were desired goals of treatment, and does this without clarifying that he had no demonstrated patient consent to talk about their cases.

How do you justify your approval of this rule against the values of medicine you claim to uphold? The existing body of literature and research, which involves 10s of thousands of trans and gender-diverse patients, was dismissed by you in favor of four studies with less than 300 patients, three of which are more than ten years old and one of which is nine years old, and all of which use outdated criteria. The expert witness of three board-certified American physicians specializing in pediatric and adolescent care was thrown out in favor of the testimony of a doctor of sociology from the United Kingdom who has no specific training in pediatric or adolescent medicine, a Finnish adolescent psychiatrist who is NOT eligible for a US medical license, and a board-certified American endocrinologist who has no specific training in pediatric or adolescent medicine as he was trained to work with adult patients only. In crafting and moving this rule forward, you have ignored the medical necessity statements of 29 major medical organizations with over 800,000 members 

and favored the recommendations of two organizations with less than 6000 members. You have made and approved a rule which will further minoritize young transgender and diverse Floridians.  This will lead to an increased risk of suicidal ideation, attempts, and completed deaths. By enacting this rule against the advice of 29 major medical organizations, 800,000 clinicians, and the existing literature, you will have those deaths on your hands. The only explanation is an ideological bias, or you will receive some form of personal benefit from the Governor or his representatives. Because no clinical reasoning or critical thinking is being applied here. 

I am appalled by your actions and believe each of you should have your own personal practice assessed for patient safety and outcomes. Based on this representation of your medical decision-making, I would be terrified to be your patient.

Sincerely,

Crystal Beal, MD

Board Certified Family Medicine Physician

References:

1. Varkey B: Principles of Clinical Ethics and Their Application to Practice. Med Princ Pract 2021;30:17-28. doi: 10.1159/000509119
2. Founding dates and membership rates of medical organizations are taken from each individual organization’s website.
3. Rew, L., Young, C.C., Monge, M. and Bogucka, R. (2021), Review: Puberty blockers for transgender and gender diverse youth—a critical review of the literature. Child Adolesc Ment Health, 26: 3-14. https://doi.org/10.1111/camh.12437
4. Turban, J. (2022 January 24). The Evidence for Trans Youth Gender-Affirming Medical Care. Psychology Today. https://www.psychologytoday.com/us/blog/political-minds/202201/the-evidence-trans-youth-gender-affirming-medical-care 
5. de Vries AL, McGuire JK, Steensma TD, Wagenaar EC, Doreleijers TA, Cohen-Kettenis PT. Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics. 2014 Oct;134(4):696-704. doi: 10.1542/peds.2013-2958. Epub 2014 Sep 8. PMID: 25201798.
6. Wiepjes CM, Nota NM, de Blok CJM, Klaver M, de Vries ALC, Wensing-Kruger SA, de Jongh RT, Bouman MB, Steensma TD, Cohen-Kettenis P, Gooren LJG, Kreukels BPC, den Heijer M. The Amsterdam Cohort of Gender Dysphoria Study (1972-2015): Trends in Prevalence, Treatment, and Regrets. J Sex Med. 
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