Advocates against gender-affirming care for minors testify in North Dakota trial

Two endocrinologists whose testimony has been disputed in other cases testified Friday in defense of North Dakota’s ban on gender-affirming care for minors.

Paul Hruz and Michael Laidlaw are outspoken advocates against using medications like puberty blockers and hormone therapy to treat people with gender dysphoria. They’ve appeared in courtrooms across the country as expert witnesses in legal battles examining the legitimacy of transgender medical care.

North Dakota hired Hruz and Laidlaw to bolster its case in a trial over a 2023 law barring health care professionals from providing gender-affirming care to anyone under 18. 

North Dakota’s ban on transgender care for minors life-threatening, doctor testifies

The lawsuit is brought by Luis Casas, a North Dakota pediatric endocrinologist who says the law is an unconstitutional infringement upon equal protection and personal autonomy rights under the state constitution. He’s bringing the case on behalf of himself, as well as his current and future patients.

On Friday, both Hruz and Laidlaw said they believe doctors like Casas are overselling the safety and effectiveness of using puberty blockers and hormone therapy to treat adolescents with gender dysphoria.

Hruz and Laidlaw said they do not prescribe puberty blockers and hormones for gender-affirming care, since they both believe the practice is unethical.

Attorneys for the plaintiffs questioned why they are holding themselves out as experts on transgender health care if they do not practice it.

Hruz and Laidlaw countered that their testimony is based on their personal experience as endocrinologists, as well as their review of the existing medical research on the subject.

They said their knowledge about how hormones guide growth and development gives them serious reservations about gender-affirming care. They also said that they could not find long-term, comprehensive research supporting the use of puberty blockers and hormone therapy for adolescents with gender dysphoria. There also aren’t any medications approved by the U.S. Food and Drug Administration specifically for treating gender dysphoria in minors.

“Generally, when there is lower-quality evidence, there is much more caution in making recommendations,” said Hruz, a pediatric endocrinologist and an associate professor at Washington University in St. Louis.

Experts called by plaintiffs earlier in the trial did not deny the lack of gold-standard research testing the effects of gender-affirming medications on minors.

Many mainstream medications are prescribed without high-quality clinical research testing their effects, they said. The plaintiffs’ experts testified that robust research is sometimes impossible to conduct due to funding and ethical constraints, especially in the area of pediatric care. They also said the majority of existing research on gender-affirming care suggests it works. Four doctors with personal experience treating transgender kids also testified that some patients cannot live happy, well-adjusted lives without gender-affirming medication.

According to Casas, there aren’t any unique risks to prescribing puberty blockers and hormone therapy to treat gender dysphoria. He continues to prescribe these medications to adolescents for other medical conditions.

Gender-affirming care for minors hangs in balance as North Dakota trial begins

Hruz said this fails to take physiological differences into account. One cannot assume that prescribing testosterone to a transgender boy would pose the same risks as prescribing testosterone to a cisgender boy, he said.

He also expressed concerns about the effect of puberty blockers on brain development.

An attorney for the plaintiff countered that puberty blockers have been used to treat gender dysphoria since the 1990s, and are still generally accepted as safe.

Laidlaw, an adult endocrinologist who runs a clinic in California, testified that transgender girls and boys put on cross-sex hormones could be at risk for conditions including high red blood cell counts, heart disease, diabetes and infertility.

“We have no idea what’s going to happen to their bones, to their reproductive tracts, to their heart, to their livers,” he said.

Casas testified that he discloses all known possible health risks to all his patients and their parents before they start gender-affirming medical treatment. This is standard practice for all pediatric endocrinologists who treat transgender patients, he said.

Laidlaw said adolescents cannot be expected to understand the implications of these risks when agreeing to treatment.

Attorneys for the plaintiffs said some courts have openly criticized the quality of previous testimony offered by Hruz and Laidlaw, finding that they do not have expertise in transgender health care or that their views are too ideologically motivated.

Hruz and Laidlaw joined three other doctors who argued against the use of gender-affirming medical treatment for minors in a friend-of-the-court brief filed with the U.S. Supreme Court in 2018.

In the brief, the group of doctors called gender dysphoria a “delusion.”

“There is no scientific or medical support for treating gender dysphoric children in accordance with their gender identity rather than their sex,” they wrote.

Father of transgender teen testifies that North Dakota law stems from ignorance

Attorneys for the plaintiffs said the stance presented by Hruz and Laidlaw is an outlier in the medical community. More than a dozen American medical associations have put out statements endorsing the safety and effectiveness of using gender-affirming care to treat gender dysphoria in adolescents, including the American Academy of Pediatrics, American Psychiatric Association and the Endocrine Society, they said.

Hruz said the statements were approved by small committees and do not necessarily reflect the views of the associations’ membership. He said he’s heard from colleagues that American medical associations have worked to suppress the opinions of members who question the legitimacy of gender-affirming treatments.

Hruz openly questioned why the World Professional Association for Transgender Health, which doctors look to for standards of care, has done away with recommending age minimums for gender-affirming medical procedures, for example. He said this is evidence the organization is not scientifically honest.

The World Professional Association for Transgender Health has also been criticized by President Donald Trump, who on Tuesday signed an executive order to limit medical treatment options for transgender children and adults under the age of 19.

In the executive order, Trump singled out the association’s health care guidelines as “junk science.”

It’s the latest in a string of orders handed down by the administration seeking to restrict the rights of transgender people at the federal level.

Three North Dakota families with transgender children were previously plaintiffs alongside Casas, but South Central Judicial District Judge Jackson Lofgren ruled earlier this month that they don’t have standing to bring the challenge. Some of the former plaintiffs testified in the trial earlier this week.

The ban also forbids minors from receiving gender-affirming surgeries, but those procedures weren’t performed on minors in North Dakota before the ban.

The trial resumes Monday and is expected to wrap up mid-week. It is a court trial, meaning the judge will issue a verdict.