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The case we discuss today, Doe v. Ladapo, 2023 WL 3833848 (N.D. Fla. 2023), appeared in our daily search results because it briefly addresses off-label use of prescription drugs. Invalidating a state statute that would have prohibited a particular off-label use, the court explained that “[o]ff-label use of drugs is commonplace” and the fact “[t]hat the FDA has not approved” a drug for a particular use “says precisely nothing about whether the drugs are safe and effective when used for that purpose.” Id. at 15. The “defendants’ contrary implication,” said the court, “is divorced from reality.” Id. Indeed. We couldn’t have said it better ourselves.

But that is not why we chose to report on Doe. We bring it to your attention because it is a refreshingly clear judicial repudiation of bigotry.

Last month, hoping to advance Ron DeSantis’s political fortunes at the expense of transgender children, the Florida legislature enacted a statute that would prevent doctors from prescribing gonadotropin-releasing hormone (GnRH) agonists—colloquially known as “puberty blockers”—to treat transgender youth suffering from gender dysphoria. See Fla. Stat. § 456.001(9)(a); id. § 456.52(1) & (5). A mental-health condition recognized in DSM-5, the diagnosis applies when, among other things, an individual experiences both a marked incongruence between their experienced gender identity and natal sex as well as clinically significant distress or impairment. As the Doe court noted, gender dysphoria causes “transgender individuals [to] suffer higher rates of anxiety, depression, suicidal ideation, and suicide than the population at large.” 2023 WL 3833848, at *3. “There are well-established standards of care for treatment of gender dysphoria.” Id. In addition to psychological therapy, there are three types of possible medical intervention: 1. GnRH agonists, which delay the onset of puberty; 2. cross-sex hormones, which promote the development and maintenance of characteristics consistent with the individual’s natal sex; and 3. surgery, which can align physical characteristics with gender identify.

The Doe plaintiffs, parents of transgender children, challenge the state’s attempt to prevent trans youth from receiving GnRH agonists, alleging that the newly enacted don’t-be-trans statute violates their children’s right to equal protection (and their own rights as parents). The court agreed and enjoined the statute’s enforcement.

Rather than walk you through each step of the court’s analysis, we want to highlight some of its most trenchant observations, which are delivered with uncommon yet welcome bluntness.

The court begins by addressing “[t]he elephant in the room”—namely, the belief “that cisgender individuals properly adhere to their natal sex and that transgender individuals have inappropriately chosen a contrary gender identity, male or female, just as one might choose whether to read Shakespeare or Grisham.” Doe, 2023 WL 3833848, at *2. But, the court said, the record makes clear that, as one defense expert admitted, “[g]ender identity is real,” not a choice. Id.

Despite this admission, said the court, there was “an unspoken suggestion running just below the surface in some of the proceedings that led to adoption of the statute … at issue—and just below the surface in the testimony of some of the defense experts—is that transgender identity is not real, that it is made up.” 2023 WL 3833848, at *2. The court observed that “[m]any people with this view tend to disapprove all things transgender” and therefore “oppose medical care that supports a person’s transgender existence.” Id. The court cited several defense experts as examples, noting that one had joined an amicus brief in another case asserting that “transgender individuals have only a ‘false belief’ in their gender identity” and “are maintaining a ‘charade’ or ‘delusion’” while another had described gender-affirming care as “evil” and “diabolical.” Id.

Pointing to the defendants’ contradictory statements, the court declared that

[a]ny proponent of the challenged statute … should put up or shut up: do you acknowledge that there are individuals with actual gender identities opposite their natal sex, or do you not? Dog whistles ought not be tolerated.

2023 WL 3833848, at *2. As a child of the 1950’s Jim Crow South, the judge knows something about dog whistles.

Proponents of the don’t-be-trans statute argued that they were motivated by a desire to protect children, who, in the words of the statute, are “threatened with being subjected to sex-reassignment prescriptions,” which the statute equates to child abuse that would justify the state “tak[ing] physical custody of the child” from the child’s parents. Fla. Stat. Ann. § 61.534(1). The Doe court was having none of it. It found that the plaintiffs are motivated by their “love for their children and the desire to achieve the best possible treatment for them” but that “[t]his is not the State’s motivation.” 2023 WL 3833848, at *7.

On the contrary, said the court, the state’s motives were discriminatory, “motivated in substantial part by the plainly illegitimate purposes of disapproving transgender status and discouraging individuals from pursuing their honest gender identities.”  2023 WL 3833848, at *10. The statute is, in short, “purposeful discrimination.” Id.

The court noted that the defendants “proffered a laundry list of purported justifications for the statute” but found that “[t]he purported justifications are largely pretextual.” 2023 WL 3833848, at *11.

As for GnRH’s purported lack of proven safety and efficacy, the court found no evidence of either, finding instead that there is “extensive clinical experience showing excellent results from treatment with GnRH agonists and cross-sex hormones” and that “[i]f these treatments are prohibited, many patients will suffer needlessly.” 2023 WL 3833848, at *12.

Resisting the medical profession’s recognition of gender dysphoria and its treatments, the defendants argued that medical organizations had been captured by “woke” activists “who pursued good politics, not good medicine.” 2023 WL 3833848, at *13. Again, the court was having none of it: “If ever a pot called a kettle black, it is here. The statute and the rules were an exercise in politics, not good medicine.” Id.

Nor did the court buy the defendants’ contention that the Florida statute reflects an international “consensus” barring minors from receiving puberty blockers.

The assertion is false. And no matter how many times the defendants say it, it will still be false. No country in Europe—or so far as shown by this record, anywhere in the world—entirely bans these treatments.

To be sure, there are countries that ban gays and lesbians and probably transgender individuals, too. One doubts these treatments are available in Iran or other similarly repressive regimes. But the treatments are available in appropriate circumstances in all the countries cited by the defendants, including Finland, Sweden, Norway, Great Britain, France, Australia, and New Zealand.

2023 WL 3833848, at *14.

Echoing anti-choice campaigners’ argument that abortion should be banned because women end up regretting abortions, the anti-trans campaigners argued that doctors should be prohibited from prescribing puberty blockers to minors because when they grow up they will regret having taken them. But, the court noted, there is no factual support for the argument. “Regret is rare; indeed, the defendants have offered no evidence of any Florida resident who regrets being treated with GnRH agonists or cross-sex hormones.” 2023 WL 3833848, at *14.

Seeing past the pretext, the court found that “the state’s disapproval of transgender status—of a person’s gender identity when it does not match the person’s natal sex—was a substantial motivating factor in enactment of the challenged statute and rules.” Such invidious discrimination, the court held, violates the equal protection and is therefore “unconstitutional.” 2023 WL 3833848, at *14.

For now at least, a federal court has kept Florida from becoming Iran.