#weak evidence

https://journals.lww.com/prsgo/fulltext/2021/11000/letter_to_the_editor__regret_after.29.aspx

https://academic.oup.com/jcem/article-abstract/107/9/e3937/6572526?login=false

https://www.sciencedirect.com/science/article/abs/pii/S1054139X22007194

https://www.mdpi.com/2227-9032/10/1/121

https://link.springer.com/article/10.1007/s10508-021-02163-w

https://www.bmj.com/content/380/bmj.p382

https://www.bmj.com/content/380/bmj.p382

https://www.reuters.com/investigates/special-report/usa-transyouth-outcomes/

https://link.springer.com/article/10.1007/s11930-023-00358-x

By: Max Stephens and Alex Barton

Published: Jun 9, 2023

By: Michael Searles

Published: Apr 10, 2024

Children who think they are transgender should not be rushed into treatment they may regret, a landmark report has concluded.

The report by paediatric consultant Dr Hilary Cass has made 32 recommendations, including: calling for the “unhurried” care of those under 25 who think they may be transgender; an end to the prescribing of powerful hormone drugs to under-18s; and early help for primary school children who want to socially transition.

The Telegraph has summarised the report’s key findings:

Doctors must be extremely cautious about giving any trans drugs to under-18s

Last month, the NHS banned the prescribing of puberty blockers outside of clinical trials. However, Dr Cass has gone further and said children who think they are transgender should not be given any hormone drugs at all until at least 18.

The former president of the Royal College of Paediatrics and Child Health said there was no evidence the drugs “buy time to think” or “reduce suicide risk”.

While the drugs can suppress puberty, research commissioned by the review and carried out by the University of York found the drugs have no effect on the person’s body satisfaction or their experience of gender dysphoria – where the person feels they are a different gender to the sex they were born – despite this being the reason they had been prescribed.

[ Dr Hilary Cass said there was no evidence hormone drugs 'buy time to think' or 'reduce suicide risk' ]

Dr Cass stated there was “concern that [puberty blockers] may change the trajectory of psychosexual and gender identity development” with most patients going on to take cross-sex hormones as a result.

She said the NHS should exert “extreme caution” in giving out cross-sex hormones to under-18s as the research carried out by her review concludes there is “a lack of high-quality research” on their effectiveness. She said their use should be incorporated into the puberty blocker trial.

Dr Cass said all children and teenagers should be given time “to keep options open during this development window” and that this would allow time to diagnose and treat other conditions while preserving fertility.

She said doctors must be able to “refer to the longer-term benefits and risks” of treatment options but this was “not currently available” for children experiencing gender incongruence or dysphoria. A systematic review by the University of York of more than 1,000 children who had been treated by the Tavistock, found that 7.4 per cent of under-16s given puberty blockers stopped their treatment.

It found that the younger children started treatment, the more likely they were to continue on to cross-sex hormones, which means the drugs “are not buying time to think”.

It had also been suggested that the drugs could improve body image and psychological wellbeing – however, the review found “no changes in gender dysphoria or body satisfaction were demonstrated.”

Young children should have therapy before they are allowed to socially transition

Families should be able to see a medical professional such as a child psychologist or paediatrician as quickly as possible if a primary school child wants to socially transition, the report recommends.

Dr Cass states that while “exploration is a normal process” in teenagers, children who are yet to go through puberty will have been affected by “parental attitudes and beliefs”.

She states the importance of “avoiding premature decisions” and seeking help early on to understand the child’s behaviour and assess whether they are experiencing any mental health issues or distress.

Research conducted for the review found that prepubescent children who socially transition – which means a child being treated as their preferred gender, including using their chosen pronouns and name, and allowing them to use the facilities such as lavatories and changing rooms of their choice – were more likely to undergo medical treatment later.

She suggests that a “partial rather than full transition can be a way of ensuring flexibility and keeping options open until the developmental trajectory becomes clearer”.

“There should be a distinction for the approach taken to pre- and post-pubertal children,” she said. “This is of particular importance in relation to social transition, which may not be thought of as an intervention or treatment because it is something that generally happens at home, online or in school and not within health services.”

The report finds that “social transition in childhood may change the trajectory of gender identity development for children with early gender incongruence”.

The younger children are when they present with “gender incongruence” the more likely they are to move on from that phase, it says.

“The current evidence base suggests that children who present with gender incongruence at a young age are most likely to desist before puberty, although for a small number the incongruence will persist.”

It recommends a clinical professional such as a mental health specialist “should help families to recognise normal developmental variation in gender role behaviour and expression”.

Parents fear being labelled transphobic

Dr Cass said her review heard concerns from many parents about their child being socially transitioned and affirmed in their expressed gender without parental involvement.

Such cases often involved an adolescent who had “come out” at school while expressing concern about how their parents might react. “Some parents felt ‘forced’ to affirm their child’s assumed identity or risk being painted as transphobic and/or unsupportive,” the report said.

In a small number of cases, there were concerns that parents were “consciously or unconsciously” influencing their child’s gender expression, it said.

“It is very important that the child/young person’s voice is heard and that perceptions of gender identity represent the child/young person’s sense of self,” it said.

Under-25s must not be rushed into changing gender

Under-25s should not be rushed into changing gender, but should receive “unhurried, holistic, therapeutic support”, Dr Cass concluded. She said “life-changing” decisions must be properly considered in adulthood, noting that brain maturation continues into the mid-20s.

The report found that “clinicians are unable to determine with any certainty which children and young people will go on to have an enduring trans identity”. Young adults aged 17 to 25 who want to change gender should be seen by “a follow-through service” rather than sent straight to an adult clinic, the report concludes.

The NHS has been accused of fast-tracking thousands of teenagers to adult clinics, because they would not be seen before their 17th birthday, and prescribing them cross-sex hormones.

Dr Cass said these people were still at a “vulnerable stage in their journey” and that regional centres offering gender services for children, as well as mental health assessments and support, should care for those aged up to 25 or link up with such services.

The consultant paediatrician said it was not possible to “know the ‘sweet spot’ when someone becomes settled in their sense of self” but that decisions should not be rushed before an individual becomes a mature adult at about 25.

“When making life-changing decisions, what is the correct balance between keeping options as flexible and open as possible as you move into adulthood, and responding to how you feel right now?” she wrote in the report’s foreword.

The report said far more consideration should be given to reaching a point of maturity before taking a decision.

“It used to be thought that brain maturation finished in adolescence, but it is now understood that this remodelling continues into the mid-20s as different parts become more interconnected and specialised,” the report notes.

“Changes in the limbic area, which is ‘present-orientated’ and concerned with risk taking and sensation seeking, begin with puberty; this part of the brain becomes super sensitised, drives emotional volatility, pleasure and novelty seeking, and also makes adolescents more sensitive to social rejection, as well as vulnerable to addiction and a range of mental health problems,” the review continues.

“The ‘future orientated’ prefrontal cortex matures later, with development continuing into an individual’s 20s, and … is concerned with executive functions such as complex decision making, rational judgement, inhibition of impulsivity, planning and prioritisation,” it states.

Trauma is prevalent among trans children

Childhood trauma, neglect and abuse feature heavily in the cohort of patients seeking gender changes, the report shows.

It cites a systematic review that found that in some services, as many as two thirds of those referred had suffered some kind of neglect or abuse, with high levels of parental mental illness, substance abuse and exposure to domestic violence. The research found about half of cases had suffered from maternal mental illness or substance abuse while almost 40 per cent had experienced paternal mental illness or substance abuse.

An early study of UK cases referred to gender services found one quarter of children had spent some time in care. More than four in 10 cases had experienced living with only one parent, with almost as many having experience of family mental health problems.

The report shows that rates of mental ill-health have risen among children and young people, especially girls and young women.

This comes in parallel with the rising numbers seeking help from NHS gender clinics, where the biggest rise has been among those registered as female at birth, seeking help in adolescence to change gender.

Within this group, there are higher levels of neurodiversity and mental health issues, it says, calling for a “holistic” appraisal of the young patient, not solely in terms of their gender-related distress.

“Children/young people referred to NHS gender services must receive a holistic assessment of their needs to inform an individualised care plan. This should include screening for neurodevelopmental conditions, including autism spectrum disorder, and a mental health assessment,” it states.

People who change gender may regret it

The report advises children expressing a desire to change gender are given time to think before being rushed into a decision they may regret.

It suggests that too many decisions about changing gender have been rushed, with too little consideration given that children might regret their actions in later life.

A survey included in the findings found “the history of the child/young person’s gender journey was rarely examined closely for signs of difficulty, regret or wishes to alter any aspect of their gender trajectory.”

Evidence considered by the Cass review included talking to those who have transitioned to the opposite sex and those who have detransitioned back. It found that “whilst some young people may feel an urgency to transition, young adults looking back at their younger selves would often advise slowing down”.

It continued: “For some, the best outcome will be transition, whereas others may resolve their distress in other ways. Some may transition and then de/retransition and/or experience regret. The NHS needs to care for all those seeking support.”

Data on the number of adults who have detransitioned are scarce, but the report said the number was “increasing”. A 2021 study found that 70 per cent of people detransitioning had another condition in the first place, while 23 per cent were actually gay, lesbian or bisexual.

By: Leor Sapir

Published: Jun 28, 2023

A growing number of countries, including some of the most progressive in Europe, are rejecting the U.S. “gender-affirming” model of care for transgender-identified youth. These countries have adopted a far more restrictive and cautious approach, one that prioritizes psychotherapy and reserves hormonal interventions for extreme cases.  

In stark contrast to groups like the American Academy of Pediatrics (AAP), which urges clinicians to “affirm” their patient’s identity irrespective of circumstance and regards alternatives to an affirm-early/affirm-only approach “conversion therapy,” European health authorities are recommending exploratory therapy to discern why teens are rejecting their bodies and whether less invasive treatments may help.  

If implemented in American clinics, the European approach would effectively deny puberty blockers and cross-sex hormones to most adolescents who are receiving these drugs today. Unlike in the U.S., in Europe surgeries are generally off the table before adulthood.  

Why are more countries turning their backs on what American medical associations, most Democrats and the American Civil Liberties Union call “medically necessary” and “life-saving” care? The answer is that Europeans are following principles of evidence-based medicine (EBM), while Americans are not.

A bedrock principle of EBM is that medical recommendations should be grounded in the best available research. EBM recognizes a hierarchy of information. The expert opinion of doctors, for example, even when based on extensive clinical experience, furnishes the lowest quality — meaning, least reliable — information. Slightly higher on the information pyramid are observational studies. Systematic reviews of evidence, meanwhile, furnish the highest quality evidence. They follow a rigorously developed, reproducible methodology. They do not cherry-pick studies with convenient results, but instead consider all the available research.  

Most importantly, systematic reviews don’t merely summarize the conclusions of available studies on a question of interest. Instead, they assess the strengths and weaknesses of these studies to determine the reliability of their findings. To do this, systematic reviews typically use the GRADE system (Grading of Recommendations, Assessment, Development and Evaluations) and rank the quality of evidence as “high,” “moderate,” “low” or “very low.”  

Systematic reviews by EBM experts in Scandinavia and the United Kingdom have concluded that there are serious gaps in the evidence base for sex modification in minors. The U.K. systematic reviews found the available research to be of “very low” quality — meaning that there is very low certainty that an observed effect, like reduced suicidality, is due to the intervention, and therefore the studies’ claimed results are unlikely to represent the truth.  

Importantly, even the famous Dutch study that is said to be the “gold standard” of research in this area received a rating of “very low” due to serious methodological problems. Sweden’s National Board of Health and Welfare has said that the risks of treating gender dysphoric minors with hormonal interventions “currently outweigh the possible benefits.”  

Last year, Florida’s health authorities commissioned what is known as an “umbrella review,” or a systematic overview of systematic reviews, from independent experts at McMaster University, home of EBM. Unsurprisingly, that overview came to the same conclusion: There is no reliable evidence that youth transition improves mental health outcomes.  

Because U.S. medical groups don’t always use EBM, their conclusions can be based on studies whose fatal flaws are overlooked or ignored. Consider, as an example, a study done at Seattle Children’s Hospital and published last year. The study’s authors reported that use of puberty blockers and cross-sex hormones was associated with 60 percent lower odds of depression and 73 percent lower odds of suicidality. Leading mainstream publications, including Scientific American and Psychology Today, celebrated the findings. More recently, major U.S. medical associations cited the study in federal court proceedings.  

But a careful look at the study’s data shows that the kids who received hormonal interventions did no better by the end of the study than at the beginning. The researchers’ claim about improvement was based on the fact that the kids in the control group, who received psychotherapy but not hormones, got worse relative to the hormone group. But even this isn’t accurate, as 80 percent of the control group dropped out by the end of the study, and a likely reason for this dramatic loss to follow-up is that many or perhaps all of the non-hormone-treated kids improved without “gender-affirming” drugs. It’s quite possible that if the researchers had followed up with all the participants, we’d see this study become Exhibit A in the case against pediatric sex changes.

Similar problems exist in studies purporting to show a rate of transition regret of less than 1 percent. The true rate of regret is not known and won’t be known for years to come. The claim that gender dysphoric teens are at high risk of suicide if not given access to “gender-affirming” drugs and surgeries is likewise baseless and irresponsible. In February, Finland’s top expert in gender medicine emphasized this point to the country’s liberal newspaper of record.

The American Academy of Pediatrics’ main statement on gender medicine, authored by a single doctor while still in his residency, is not a systematic review. The author himself has conceded as much. A later published peer-reviewed fact check found the AAP statement to be a textbook example of cherry-picking and mischaracterization of evidence.

The World Professional Association of Transgender Health (WPATH) says in its latest “standards of care” that a systematic review of evidence is “not possible.” Instead, WPATH used a “narrative review,” which has a high risk of bias according to EBM because it doesn’t utilize a reproducible methodology. England has broken from WPATH, and the director of Belgium’s Center for Evidence-Based Medicine has said he would “toss them [WPATH’s guidelines] in the bin.” In the U.S., WPATH’s standards are widely accepted as authoritative.

The U.S. Endocrine Society has relied on two systematic reviews in developing its own guideline. But these reviews were not for mental health benefits, and in any case the Endocrine Society ranks the quality of evidence behind its own recommendations as “low” or “very low.”

All other U.S. medical groups cite these three sources when assuring the public about “gender-affirming care,” thus creating an illusion of consensus around “settled science.”  

Earlier this year, an investigative report in the prestigious British Medical Journal concluded that although pediatric gender medicine in the U.S. is “consensus-based,” it is not “evidence-based.” Gordon Guyatt, distinguished professor in the Department of Health Research Methods, Evidence, and Impact at McMaster University, Ontario, and one of the founders of EBM, recently called American guidelines for managing youth gender dysphoria “untrustworthy.” 

Consensus can be produced by misguided empathy, ideological capture or political pressures. Consensus can also be manufactured. The new president of the American Medical Association (AMA) has said there should be “no debate” when it comes to offering kids “gender-affirming” drugs and surgeries.  

Yale School of Medicine’s Dr. Meredithe McNamara calls the questioning of the evidence behind pediatric sex changes “science denialism.” Her protest is ironic. Science is a process of ongoing inquiry and debate, not a set of predetermined conclusions. Science depends on skepticism, especially about sensitive subjects. True science denialism means restricting rational, evidence-based debate — exactly what McNamara and the AMA’s new president want to do.

Their calls are bearing fruit. Just this month, gender activists successfully pressured a medical journal to retract a paper whose conclusions they found inconvenient. The ongoing campaign to suppress scientific debate allows a pseudo-consensus to emerge around “gender-affirming care.”

Put simply, pediatric gender medicine in the U.S. is out of control. Medicalization of gender diversity in children is a fast-growing industry that shows no signs of self-correction. Doctors and therapists who practice “affirmative” medicine consistently demonstrate ignorance about EBM principles and deceive the public about the grim realities behind the euphemism “gender-affirming care.”  

A Reuters investigation last year interviewed providers at 18 pediatric gender clinics and found that none were doing comprehensive mental health assessments and differential diagnosis. Those who promote and practice “gender-affirming care” themselves tell us that their approach is child-led. “Gatekeeping” of medical transition, they insist, is pointless, even “dehumanizing.”

The author of the AAP’s position paper on gender medicine has said that a “child’s sense of reality” is the “navigational beacon to orient treatment around.” The director of the gender clinic at Boston Children’s Hospital has admitted that they give out puberty blockers “like candy.” Even the founding psychologist of that clinic has warned that kids are being inappropriately “rushed toward the medical model.”

Why the U.S. has become an outlier on pediatric transgender medicine is a complicated question, but at least part of the answer is that European welfare states have centralized health bureaucracies and public health insurance. Before medicines can be approved for state funding, their evidence base needs to be evaluated. The American health care system is more vulnerable to profit motives, activist doctors and political pressures. Medical associations claim to advocate for patient health but can have other motives as well.

The situation is so dire that when pediatric gender medicine experts in other countries want to defend their practices before a skeptical public, they sometimes say that at least they are not as bad as the Americans. That is one kind of American exceptionalism we can do without.

==

[A] “child’s sense of reality” is the “navigational beacon to orient treatment around.”

Holy shit.

How can you claim that it's "settled science" and "consensus," and then leave everything up to the most immature, most depressed, most anxious, least experienced person in the room?

By: Bernard Lane

Published: Apr 29, 2024

Into the unknown

Australian gender clinics have been criticised by England’s Cass review for using an experimental fast-track path to puberty blockers for children as young as age 8-9.

This practice could mean Australian minors stay on puberty blockers longer or start cross-sex hormones earlier, with no good data to predict safety or beneficial outcomes, according to a Cass-commissioned research paper reporting a landmark survey of international gender clinics.

“Puberty blockers [which suppress natural sex hormones] are intended to be a short-term intervention and the impact of use over an extended period of time is unknown, although the detrimental impact to bone density alone makes this concerning,” says the Cass report, noting that some patients discharged from the London-based Tavistock clinic were still on blockers in their early to mid-20s.

Australia’s health ministers and gender clinicians have sought to deny the local relevance of the Cass report by making vague claims about different pathways to treatment in the two countries. However, Australia’s gender clinics loom large in research commissioned by Dr Cass, especially in a survey of 15 international clinics and an independent evaluation of 21 treatment guidelines around the world.

In the newly published guideline research, not one of the three reviewers recommended use of the 2018 “Australian standards of care” treatment guideline issued by the Royal Children’s Hospital (RCH) Melbourne1.

The RCH guideline scored only 19/100 for the rigour of its development, compared with 71/100 for the more cautious and up-to-date treatment advice from Sweden. The RCH guideline—judged untrustworthy by a pioneer of evidence-based medicine, Professor Gordon Guyatt—is used by Australia’s children’s hospital gender clinics and the stand-alone Maple Leaf House clinic.

In the Cass-commissioned survey, the majority of the international clinics that responded said they did not routinely collect outcome data on their young patients. Clinics were listed by country, not name, although clues in survey responses identify some clinics. Australia had the largest number of clinics—five of the 15—in the survey.

The research paper reporting the 2022-23 survey—published in the BMJ’s Archives of Disease in Childhood—highlights the fact that three Australian gender clinics offer a “unique” pathway for “peri-pubertal” children who are given priority on the waiting list for psychological support and access to puberty blockers when eligible.

The paper says the age of entry to this pathway is 8-9, as early as Tanner Stage 1; Tanner Stage 2 marks the onset of puberty.

Answers to survey questions identify the three fast-track clinics as those of the Perth Children’s Hospital2, the Queensland Children’s Hospital and RCH (which appears most responsible for entrenching the contentious “gender-affirming” treatment approach in Australia.)

In a 2018 journal article, the RCH clinic authors describe the setting up of its “innovative” single-session nurse-led assessment clinic, stating that this new “system enables those patients who will benefit most from puberty-blocking treatment to be fast tracked into the multidisciplinary assessment pathway to access treatment as required.”

The Queensland gender clinic had the shortest waiting time in the Cass survey, with just two to three appointments over two to three months3.

Writing in the BMJ earlier this month, Dr Cass said: “The rationale for early puberty suppression remains unclear, with weak evidence regarding the impact on gender dysphoria and mental or psychosocial health. The effect on cognitive and psychosexual development remains unknown.”

[ Chart: Puberty by Tanner stage. Credit: Cass report ]

No outcome data

The survey research paper, authored by University of York researchers commissioned by Dr Cass, notes that the Australian fast-track to puberty blockers is supported by the 2018 RCH treatment guideline for youth gender dysphoria.

But the York paper points out that “the impact of this [fast-track pathway], which might entail longer use of interventions to suppress puberty or earlier commencement of masculinising/feminising hormones, remains unknown4 as early studies of outcomes of interventions to suppress puberty mandated a minimum age of 12.”

“Traditionally, ‘watchful waiting’ has been recommended to observe how gender feelings and any distress develops [in pre-pubertal children], as the evidence suggests that many children’s gender questions or concerns may not persist into adolescence.”

In 2019, RCH head of research Dr Ken Pang advertised a PhD project on the unknown effects of hormone suppression on the brain, stating “this use of puberty blocking medication typically occurs for several years”5.

A 2020 journal article, with RCH gender clinicians and University of Melbourne bioethicists among the authors, considers the case of 15-year-old male child “EF”, a hypothetical “non-binary” patient combining features of real cases.

After three years of hormone suppression EF’s bone mineral density has fallen to the lowest 2.5 percentile, “although there have been no fractures,” the authors say.

“EF, whose desire for biological children in the future remains unclear, wishes to continue puberty suppression until they are at least 18 years old [thereby keeping a seemingly androgynous body]. Their clinicians contact the clinical ethics consultation team to ask, ‘Is that appropriate?’”

The paper assumes, contrary to systematic reviews of the evidence, that blockers can be counted on to ease the distress of gender dysphoria and confer mental health benefits. In other words, the paper does not accept that the use of blockers with dysphoria is experimental.

Three of the Melbourne authors suggest the “attractive” option of maintaining EF on blockers while making experimental use of another medication. They say that “selective estrogen receptor modulators” (SERMs) might “theoretically promote improved bone density” without growing undesired breast tissue. It is “attractive”, they suggest, despite this new medication’s side effects including hot flashes, blood clots and possibly cognitive impairment.

Another 2020 paper involving authors from the RCH clinic and the University of Melbourne contemplates the composite case of “Phoenix”, a non-binary adult requesting ongoing puberty suppression (OPS) to permanently prevent the development of secondary sex characteristics, as a way of affirming their gender identity.”

The hypothetical Phoenix is an 18-year-old girl who has mostly identified as non-binary and began hormone suppression at age 11 after she became “extremely distressed” by the appearance of breast buds and the thought of approaching menarche.

The authors declare perpetual puberty blockers “ethically justifiable”, because the possible harms would be outweighed by benefits such as “a physical appearance that better matches gender identity.”

“We have also contended that Phoenix’s request can be regarded as substantially autonomous. Arguably, medicine is moving beyond its traditional, narrow goal of promoting health, biostatistically conceived.”

Under the rubric of more ethical work to be done with non-binary adults, the authors ask, “Should a diagnosis of gender dysphoria be required for an individual to be eligible for puberty suppression?”

All this is in stark contrast to the Cass report, which says—“Puberty suppression was never intended to continue for extended periods, so the complex circumstances in which young people may remain on puberty blockers into adulthood is of concern.”

“In some instances, it appears that young adults are reluctant to stop taking puberty blockers, either because they wish to continue as non-binary, or because of ongoing indecision about proceeding to masculinising or feminising hormones.”

But the Cass report warns that “a known side effect of puberty blockers on mood is that it may reduce psychological functioning.”

“Even at Tanner stages 2-3 [roughly ages 9-13], young people have had minimal experience of their own biological puberty, and such experience as they have had may have been distressing for a wide range of reasons.

“Once on puberty blockers, they will enter a period when peers are developing physically and sexually whilst they will not be, and they may be experiencing the side effects of the blocker. There are no good studies on the psychological, psychosexual and developmental impact of this period of divergence from peers.

“However, if a young person is already on puberty blockers, they will need to make the decision to consent to masculinising [or] feminising hormones at a point when their psychosexual development has been paused, and possibly with little experience of their biological puberty.”

[ Video: Helen Joyce of the UK gender-critical group Sex Matters discusses the Cass report with John Anderson, a former deputy prime minister of Australia ]

Misguideline

In their paper on the survey of international gender clinics, the University of York authors note that the RCH treatment guideline—used by gender clinicians in Australia’s children’s hospitals and the Maple Leaf House clinic in regional NSW—had abandoned key safeguards of the 2011-14 “Dutch protocol” studies which provide the evidence base for gender medicalisation with puberty blockers, cross-sex hormones and surgery.

Unlike the original Dutch protocol, the RCH guideline does not restrict this medicalisation to patients with gender dysphoria since early childhood who are otherwise psychologically stable. The RCH document says psychosis, depression and anxiety are not necessary barriers to starting minors on life-altering hormonal treatment which can cause sterilisation, sexual dysfunction and other poor health outcomes.

The York researchers contrast the radical RCH guideline with Finland’s more cautious 2020 treatment policy, which returned to the stricter Dutch approach after clinicians noted the poor outcomes for patients with adolescent-onset dysphoria, this being the typical case profile since around 2015. (The Dutch studies, still considered the best available evidence, have recently come under closer scrutiny for their shortcomings.)

Only the Finnish and Swedish 2022 guidelines—which recognise the very weak evidence base confirmed by systematic reviews—were recommended by the Cass report following the evaluation run by the York researchers.

The Swedish guideline was rated 71/100 for the rigour of its development and Finland’s score for rigour was 51, while the RCH guideline scored 19. The rating for the Endocrine Society’s 2017 guideline was 42 and the rigour score for the 2022 standards of care from the World Professional Association for Transgender Health (WPATH) was 35.

For editorial independence, the scores were 14 for RCH, 39 for WPATH and 92 for the Endocrine Society.

Australia’s health authorities typically invoke three guidelines—from RCH, the Endocrine Society and WPATH—when giving public assurances about the quality and safety of care at gender clinics.

Citing the low quality of most treatment guidelines, the Cass report recommends that “healthcare services and professionals” adopt a cautious approach7.

By: Roy Eappen and Ian Kingsbury

Published: Jun 28, 2023

A federal court last week struck down an Arkansas law banning the provision of sex-change procedures—off-label “puberty blockers,” opposite-sex hormones and surgery—to minors. In the June 20 ruling, Judge James M. Moody Jr. repeatedly cited the Endocrine Society, the professional organization of physicians who specialize in hormones. He wrote that the society has “published widely-accepted clinical practice guidelines for the treatment of gender dysphoria” that “were developed by experts in the field” and “are recognized as best practices.”

In truth, over the past decade transgender activists have co-opted the Endocrine Society and other professional organizations to promote such treatments for adolescents and even young children. Their guidelines are based on flimsy evidence, giving the appearance that invasive and irreversible treatments are beneficial for young patients despite a growing body of evidence to the contrary. The guidelines have been used by lawmakers in states such as California and New York to endanger children—and now by judges to block state efforts at protecting youngsters.

A few days before Judge Moody’s ruling, we attended the annual meeting of the Endocrine Society, of which one of us (Dr. Eappen) is a member. We found that endocrinologists are aware of the society’s failings and rue its elevation of transgender activism over medical expertise and patient needs.

The Endocrine Society endorsed medical “transition” for young people in 2017. It published the “clinical practice guidelines” for the “treatment of gender-dysphoric/gender-incongruent persons” that Judge Moody cited. At the time, there was little good research on this issue, and the Endocrine Society admitted the guidelines were largely based on evidence of “low” or “very low” quality. The society nonetheless recommended that some children receive a “hormone regimen that will suppress the body’s sex hormone secretion, determined at birth and manifested at puberty.”

At this year’s meeting, we had frank and fruitful discussions with endocrinologists who provide hormonal treatments to kids with gender dysphoria, as well as some who don’t. Without exception, they acknowledged that the society’s evidence base for pediatric gender transition is weak, at best. Yet while they’re aware of the guidelines’ shortcomings, they’re afraid to voice their concerns. The society’s full-throated endorsement of gender-affirming care implied condemnation of anyone who holds differing views. Medical professionals are being cowed into silence and coerced into providing treatments they know are dangerous to children.

Perhaps the most telling interactions were with European endocrinologists, who were there to discuss the latest research and treatments in the specialty. Those we spoke with expressed surprise that the U.S. hasn’t banned, or at least severely restricted, such treatments for adolescents and children.

England, Sweden and Finland have all taken this path, and Norway is likely to follow. Belgium, France, Ireland and Italy are also raising concerns. These countries are following the science, which shows that the claimed benefits of hormonal intervention for young people fail to outweigh the risks.

Most disturbing, endocrinologists on all sides of this debate told us that practitioners aren’t complying with the precautions set forth in the society’s guidelines. Despite the document’s call for careful mental-health screening and its acknowledgment that most cases of childhood gender dysphoria naturally resolve during puberty, endocrinologists recognize that some of their peers are rushing young patients to irreversible hormonal treatments. Every endocrinologist we spoke with supports doing more to ensure that these guardrails are enforced, and many favor erecting new ones.

Judge Moody’s ruling cites the Endocrine Society’s guidelines in a lengthy section titled “Findings of Fact,” which is essentially a recitation of transgender ideology. A trial judge’s findings of fact are all but unreviewable on appeal. By allowing ideologues to hijack their organization, endocrinologists are making themselves complicit in a scientifically baseless movement that inflicts serious harm on children’s physical and mental health.

Dr. Eappen is a practicing endocrinologist in Montreal and a senior fellow at Do No Harm. Mr. Kingsbury is Do No Harm’s research director.

[ Via: https://archive.is/TPpis ]

Published: Jul 9, 203

Stephen Hammes’s response (Letters, July 5) to our op-ed (“The Endocrine Society’s Dangerous Transgender Politicization,” June 29) proves our point: The Endocrine Society is ignoring the dangers that sex-change treatments pose to children.

Dr. Hammes, president of the Endocrine Society, leaves out that the society’s pro-sex-change guidelines are based on “low” or “very low” quality evidence. He says nothing about the growing number of progressive European countries that are abandoning America’s model of gender-affirming care following systematic reviews of the evidence.

Dr. Hammes says that “2,000 studies published since 1975” support gender-affirming care. Yet many of these studies show negative results or nonresults, while all suffer from methodological problems like selection bias or a lack of proper control groups. These failings make it impossible to say whether drugs and surgeries were superior to less invasive alternatives like psychotherapy or even placebos. All but two dozen studies involved adults who transitioned as adults, not children, meaning more than 1,900 of the studies Dr. Hammes cites have no bearing on this issue. The layman may be impressed by the large number, but evidence-based medicine is concerned with the quality and reliability of research, not its quantity.

If Dr. Hammes is so confident in the Endocrine Society’s guidelines, he should have no problem launching a systematic review of all risks and benefits of hormonal interventions. It is more than warranted, six years after the guidelines were released. Until then, states have no choice but to pass laws to protect children from well-intended but harmful practices.

Roy Eappen, M.D., and Ian Kingsbury, Ph.D. Do No Harm Montreal and Marblehead, Mass.

[ Via: https://archive.is/2wUMl ]

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