Scrutinizing Gender-Affirming Care for Minors: A Closer Look at Systematic Reviews and Their Implications

Earlier this year, clinical epidemiologist Gordon Guyatt co-authored three systematic reviews focusing on various aspects of gender-affirming care tailored for children and young adults, including puberty blockers, hormonal treatments, and top surgery. Under the leadership of a Ph.D. student, Guyatt was enlisted to maintain objectivity during the review process, leveraging his extensive experience in evaluating medical interventions.

The Authority Behind the Reviews

Gordon Guyatt holds a position as a professor of health research methods, evidence, and impact at McMaster University in Canada. He is credited with coining the term “evidence-based medicine” in 1991, and has dedicated over 45 years to scrutinizing the safety and efficacy of diverse medical treatments, culminating in numerous systematic reviews and clinical guidelines. His approach to the gender-affirming care reviews adhered strictly to the established methodology he has employed throughout his career.

“I do the work. I do it well. I present it properly. I make the right conclusions. I put it out in an optimal way. And my work is done,” Guyatt expressed in a recent interview. “This is the first time that has not worked out.”

While the reviews were made publicly available, they immediately faced scrutiny regarding their funding sources. The Society for Evidence Based Gender Medicine (SEGM), a nonprofit organization that questions the safety and efficacy of gender-affirming treatments, funded these reviews and helped determine the focus of the research questions.

The Implications of Funding

Although SEGM does not overtly advocate for laws that restrict gender-affirming care, they consistently highlight the frailty of the current evidence base, which has provided ammunition to proponents of such bans. For instance, the organization submitted an amicus brief for a Supreme Court case challenging Tennessee’s ban on gender-affirming treatments for minors. The brief labeled gender-affirming care as “experimental” and criticized its “remarkably weak scientific foundation.”

Reflecting on the controversy, Guyatt disclosed that he was previously unaware of SEGM’s level of involvement. After the publication of the reviews, he noted that SEGM’s influence on the perceived legitimacy of the research prompted significant backlash.

Quality of Evidence and Misuse of Findings

The McMaster team’s reviews categorized the evidence supporting each type of gender-affirming care as either low or very low in certainty. Guyatt stands by these findings, explaining that low quality does not equate to ineffective care. In his words, “Low quality evidence doesn’t mean it doesn’t work. It means we don’t know. And so, we try.” Patient accounts of experiencing substantial benefits from gender-affirming therapies attest to this ambiguity.

However, these findings were quickly pounced upon by opponents of gender-affirming care, including the Trump administration. Their report on gender dysphoria cited Guyatt’s work numerous times, framing it as justification for their calls to restrict access to such care.

“To use the systematic reviews as justification for banning gender-affirming care is an ‘egregious and unconscionable’ misuse of the work,” Guyatt stated emphatically.

Understanding the Origins of the Systematic Reviews

In discussing the impetus for the reviews, Guyatt explained, “There’s a woman named Romina Brignardello, who worked as my postdoctoral fellow. She came to me and said, ‘Gordon, I’m doing these systematic reviews, and one of my Ph.D. students is going to be leading the reviews.’” He was drawn in to ensure the reviews would be rigorous and free from bias, a vital consideration given the potential for controversy surrounding the subject.

Broader Implications for Medical Evidence

The central findings of the reviews highlighted that existing studies were significantly limited. Critical outcomes regarding personal well-being post-treatment yielded low certainty, raising important questions about the ongoing application of these treatments even in the face of scant evidence. Guyatt insightfully pointed out that many medical recommendations fall into similar categories of weak evidence:

“Most of what we do. ‘UpToDate,’ which is the most widely used decision-support tool for clinicians, uses our GRADE approach. It has over 10,000 graded recommendations, and two-thirds of them are weak recommendations.”

Navigating the Challenges of Evidence Misinterpretation

Guyatt expressed concern over the increasing political misinterpretation of the reviews, particularly from the trans advocacy community. As discussions escalated regarding the political implications of the reviews, he recognized a troubling trend of using academic findings to support harmful legislative measures against gender-affirming care.

His frustration mounted when he struggled to address misleading interpretations openly. After multiple failed attempts to have his positions published in relevant journals, McMaster University finally issued a statement clarifying the intent and implications of the reviews.

Navigating Different European Approaches to Care

In 2023, the stance taken by the American Academy of Pediatrics (AAP) regarding gender-affirming care came under scrutiny as they recommended a review of existing evidence while simultaneously reaffirming prior policies. When questioned regarding varying international approaches, Guyatt pointed out that European countries had already conducted reviews that could have informed the AAP’s stance.

“It would be great to get some high-quality evidence,” he remarked, stressing the urgency of thorough research in guiding clinical practice.

In sharing his insights, Guyatt emphasized the importance of weighing patient autonomy against potential risks, highlighting that diminished access to care could ultimately result in grave consequences for those who would benefit from gender-affirming treatment.

Conclusion: Continuing the Conversation

Gordon Guyatt’s experiences underscore the intricate relationship between clinical evidence, patient autonomy, and political motivations in the healthcare arena. As discussions surrounding gender-affirming care for minors rage on, the medical community must navigate these complexities while striving for objective, evidence-based practices that prioritize patient welfare above all else.

As he concluded, Guyatt’s commitment to continuing this vital conversation remains steadfast, ensuring that science and patient care are not overshadowed by political biases.