Hard look
Gender-affirming guidelines under the microscope
Contentious treatment guidelines linked with the explosive growth in medicalised gender change for minors have been exposed to new scrutiny.
Three guidelines and one policy recommending the “gender-affirming” treatment approach for children and adolescents are being evaluated by England’s independent review of gender dysphoria care led by paediatrician Dr Hilary Cass.
The four documents are the 2022 Standards of Care from the World Professional Association for Transgender Health (WPATH), the 2018 affirmation-only policy of the American Academy of Pediatrics, the 2017 Endocrine Society guideline, and a 2018 Australian guideline promoted as the first specific to dysphoric minors and the world’s “most progressive”.
The Cass review team confirmed to GCN the inclusion of these four documents in its current review of existing guidelines. In Dr Cass’s January 31 letter to the National Health Service England, she said her team was “making excellent progress” on this and other reviews, with results expected in the Northern Spring.
This is likely to intensify the scrutiny of gender-affirming guidelines and policy documents, which have been criticised for recommending social and medical transition of young people with more confidence than the weak and uncertain evidence base safely allows.
Pro-transition guidelines and policy statements by health professional bodies have been described as “eminence-based medicine”, with critics arguing that public trust and emotive identity politics have been misused to compensate for low quality or missing data.
Straight after publication last year, the 8th version of the WPATH standards of care switched from lower age minimums for life-altering hormonal and surgical treatment to no age constraints at all. Although WPATH recognised the surge in teenagers seeking treatment, it claimed that a systematic review of the medical literature for this group was “not possible.”
Since 2020, there have been five systematic reviews carried out by public health authorities in Finland, Sweden, England (two for the Cass review) and the American state of Florida. All concluded that the evidence base for medicalised gender change with minors was weak and uncertain.
In a 2021 international appraisal of clinical guidelines by six independent reviewers, none recommended use of WPATH’s previous, 7th version of its standards of care, with particular problem areas being lack of rigour in development and questionable editorial independence.
A follow-up comment on the latest incarnation of WPATH’s guideline said: “It appears WPATH expects readers to faithfully accept potentially biased judgments of the literature rather than confidently submitting [the 8th version standards of care] to open scientific scrutiny. [The guideline] could have been much better: its evidence base and recommendations cannot yet be relied upon.”
The 2017 Endocrine Society guideline, often invoked to support gender-affirming hormonal treatment, rated the evidence for almost all its recommendations as “low” or “very low” quality.
Despite its use by activists claiming a consensus for gender-affirming care, the Endocrine Society document itself is presented as a practice guideline, not an authoritative standard of care, and it cautions that its treatment suggestions “cannot guarantee any specific outcome, nor do they establish a standard of care.”
Video: The pediatrics academy anatomised
Truth-adjacent?
The dogmatic endorsement of the gender-affirming model by the American Academy of Pediatrics (AAP) as the only proper treatment for youth gender dysphoria involved wholesale misrepresentation of the evidence, which in truth favoured the more cautious “watchful waiting” approach, according to a “fact check” of the document by clinical psychologist and researcher Dr James M. Cantor.
“In its [2018] policy statement, AAP told neither the truth nor the whole truth, committing sins both of commission and of omission, asserting claims easily falsified by anyone caring to do any fact-checking at all,” Dr Cantor said.
The academy has failed to take up multiple opportunities since 2018 to rebut the Cantor critique and has reportedly ignored requests for a thorough review of the gender-affirming policy from its own paediatrician members, as well as detransitioners who regret their treatment as a harmful mistake.
Video: American gender clinic whistleblower Jamie Reed
Child-led
In 2018 the journal The Lancet celebrated a new Australian treatment guideline under the heading “Gender-affirming care needed for transgender children.” This was the first dysphoria guideline “focusing solely” on children and adolescents, according to the journal’s unsigned editorial.
The guideline was badged as Australian Standards of Care and Treatment Guidelines for Trans and Gender-Diverse Children and Adolescents. All four of its authors were from the gender clinic at the Royal Children’s Hospital Melbourne (RCH).
The Lancet’s editorial said the Australian guideline broke new ground by insisting that social transition — the process of living as the opposite sex, a psychosocial intervention which may lock-in gender distress — “should be led by the child.” Minimum ages for medical interventions were discarded in favour of individualised timing for each patient.
Criticism of the new guideline began with a letter to the editor of The Lancet from Professor Richard Byng of the University of Plymouth and three other physicians, who said:
“The health of transgender children is addressed with imprecise language [“sex assigned at birth”] and overplayed empirical evidence in new Australian guidelines and in [your] editorial. The evidence of medium-term benefit from hormonal treatment and puberty blockers is based on weak follow-up studies.
“The guideline does not consider longer-term effects, including the difficult issue of detransition. Patients need high-quality research into the benefits and harms of all psychological, medical, and surgical treatments, as well as so-called wait-and-see strategies.”
The RCH guideline advises that “psychiatric morbidities such as depression, anxiety and psychosis [should] not necessarily prevent” medicalised gender change, although it concedes the clinical decisions might be more complex.
The guideline advises that “chest reconstructive surgery” (trans mastectomy) is regularly performed across the world in countries where the age of majority for medical procedures is 16 years.”
A version of the guideline published as a peer-reviewed paper in The Medical Journal of Australia said: “The scarcity of high-quality published evidence on the topic prohibited the assessment of level (and quality) of evidence for these recommendations.”
This statement does not appear in the publicly available guideline (Version 1.3, 2020) on the hospital’s website.
In May last year a project to revise the RCH guideline was announced.
An outline for the project suggests the updated guideline could include links to patient information sheets, consent forms and a directory of clinicians in order to roll-out puberty blockers and hormones across Australia.
In 2019, the Melbourne hospital defended its treatment guidelines as “peer reviewed at the highest level [and] adopted by healthcare providers across Australia and the globe.”
Tavistock clinic made early puberty blocking standard clinical treatment mid-way through a study of this intervention, then buried the disappointing results for years.
Hormonal treatments at RCH began to take off with sharply rising patient numbers around 2014. They started recruiting for long-term study in 2017 & published the research protocol two years later with the statement that more evidence for these treatments was “urgently needed”. In 2023 even preliminary data on outcomes is yet to be published.
The UK seems to have had the best political leadership so far — the bureaucracy can’t have encouraged ministers to set up & take seriously the Cass review — and yet even in the UK the politicians are erratic, as seen by the embrace of a gender identity conversion therapy ban, as if it has nothing to do with the Cass review.