Why Europe and America are going in opposite directions in youth transgender medicine

A growing number of countries, including some of the most progressive in Europe, are rejecting the American model of gender affirmation care for identified transgender youth. These countries have adopted a much more restrictive and cautious approach, prioritizing psychotherapy and reserving hormonal interventions for extreme cases.

In stark contrast to groups such as the American Academy of Pediatrics (AAP), which urges doctors to “affirm” their patient’s identity, regardless of the circumstances and regarding alternatives to an early affirmation/affirmation-only “conversion therapy”, European health authorities recommend exploratory therapy to discern why adolescents reject their bodies and whether less invasive treatments can help.

If implemented in American clinics, the European approach would effectively deny puberty blockers and cross-sex hormones to the majority of teenagers receiving these drugs today. Unlike the USin 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 “lifesaving” care? The answer is that Europeans follow the principles of evidence-based medicine (EBM), while Americans do not.

A fundamental principle of EBM is that medical recommendations should be based on the best available research. EBM recognizes a information hierarchy. The expert opinion of doctors, for example, even when based on extensive clinical experience, provides the lowest quality, ie least reliable, information. A little higher up the information pyramid are observational studies. Systematic reviews of the evidenceMeanwhile, they provide the highest quality evidence. They follow a rigorously developed and reproducible methodology. They do not choose studies with convenient results, but consider all available research.

Most importantly, systematic reviews do not simply summarize the findings of available studies on a question of interest. Instead, they evaluate the strengths and weaknesses of these studies to determine the reliability of their findings. Systematic reviews are usually used to do this the GRADE system (Grading of Recommendations, Assessment, Development and Evaluations) and classify the quality of the evidence as ‘high’, ‘moderate’, ‘low’ or ‘very low’.

Systematic reviews of EBM experts in Scandinavia i the united kingdom have concluded that there are serious gaps in the evidence base for sex reassignment in minors. UK systematic reviews found that the available research was of ‘very low’ quality, meaning that there is very low certainty that an observed effect, such as a reduction in suicide, is due to the intervention and therefore , the claimed results of the studies 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 was rated “very low” because of serious methodological problems. The Swedish National Board of Health and Social Welfare has said that the risks of treating gender dysphoria minors with hormonal interventions “currently outweigh the potential benefits.”

Last year, Florida health authorities commissioned what’s known as an “umbrella review,” or a systematic overview of systematic reviews, from independent experts at McMaster University, home of the EBM. Not surprisingly, this overview reached the same conclusion: there is no reliable evidence that youth transition improves mental health outcomes.

Because medical groups in the US don’t always use EBM, their conclusions may be based on studies whose fatal flaws are overlooked or ignored. Consider, as an example, a study conducted at Seattle Children’s Hospital and published last year. The study authors reported that the use of puberty blockers and cross-sex hormones was associated with 60 percent lower odds of depression and 73 percent higher odds of suicide. Main publications, incl American scientist i Psychology today, celebrated the findings. More recently, major US medical associations he cited the study in federal court proceedings.

But to attentive look Study data show that children who received hormonal interventions did no better at the end of the study than at the beginning. The researchers’ claim of improvement was based on the fact that children in the control group, who received psychotherapy but not hormones, did worse relative to the hormone group. But even this is imprecise, as 80 percent of the control group dropped out at the end of the study, and a likely reason for this dramatic loss to follow-up is that many or perhaps all of the children not treated with hormones enhanced 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 Annex A in the case against pediatric sex changes.

There are similar problems in studies that purport to show a transition regret rate of less than 1 percent. The true regret rate is not known and it will not be known for years to come. The claim that gender-dysphoric teenagers are at high risk of suicide if they don’t have access to “gender-affirming” drugs and surgeries is equally true. baseless and irresponsible. In February, Finland’s top expert in gender medicine emphasized this point in the country’s liberal newspaper.

The American Academy of Pediatrics’ major statement on gender medicine, written by a single physician while still in residency, is not a systematic review. The same author has granted at most. A later published peer-reviewed fact-checking found the AAP’s statement to be a textbook example of cherry-picking and mischaracterization of the evidence.

The World Professional Association for Transgender Health (WPATH) says in its latest “standards of care” that a systematic review of the evidence “is not possible”. Instead, WPATH used a “narrative review,” which has a high risk of bias according to EBM because it does not use a reproducible methodology. England has it broken from WPATHand the director of the Center for Evidence-Based Medicine in Belgium has said I would “throw them away [WPATH’s guidelines] in the trash can.” In the US, the WPATH standards are widely accepted as authoritative.

The American Endocrine Society has relied on two systematic reviews in its development its own pattern. But those reviews had no mental health benefits, and in any case the Endocrine Society rates the quality of evidence behind its own recommendations as “low” or “very low.”

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

At the beginning of this year, research report in the prestigious British Medical Journal concluded that although pediatric gender medicine in the US 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 to manage “unreliable” youth gender dysphoria.

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

Dr. Meredithe McNamara of the Yale School of Medicine shouts the questioner of the evidence behind pediatric sex changes ‘science denial’. His protest is ironic. Science is an ongoing process of inquiry and debate, not a set of predetermined conclusions. Science depends on skepticism, especially about sensitive topics. True science denial means restricting rational, evidence-based debate, which is exactly what McNamara and the new WADA president want to do.

Their appeals are paying off. This same month, gender activists successfully pressed a medical journal to retract an article whose conclusions they found uncomfortable. The ongoing campaign to suppress scientific debate allows a pseudo-consensus to emerge around “gender-affirming care.”

Simply put, pediatric gender medicine in the US is out of control. The medicalization of gender diversity in children is a fast-growing industry that shows no signs of self-correcting. Doctors and therapists who practice “affirmative” medicine. constantly demonstrates ignorance about the principles of EBM and mislead the public about the sad realities behind the euphemism “attention to gender affirmation.”

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 the medical transitionthey insist, it makes no sense, even “dehumanizing.”

The author of the AAP position paper on gender medicine has said that a “The child’s sense of reality” is the “navigational beacon to guide treatment.” The director of the gender clinic at Boston Children’s Hospital he has admitted it offer puberty blockers “like candy”. Even the founding psychologist of that clinic has warned children are being inappropriately “pressured into the medical model.”

Why the US has become an outlier in 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 government funding, the evidence base must be assessed. The American health care system is more vulnerable to profit motives, activist doctors and political pressures. Medical colleges they aim to defend the patient’s health but may have other reasons too.

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

Leor Sapir is a fellow at the Manhattan Institute.