McMaster University in Ontario is known as the birthplace of evidence-based medicine—the practice of integrating clinical expertise with the best available research findings and considerations of patient values and preferences. That legacy makes recent remarks on so-called gender medicine by several McMaster researchers especially baffling.
Earlier this month, five McMaster researchers from the university’s Department of Health Research Methods, Evidence and Impact (HEI) released a statement condemning the “misuse” of systematic reviews that they had authored to justify restrictions on sex-rejection procedures for minors. The controversy is fueled by a growing schism between the university and the Society for Evidence-Based Gender Medicine (SEGM), which funded the reviews. After the Southern Poverty Law Center attempted to smear SEGM by formally labeling it a pseudoscientific “hate group,” McMaster’s leadership became uncomfortable with the SEGM affiliation and urged the HEI researchers to distance themselves. Crucially, though, SEGM was forthcoming with McMaster at all stages of their collaboration and agreed to the university’s research agreement and terms for managing conflicts of interest. The reviews, like other systematic reviews in this area of study, found only “low certainty” evidence for the benefits of gender “affirming care.”
Revealingly, the researchers did not dispute the reviews’ methodological integrity or findings. Their concern lay instead with reputational fallout, particularly from “members and allies of 2SLGBTQIA+ communities.” Advocates in this camp have targeted HEI researchers, including through a social media operation, and accused them of collaborating with a hate group to “harm trans youth” and “deny gender-affirming care.” Ironically, the very researchers devoted to eliminating bias in medical decision-making have fallen prey to political pressures.
The researchers—including Gordon Guyatt, the so-called godfather of evidence-based medicine—argued that the principles of evidence-based decision-making require that patient “values and preferences” guide shared decisions, especially when evidence is uncertain.
The statement makes several bad-faith claims about the context surrounding the McMaster reviews. It also arguably overvalues patient autonomy at the expense of medicine’s commitment to the principle of “do no harm,” a concern even more pressing when the patients in question are minors.
The McMaster researchers begin their statement by accusing critics of using their reviews in “profoundly misguided” ways—framing “affirming care” as “bad care” on the grounds that it rests on “low-certainty evidence” and is “driven by ideology.” Presumably, this claim references the inclusion of three McMaster reviews in the Department of Health and Human Services’ report on pediatric gender dysphoria.
The HHS report, however, makes no explicit policy recommendations. Its stated aim is to “provide the most accurate and current information available regarding the evidence base for the treatment of gender dysphoria.” Citing the findings of the McMaster reviews is entirely consistent with that mission. Moreover, accurately describing the state of the research is a public service, necessary to counterbalance the society-wide gaslighting campaign by virtually every medical association to convince the public that “affirming care” is “evidence-based” and the unambiguous medical standard.
Part III of the HHS report on clinical realities clearly establishes that “affirming care” rests partly on contested ideological claims about dysphoria and cross-sex identities, and that political pressures have influenced treatment guidelines. Indeed, the McMaster researchers’ own reply shows signs of such pressure. They signal ideological solidarity by adopting activist language, describing the Society for Evidence-Based Gender Medicine as composed of “non-trans, cis-gender researchers.”
They further assume that, in the face of low-certainty evidence, patient autonomy should be decisive in “affirming care.” They add that many medical interventions also rest on low-certainty evidence, and that “enlightened individuals often legitimately and wisely choose such interventions.”
Analogizing “affirming care” to other areas of medicine falls short for several reasons. For one, pediatric medical transition involves minors, who are widely recognized to lack the emotional and cognitive maturity of adults, raising moral considerations about their ability to understand the long-term consequences of medical interventions. This intersects with the ethical principle of preserving a child’s right to an “open future.”
We also know that gender dysphoria is not a stable diagnosis. Many youths tend to outgrow it during the normal course of development. Similarly, trans-identification itself is not static but dynamic.
Finally, confusion persists about what condition pediatric medical interventions are meant to treat. For example, the World Professional Association for Transgender Health’s SOC-8 guidelines advocate for the International Classification of Disease-11’s “Gender Incongruence” diagnosis, which removes patient distress as a diagnostic feature to reduce stigma associated with the condition. Unlike other medical diagnoses, though, gender incongruence does not involve an underlying disease state. Without clear evidence for health benefits, it’s hard to claim that medical transition is consistent with the UN’s recognition that children are entitled to “the highest attainable standard of health.”
This concern grows sharper when we consider the potential harms of pediatric medical transition. While systematic reviews may find only low-certainty evidence of harm, another point must be stressed. As the HHS report notes, our knowledge of the effects and mechanisms of puberty blockers and cross-sex hormones—as well as normal human physiology—allows us to anticipate multiple risks. These include fertility and sterility issues, sexual dysfunction, neurodevelopmental challenges, loss of bone density, metabolic and cardiovascular issues, and psychiatric problems, among others.
In light of these points, the McMaster researchers’ claim that it is “unconscionable” to restrict access to “affirming care” represents shortsighted ethical analysis and a retreat from other values that ought to guide clinical ethics. Patient autonomy is indeed a core value in medical ethics, but it should not be valued at the expense of “beneficence” and “non-maleficence.” Notably, in an interview with journalist Jesse Singal, Guyatt argues that some physicians may determine that an adolescent possesses the maturity to make serious medical decisions. He goes on to concede, however, that “they may be wrong. Maybe no 14-year-old is ever in that position. I’m not the person who can say.”
Basing support for pediatric gender medicine on a combination of low-certainty evidence and a minor’s protean desires is not an act of compassion. True compassion requires weighing risks and benefits in a way that may limit children’s immediate desires but will preserve their capacity to make irreversible medical decisions—after they come of age.
Photo by R.J. Johnston/Toronto Star via Getty Images
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