The Texas Medical Association Is Misleading Doctors on Transgender Health Care

The Texas Medical Association (TMA), the state’s largest organization of doctors, has a long track record of endorsing pediatric gender medicine despite a lack of high-quality evidence and growing bioethical concerns. It is thus little surprise that the TMA’s Continuing Medical Education (CME) course on transgender health care fails to adhere to basic standards for physician education.

A review of the CME and slide deck reveals that the course violates multiple standards set by the Accreditation Council for Continuing Medical Education (ACCME), including the requirement that educational content be “fair and balanced” and support “safe, effective patient care.” The course materials may fail to meet the content standards outlined in Standard 1 of ACCME’s guidelines.

The TMA’s course on transgender health care extends the organization’s institutional stance beyond just its membership: it shapes how primary care physicians, who must complete continuing education requirements to keep their medical licenses up to date, conceptualize and treat gender dysphoria. Serious accountability is needed, before the TMA and organizations like it further undermine serious, evidence-based medicine and jeopardize the health of patients who look to them for guidance.

Troublingly, the CME misrepresents the evidence for the benefits of pediatric medical transition and relies on controversial clinical practice guidelines produced by the World Professional Association for Transgender Health (WPATH) and the Endocrine Society. Both of these were deemed unsuitable for use in clinical practice by the U.K.’s Cass Report. The CME presenters use WPATH guidelines, dismissed by the Trump administration as “junk science,” as a proxy for the “standard of care.”

WPATH guidelines are not based on systematic reviews, the highest-quality standard in evidence-based medicine. The Economist reported that WPATH commissioned systematic reviews for inclusion in its guidelines but suppressed them after their findings of “low certainty” evidence undermined its mission to expand access to medical transition.

While the Endocrine Society’s guidelines do rely on systematic reviews, its controversial recommendations of medical transition for minors are considered  “discordant,” in evidence-based medicine parlance, because the evidence supporting them is only of “low certainty.”

The psychiatrist who provided an overview of the evidence in the TMA’s course, Aekta Malhotra, did not appear to understand the evidence hierarchy. The slide Malhotra presented on the evidence of benefits for “affirming care” asserts that the practice reduces depression by 60 percent and suicidality by 73 percent. “[W]hen we look at the outcomes, this is really good for medical standards,” Malhotra said.

That is a misleading characterization of the state of the evidence. The findings derive from a controversial 2022 observational cohort study by Diana M. Tordoff and colleagues. An observational study cannot determine causality. Thus, its findings may not reflect the true impact of an intervention. It is for this reason that systematic reviews are used to provide a better sense of the true impact of an intervention in a given field.

In 2022, both journalist Jesse Singal and Manhattan Institute senior fellow Leor Sapir fact-checked the Tordoff study. Sapir noted that patients “experienced no statistically significant reduction in any of the assessed mental health problems.” The study also suffers from high loss to follow-up—patients dropped out before they could be reinterviewed—and other methodological issues.

The CME’s presentation of the Tordoff study findings arguably violated ACCME’s Standard 1.2, which asserts that all research referenced as part of a recommendation must reflect accepted standards of “experimental design . . . analysis, and interpretation.”

Though the course alludes to the U.K.’s Cass report in passing, the presenters did not engage with its findings, which were based on several systematic reviews commissioned from the University of York. By omitting the report’s relevant findings of “remarkably weak evidence” for pediatric medical transition, the CME violated ACCME’s Standard 1.1, which maintains that content must be “based on current science, evidence, and clinical reasoning.”

Other aspects of the course contravene ACCME Standards 1.3 and 1.4. The first asserts that on “new and evolving topics” accredited providers must facilitate engagement “without advocating for . . . practices that are not . . . adequately based on current science, evidence, and clinical reasoning.” Meantime, 1.4 asserts that an accreditor’s status can be compromised if his or her education “promotes recommendations” that are “determined to have risks or dangers that outweigh the benefits or are known to be ineffective in the treatment of patients.”

One particularly controversial slide on the risk-benefit analysis of medical transition suggests that reasons for transitioning include “the relief of gender dysphoria, reversibility, and improved mental health outcomes.” Based on the findings of systematic reviews, however, “affirming care” has not been shown to reduce dysphoria or to improve psychiatric functioning. Given that many of the long-term effects of hormone therapy and puberty blockers are unknown, it is misleading to label these interventions as reversible.

There is also considerable evidence of harms, including sexual dysfunction, adverse cognitive impacts, changes in bone density, cardiovascular and metabolic disorders, and regret. Physicians taking the TMA’s course would be fundamentally misled about the risk-benefit ratio, thus making them more likely to compromise the integrity of the informed consent process by unwittingly misleading patients and families.

The CME also fails to advance “fair and balanced” perspectives more generally. It teaches “gender identity” as social fact. Brett Cooper, a former TMA trustee currently being sued by Texas attorney general Ken Paxton for violating state law prohibiting physicians from rendering “affirming care” to dysphoric minors, introduced course members to the “genderbread person” and “gender unicorn” concepts, which are used to teach that “gender identity” is a stable trait without acknowledging the reality of detransitioners.

Significantly, the course promotes “affirmation” as the default treatment approach. While it acknowledges assessment guardrails recommended by WPATH, it undermines them by emphasizing deference to patient identity claims. Significantly, the presenters recommended only pro-affirming resources, including webinars by Fenway Health and the National LGBTQI center.

“We as physicians should respect that gender identity of transgender and non binary patients and ensure that their care is consistent with their identity. This includes using appropriate pronouns, providing gender-affirming care and respecting their chosen name,” Malhotra said.

Researcher J. Cohn recently analyzed how medical societies and journals misrepresent the evidence for medical transition through misleading statements and by relying on “non-representative individual studies.” The Texas Medical Association’s CME on Transgender Healthcare is a microcosm of this phenomenon.

Perversely, ACCME allows accredited providers like the TMA to promote content that violates its own standards. Meantime, it has allegedly bowed to activist pressure and forced Washington State University to remove a CME created by the Society for Evidence-Based Gender Medicine (SEGM) even after it had passed the medical school’s rigorous vetting process.

If ACCME is serious about its mission, it should investigate the TMA’s transgender course. As Cohn points out, medical societies that promote misinformation on gender medicine do a profound disservice to clinicians, patients, and the public.

Photo: Mikala Compton/The Austin American-Statesman via Getty Images