"One of those treatments, Karasic says, is antidepressants. A systematic review performed by Cochrane, an international nonprofit research organization that has conducted thousands of systematic reviews, found that for children and adolescents “most antidepressants may be associated with a ‘small and unimportant’ reduction in depression symptoms.” And even this “small and unimportant” association was “low certainty” for some of these drugs.
And, like gender-affirming treatments, antidepressants come with serious risks. These risks include potential bone density loss, which is a commonly cited risk of puberty blockers, as well as suicidality. “Antidepressants have a black box warning in minors for an increase in suicidality, and yet we use them all the time because they help a lot of people,” Karasic said.
Karasic also pointed to the fact that there are no studies showing that anything else works for gender dysphoria. “For those who do need it, there’s not an alternative treatment,” he said.
Dr. Meredithe McNamara, assistant professor of Pediatrics at Yale, agrees that the term “low quality” can be misleading. “I would say that the problem is that ‘low quality’ evidence is a technical term that spiraled out from the GRADE method,” she said.
Last year, McNamara led a team of researchers who wrote a critical analysis of Florida’s new guidelines that cited “low quality” evidence to justify ending Medicaid coverage for gender-affirming care both for children and adults. McNamara’s analysis showed that a consistent application of this standard would force the state to deny coverage for mammograms, routine surgeries, and drugs that lower cholesterol.
She argued that high-quality evidence is often not available to assess treatments on minors and for rare conditions, and so the lack of it isn’t a good reason to deny treatment.
“You don’t need high-quality evidence to practice good care. You don’t need high-quality evidence to follow strong recommendations,” she said."