Hi @Appalonia, I hope you don't mind but this week has seen another flurry of content that anyone with any interest in 'gender affirming care' should be reading or watching.
This week seems to be about the appalling weakness of evidence that has formed the basis of these treatment plans. You never know, posters like Tandora might actually start taking notice of what many of us are saying if they really do care about the standard of medical treatment recommendations. Rather than saying they do yet never once acknowledging the issues with it. That is a very sure sign of ideological thinking, yet those posters will also never either see that or acknowledge that.
www.bmj.com/content/380/bmj.p382
Gender dysphoria in young people is rising—and so is professional disagreement
Jennifer Block, investigations reporter 23 February 2023
These are just a few of the relevant paragraphs:
Guyatt, who co-developed GRADE, found “serious problems” with the Endocrine Society guidelines, noting that the systematic reviews didn’t look at the effect of the interventions on gender dysphoria itself, arguably “the most important outcome.” He also noted that the Endocrine Society had at times paired strong recommendations—phrased as “we recommend”—with weak evidence. In the adolescent section, the weaker phrasing “we suggest” is used for pubertal hormone suppression when children “first exhibit physical changes of puberty”; however, the stronger phrasing is used to “recommend” GnRHa treatment.
“GRADE discourages strong recommendations with low or very low quality evidence except under very specific circumstances,” Guyatt told The BMJ. Those exceptions are “very few and far between,” and when used in guidance, their rationale should be made explicit, Guyatt said. In an emailed response, the Endocrine Society referenced the GRADE system’s five exceptions, but did not specify which it was applying.
Helfand examined the recently updated WPATH Standards of Care and noted that it “incorporated elements of an evidence based guideline.” For one, WPATH commissioned a team at Johns Hopkins University in Maryland to conduct systematic reviews.3435 However, WPATH’s recommendations lack a grading system to indicate the quality of the evidence—one of several deficiencies. Both Guyatt and Helfand noted that a trustworthy guideline would be transparent about all commissioned systematic reviews: how many were done and what the results were. But Helfand remarked that neither was made clear in the WPATH guidelines and also noted several instances in which the strength of evidence presented to justify a recommendation was “at odds with what their own systematic reviewers found.”
For example, one of the commissioned systematic reviews found that the strength of evidence for the conclusions that hormonal treatment “may improve” quality of life, depression, and anxiety among transgender people was “low,” and it emphasised the need for more research, “especially among adolescents.”35 The reviewers also concluded that “it was impossible to draw conclusions about the effects of hormone therapy” on death by suicide.
Despite this, WPATH recommends that young people have access to treatments after comprehensive assessment, stating that the “emerging evidence base indicates a general improvement in the lives of transgender adolescents.”12 And more globally, WPATH asserts, “There is strong evidence demonstrating the benefits in quality of life and well-being of gender-affirming treatments, including endocrine and surgical procedures,” procedures that “are based on decades of clinical experience and research; therefore, they are not considered experimental, cosmetic, or for the mere convenience of a patient. They are safe and effective at reducing gender incongruence and gender dysphoria.”12
and
Sweden conducted systematic reviews in 2015 and 2022 and found the evidence on hormonal treatment in adolescents “insufficient and inconclusive.”24 Its new guidelines note the importance of factoring the possibility that young people will detransition, in which case “gender confirming treatment thus may lead to a deteriorating of health and quality of life (i.e., harm).”
Cochrane, an international organisation that has built its reputation on delivering independent evidence reviews, has yet to publish a systematic review of gender treatments in minors. But The BMJ has learnt that in 2020 Cochrane accepted a proposal to review puberty blockers and that it worked with a team of researchers through 2021 in developing a protocol, but it ultimately rejected it after peer review. A spokesperson for Cochrane told The BMJ that its editors have to consider whether a review “would add value to the existing evidence base,” highlighting the work of the UK’s National Institute for Health and Care Excellence, which looked at puberty blockers and hormones for adolescents in 2021. “That review found the evidence to be inconclusive, and there have been no significant primary studies published since.”
In 2022 the state of Florida’s Agency for Health Care Administration commissioned an overview of systematic reviews looking at outcomes “important to patients” with gender dysphoria, including mental health, quality of life, and complications. Two health research methodologists at McMaster University carried out the work, analysing 61 systematic reviews and concluding that “there is great uncertainty about the effects of puberty blockers, cross-sex hormones, and surgeries in young people.” The body of evidence, they said, was “not sufficient” to support treatment decisions.