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Dr. Gordon Guyatt is no lightweight. Inducted into the Canadian Medical Hall of Fame in 2016, Guyatt is one of Canada’s most cited researchers with over 1,200 publications, which have been cited by other scholars at least 100,000 times.
Guyatt is most known for his contributions to evidence-based medicine. In fact, he coined that very term. Evidence-based medicine is “one of the great innovations in general medical practice over the last several decades.” As its name implies, the goal of evidence-based medicine is to make medical decisions based on scientific evidence. This might seem to be an obvious goal (e.g. what would medicine be based on if not evidence?). But the novelty of evidence-based medicine was to apply the most rigorous standards to assess existing evidence and then make medical recommendations.
Guyatt was also an architect of one specific tool of evidence-based medicine: the Grading of Recommendations Assessment, Development and Evaluation (GRADE). GRADE assesses the degree of certainty of academic studies and how various factors increase the certainty or uncertainty of the study’s findings. For example, GRADE will assess whether studies are biased towards certain findings. Evidence of bias reduces the certainty of a study’s findings.
“The goal of evidence-based medicine is to make medical decisions based on scientific evidence.”
Evidence-based medicine and GRADE have become the gold standard in science. In a world with so much information available, so many different study methodologies, and so much politicization in academics, evidence-based medicine helps medical practitioners to make the best medical decisions.
Evidence-based medicine and medical gender transitions
This GRADE methodology was briefly mentioned in the United Kingdom’s Cass Review and extensively used in the United States’ Treatment for Pediatric Gender Dysphoria: Review of Evidence and Best Practices. Both of these seminal reviews strongly recommended against medical transitioning for minors. But relatively little work has been done in Canada.
So, Guyatt and a team of researchers from McMaster University decided to apply evidence-based medicine and GRADE to assess the academic literature on medical gender transitions. The Canadian team of researchers wrote two papers, applying GRADE methodology to review studies on the effect of puberty blockers and cross-sex hormone therapy on youth under the age of 26.
The results confirmed earlier reviews. They found that there was very low certainty about the effects of giving puberty blockers to children and adolescents with gender dysphoria on global function (i.e. overall well-being), depression, gender dysphoria, bone mineral density, and likelihood to progress to receive “gender-affirming hormone therapy.” The authors noted that all the studies suffered from methodological issues such as high risk of bias and imprecision. This study “is the first systematic review and meta-analysis to assess the effects of puberty blockers in children, adolescents and young adults with GD [gender dysphoria] using the highest methodological standards.”
Guyatt’s team’s analysis of cross-sex hormones did not fare much better. The researchers had very low certainty about the effects of giving cross-sex hormones to children, adolescents, and young adults regarding their global function, depression, gender dysphoria, sexual dysfunction, and bone mineral density. The only finding that the researchers were highly certain of was that taking cross-sex hormones increased the risk of cardiovascular events (e.g. heart attacks or strokes) within 7-109 months.
“Here we have two more studies that we can pile onto the growing list of academic papers that caution against medical transitioning for minors.”
Notably, the two studies used the age cut-off of 26. Most studies, medical systems, and legal codes focus on children and adolescents under the age of majority (usually 18 or 19). But the Finnish guidelines, commentary on the Swedish guidelines, and the Cass Review on medical transitioning for minors have noted that the human brain isn’t fully developed until age 25.
Yet children, youth, and young adults are currently allowed to make irreversible decisions about their bodies before their brain is fully developed. Puberty blockers affect the development of their brain. Some of their impacts might not be fully apparent until brain development ends. Given these realities, it makes sense not only to assess the impact of a medical transition, not just on children and adolescents up to 18 or 19, but on young adults up to 26 as well.
Here we have two more studies that we can pile onto the growing list of academic papers that caution against medical transitioning for minors.
But that’s not the end of the story.
Evidence meets ideology
In the months after publishing these two studies, Dr. Guyatt was condemned by trans activists for publishing the study. They didn’t like an academic paper that failed to wholeheartedly support medical transitioning. Under pressure, Guyatt, his fellow researchers, and McMaster published a letter saying that “We are concerned our findings will be used to justify denying care such as puberty blockers and hormone replacement therapy to TGD individuals… it is unconscionable to forbid clinicians from delivering gender-affirming care… forbidding delivery of gender-affirming care and limiting medical management options on the basis of low certainty evidence is a clear violation of the principles of evidence-based shared decision-making and is unconscionable.”
Well, it is only unconscionable if patient autonomy is far more important than evidence. The entire practice of “gender-affirming care” is predicated on the idea that puberty blockers, cross-sex hormones, and surgeries are beneficial treatments for gender dysphoria. Guyatt’s studies find that there is very low certainty that these benefits exist. If that is true, then medical transitioning can hardly be “medically necessary.” Actually, it can’t reasonably be called “health care” if there is very low certainty that it improves health. Trans advocates often speak about “embodiment goals,” using puberty blockers, cross-sex hormones, or surgeries to achieve a certain appearance. Interventions for these reasons certainly aren’t a form of health care. They are cosmetic interventions.
“Guyatt’s studies find that there is very low certainty that these benefits exist.”
As part of their penance for their ideological sins, the researchers “personally made a donation to Egale Canada’s legal and justice work, noting their litigation efforts aimed at preventing the denial of medically necessary care for gender-diverse youth”. Egale Canada is a pro-trans group that, among other things, launched a legal challenge of Alberta’s restrictions on medical transitioning for minors. So the champions of a bias-detecting tool like GRADE made very public donations to an activist group. Not a great fit.
To further complicate the story, Guyatt later said that he strongly disagreed with EGALE’s stated view that medical transitioning is “medically necessary care for gender-diverse youth.” Yet that statement was made in a letter that Guyatt signed. When asked about why he signed a letter he didn’t agree with, Guyatt responded that he must not have read the 507-word letter carefully enough before signing it.
Dr. Guyatt may be a Medical-Hall-of-Famer, but that’s a rookie mistake.
Evidence-based and ethical medicine
Evidence can’t exist in a value-free vacuum. We are convinced that medical transitioning for minors isn’t a value-free activity either. The prevalence of harm, the question of consent, the rush to transition, and the immutability of sex all justify efforts by governments to curtail the practice. When studies find little certainty that medical transitioning improves the health and well-being of those suffering from gender dysphoria, greater caution over these interventions must be exercised.