A growing number of countries, including some of the most progressive in Europe, are rejecting the U.S. “gender-affirming” model of care for transgender-identified youth. These countries have adopted a far more restrictive and cautious approach, one that prioritizes psychotherapy and reserves hormonal interventions for extreme cases.
In stark contrast to groups like the American Academy of Pediatrics (AAP), which urges clinicians to “affirm” their patient’s identity irrespective of circumstance and regards alternatives to an affirm-early/affirm-only approach “conversion therapy,” European health authorities are recommending exploratory therapy to discern why teens are rejecting their bodies and whether less invasive treatments may help.
If implemented in American clinics, the European approach would effectively deny puberty blockers and cross-sex hormones to most adolescents who are receiving these drugs today. Unlike in the U.S., in Europe surgeries are generally off the table before adulthood.
Why are more countries turning their backs on what American medical associations, most Democrats and the American Civil Liberties Union call “medically necessary” and “life-saving” care? The answer is that Europeans are following principles of evidence-based medicine (EBM), while Americans are not.
A bedrock principle of EBM is that medical recommendations should be grounded in the best available research. EBM recognizes a hierarchy of information. The expert opinion of doctors, for example, even when based on extensive clinical experience, furnishes the lowest quality — meaning, least reliable — information. Slightly higher on the information pyramid are observational studies. Systematic reviews of evidence, meanwhile, furnish the highest quality evidence. They follow a rigorously developed, reproducible methodology. They do not cherry-pick studies with convenient results, but instead consider all the available research.
Most importantly, systematic reviews don’t merely summarize the conclusions of available studies on a question of interest. Instead, they assess the strengths and weaknesses of these studies to determine the reliability of their findings. To do this, systematic reviews typically use the GRADE system (Grading of Recommendations, Assessment, Development and Evaluations) and rank the quality of evidence as “high,” “moderate,” “low” or “very low.”
Systematic reviews by EBM experts in Scandinavia and the United Kingdom have concluded that there are serious gaps in the evidence base for sex modification in minors. The U.K. systematic reviews found the available research to be of “very low” quality — meaning that there is very low certainty that an observed effect, like reduced suicidality, is due to the intervention, and therefore the studies’ claimed results are unlikely to represent the truth.
Importantly, even the famous Dutch study that is said to be the “gold standard” of research in this area received a rating of “very low” due to serious methodological problems. Sweden’s National Board of Health and Welfare has said that the risks of treating gender dysphoric minors with hormonal interventions “currently outweigh the possible benefits.”
Last year, Florida’s health authorities commissioned what is known as an “umbrella review,” or a systematic overview of systematic reviews, from independent experts at McMaster University, home of EBM. Unsurprisingly, that overview came to the same conclusion: There is no reliable evidence that youth transition improves mental health outcomes.
Because U.S. medical groups don’t always use EBM, their conclusions can be based on studies whose fatal flaws are overlooked or ignored. Consider, as an example, a study done at Seattle Children’s Hospital and published last year. The study’s authors reported that use of puberty blockers and cross-sex hormones was associated with 60 percent lower odds of depression and 73 percent lower odds of suicidality. Leading mainstream publications, including Scientific American and Psychology Today, celebrated the findings. More recently, major U.S. medical associations cited the study in federal court proceedings.
But a careful look at the study’s data shows that the kids who received hormonal interventions did no better by the end of the study than at the beginning. The researchers’ claim about improvement was based on the fact that the kids in the control group, who received psychotherapy but not hormones, got worse relative to the hormone group. But even this isn’t accurate, as 80 percent of the control group dropped out by the end of the study, and a likely reason for this dramatic loss to follow-up is that many or perhaps all of the non-hormone-treated kids improved without “gender-affirming” drugs. It’s quite possible that if the researchers had followed up with all the participants, we’d see this study become Exhibit A in the case against pediatric sex changes.
Similar problems exist in studies purporting to show a rate of transition regret of less than 1 percent. The true rate of regret is not known and won’t be known for years to come. The claim that gender dysphoric teens are at high risk of suicide if not given access to “gender-affirming” drugs and surgeries is likewise baseless and irresponsible. In February, Finland’s top expert in gender medicine emphasized this point to the country’s liberal newspaper of record.
The American Academy of Pediatrics’ main statement on gender medicine, authored by a single doctor while still in his residency, is not a systematic review. The author himself has conceded as much. A later published peer-reviewed fact check found the AAP statement to be a textbook example of cherry-picking and mischaracterization of evidence.
The World Professional Association of Transgender Health (WPATH) says in its latest “standards of care” that a systematic review of evidence is “not possible.” Instead, WPATH used a “narrative review,” which has a high risk of bias according to EBM because it doesn’t utilize a reproducible methodology. England has broken from WPATH, and the director of Belgium’s Center for Evidence-Based Medicine has said he would “toss them [WPATH’s guidelines] in the bin.” In the U.S., WPATH’s standards are widely accepted as authoritative.
The U.S. Endocrine Society has relied on two systematic reviews in developing its own guideline. But these reviews were not for mental health benefits, and in any case the Endocrine Society ranks the quality of evidence behind its own recommendations as “low” or “very low.”
All other U.S. medical groups cite these three sources when assuring the public about “gender-affirming care,” thus creating an illusion of consensus around “settled science.”
Earlier this year, an investigative report in the prestigious British Medical Journal concluded that although pediatric gender medicine in the U.S. is “consensus-based,” it is not “evidence-based.” Gordon Guyatt, distinguished professor in the Department of Health Research Methods, Evidence, and Impact at McMaster University, Ontario, and one of the founders of EBM, recently called American guidelines for managing youth gender dysphoria “untrustworthy.”
Consensus can be produced by misguided empathy, ideological capture or political pressures. Consensus can also be manufactured. The new president of the American Medical Association (AMA) has said there should be “no debate” when it comes to offering kids “gender-affirming” drugs and surgeries.
Yale School of Medicine’s Dr. Meredithe McNamara calls the questioning of the evidence behind pediatric sex changes “science denialism.” Her protest is ironic. Science is a process of ongoing inquiry and debate, not a set of predetermined conclusions. Science depends on skepticism, especially about sensitive subjects. True science denialism means restricting rational, evidence-based debate — exactly what McNamara and the AMA’s new president want to do.
Their calls are bearing fruit. Just this month, gender activists successfully pressured a medical journal to retract a paper whose conclusions they found inconvenient. The ongoing campaign to suppress scientific debate allows a pseudo-consensus to emerge around “gender-affirming care.”
Put simply, pediatric gender medicine in the U.S. is out of control. Medicalization of gender diversity in children is a fast-growing industry that shows no signs of self-correction. Doctors and therapists who practice “affirmative” medicine consistently demonstrate ignorance about EBM principles and deceive the public about the grim realities behind the euphemism “gender-affirming care.”
A Reuters investigation last year interviewed providers at 18 pediatric gender clinics and found that none were doing comprehensive mental health assessments and differential diagnosis. Those who promote and practice “gender-affirming care” themselves tell us that their approach is child-led. “Gatekeeping” of medical transition, they insist, is pointless, even “dehumanizing.”
The author of the AAP’s position paper on gender medicine has said that a “child’s sense of reality” is the “navigational beacon to orient treatment around.” The director of the gender clinic at Boston Children’s Hospital has admitted that they give out puberty blockers “like candy.” Even the founding psychologist of that clinic has warned that kids are being inappropriately “rushed toward the medical model.”
Why the U.S. has become an outlier on pediatric transgender medicine is a complicated question, but at least part of the answer is that European welfare states have centralized health bureaucracies and public health insurance. Before medicines can be approved for state funding, their evidence base needs to be evaluated. The American health care system is more vulnerable to profit motives, activist doctors and political pressures. Medical associations claim to advocate for patient health but can have other motives as well.
The situation is so dire that when pediatric gender medicine experts in other countries want to defend their practices before a skeptical public, they sometimes say that at least they are not as bad as the Americans. That is one kind of American exceptionalism we can do without.
Leor Sapir is a fellow at the Manhattan Institute.