The following is an op-ed submission from Jay T. Allen, a board certified medical doctor currently living in Maine. He retired last year.
In the words of Patrick K. Hunter, MD, who gave testimony at a joint meeting of the Florida Board of Medicine and the Florida Board of Osteopathic Medicine, “Children and youth with gender dysphoria are suffering. They need care—the best possible care, excellent care.”
The vast majority (if not all) of the American gender clinics and specialists, if asked, would declare that “gender affirming” care is the best possible care. They will tell you that “gender affirming” care is endorsed by the World Professional Association for Transgender Health (WPATH) and all major American medical societies, including the American Academy of Pediatrics (AAP) and the Endocrine Society.
They will also tell you that the guidelines are 1) evidence-based, 2) medically necessary, 3) effective in reducing gender dysphoria, 4) effective in reducing suicide, and 5) safe.
What advocates for “gender affirming” care won’t tell you is that the United States is increasingly out of step with other countries that treat gender dysphoria. They also won’t tell you that the reason for this separation of treatment paths is because the countries of Europe are following evidence-based medicine and the Americans are not (even though they claim that they are).
The gold standard for analyzing scientific evidence of this type is a systematic review, which involves reviewing all available evidence, assessing the quality of that evidence and then making recommendations based on the quality of the evidence. Narrative reviews and observational studies are both considered lower quality studies, prone to bias and weaker evidence. Each of the recommendations by major US medical organizations is the product of weak evidence and sometimes outright bias.
WPATH recently published Version 8 of their transgender medicine treatment guidelines. In Chapter 6, which deals with adolescents, they state, “[A] systematic review regarding outcomes of treatment in adolescents is not possible. A short narrative review is provided instead.” In other words, the WPATH recommendations are based on weak evidence.
The AAP guidelines, which are nearly 5 years old (01 Oct 2018) and are thus due to expire, are the work of a single physician, Dr. Jason Rafferty. In a statement at the end of the document, Dr. Rafferty says that he “conceptualized the statement, drafted the initial manuscript, reviewed and revised the manuscript, approved the final manuscript as submitted, and agrees to be accountable for all aspects of the work.”
For an organization with 67,000 members, it is unconscionable to allow a single physician, with his biases (some of which are clear within the finished document) to have this much power in directing the course of the Academy on such a divisive and important issue. In commenting on this document, one longtime AAP member said, “There was clearly no fact-checking. The AAP thought trans was the next civil rights crusade and got boondoggled by enthusiastic young doctors.”
According to a fact check of the AAP recommendations as performed by James M. Cantor, PhD, who was Director of the Toronto Sexuality Centre, “[AAP] provided recommendations entirely unsupported and even in direct opposition to [current available] research and [expert] opinion.” He went on to say that, “AAP’s statement is a systematic exclusion and misrepresentation of entire literatures. Not only did AAP fail to provide extraordinary evidence, it failed to provide the evidence at all. Indeed, AAP’s recommendations are despite the existing evidence.”
Five times over the last four years, members of the academy have submitted a resolution calling on the AAP to perform a systematic review of the evidence and aligning their recommendations with previous systematic reviews that have been performed. Each time, the AAP leadership has prevented the resolution from coming up on the floor of the AAP congress for discussion. In other words, the AAP has had multiple opportunities over the past four years to ensure that their guidelines represent the current research and the best quality research, but they have refused to do so.
The Endocrine Society guidelines, which are now 6 years old (13 Sep 2017), admit that their recommendations for adolescent are based on low-quality or very low-quality evidence. They give six recommendations for the hormonal treatment of adolescents. According to their own assessments, each of these hormonal recommendations is associated with low-quality or very low-quality evidence. They also give six recommendations for surgical treatment (not broken down by age except recommendations 5 and 6 which both give recommended minimum ages for genital surgery and chest surgery, respectively). According to their own assessments, each of these surgical recommendations is associated with low-quality or very low-quality evidence.
On the other hand, the United Kingdom, Norway, Finland, Sweden, and Florida have all performed systematic reviews. Again, systematic reviews are the highest quality of evidence. Each of these reviews found that the harms of “gender affirming care” significantly outweigh the benefit. All these countries have limited or stopped the use of hormones and surgery (Florida’s law is being challenged in court).
To summarize, each of the recommendations from WPATH, AAP, and the Endocrine Society rely on low or very low quality evidence even though there are several systematic reviews (considered the highest level of evidence) available in the literature today. In addition, each of these three recommendations is out of line with the current best level of evidence, which means that treatment for gender dysphoria based on the WPATH, AAP, and the Endocrine Society guidelines is substandard care.
On 13 July 2023, 21 gender medicine specialists from 9 countries, responding to a letter from Stephen Hammes, the President of the Endocrine Society, confirmed that American recommendations for transgender care were “not supported by the best available evidence.”
At the beginning of this column, I included a portion of a quote from Patrick K. Hunter, MD. I would like to give the full quote here: “Children and youth with gender dysphoria are suffering. They need care—the best possible care, excellent care. We need to return to the community standard of care for treating stress and that is psychotherapy—ethical, compassionate psychotherapy that respects the child’s experience. Let me say that again: ethical, compassionate psychotherapy that respects the child’s experience. This is what Europe is doing. Our colleagues in Great Britain, Sweden, Finland and elsewhere agree change is needed. Less harm needs to be done. Safety and ethics need to prevail.”
At the present time, our transgender youth are receiving substandard care. Shouldn’t they receive the best quality of care—care that is based on evidence rather than the biases of those in charge of writing and publishing recommendations?
Jay T. Allen, MD
Board Certified in Family Medicine
This is an excellent article that has the best of care for gender dysphoria in mind. What should be added is that teachers and school social workers are NOT qualified to be in charge of a child’s welfare or mental health! That is classified as grooming and should be illegal mental treatment. This is an issue that was nearly non-existent twenty years ago, and seems to have evolved from teachers unions and the hiding of curriculum from parents. The failure of school boards to represent the parents is a major roadblock to children’s welfare and mental health, until school boards are brought back to reality the devolution of education and welfare of children will continue. And every year the U.S. falls farther down the list of best educated as more and more money is spent!
WHAT a bunch of ID-10-Ts you have voted into state government. They are NOT LEADERS! They are public servants and we should demand that they get mental evals for what they are doing, especially in this effort to address the “gender dysphoria” mental illness! This is just wrong-headed! What you adults do in your own bedroom is your business, but do not try to change the rest of us, try to change the laws to give special benefits to yourself, or bring people under 25 into your mix! That applies to everyone that wants special treatment!
TRANS gender humans are like unicorns, they do NOT exist except in an individual’s make believe world. No human ever has, nor ever will, TRANSform or TRANSition into a fully functioning member of the opposite sex. Call them what they are, mentally ill. They need psychological help, not sexual mutilation.