Ignoring the Evidence

The Canadian Minister of Health gives a non-response to a petition on gender medicine

Photo by Chris DeSort on Unsplash

The response of the federal Minister of Health to a petition calling for the Government of Canada to develop evidence based guidelines for the treatment of gender dysphoria in children, adolescents, and young adults illustrates the sorry state of the government’s thinking (or lack of thinking) on this issue. The petition which was presented by MP Larry Maguire reads:

The incidence of gender dysphoria has been increasing rapidly in Canada, particularly in youth and young adults without a prior history of gender dysphoria in childhood;

The gender affirming model of treatment which is currently being followed in Canada is not evidence based as it has never been validated by a systematic review; and

The health authorities in Finland, Sweden and the United Kingdom, which have conducted all systematic reviews, have found that the evidence in support of the gender affirming model is low quality and have adopted guidelines which make exploratory psychotherapy the first line of treatment.

We, the undersigned, citizens and residents of Canada, call upon the Government of Canada to commission the Canadian Task Force on Preventive Health Care to conduct its own systematic review and to then develop evidence-based guidelines for the treatment of gender dysphoria of children, adolescents, and young adults.

The petition asks the government to respond to developments in Finland, Sweden and the United Kingdom which have all changed course on medical transition of children and adolescents by restricting the use of puberty blockers and hormones and making psychotherapy the first line of treatment for gender dysphoria. The specific request is the the government  follow the lead of these countries by developing evidence-based guidelines for Canada.

The principles of evidence-based medicine were developed to counteract the bias that inevitably creeps in when doctors attempt to sort through the mass of studies on a condition and develop recommendations for treatment. In the conventional process of relying on expert consensus, there is a danger that the experts on the committee will cherry-pick studies that support their preferred model of treatment and ignore the rest.

An evidence-based process has two requirements. First, there is a systematic review of all the research on a topic. In a systematic review, relevant studies are selected and evaluation using pre-determined criteria. These criteria are put on a public registry in advance so the process is transparent. Second, the guidelines themselves rate the strength of their recommendations in accordance with the strength of the supporting evidence.

The whole process has to be free from conflict of interest. The reviews are normally conducted by specialists in evaluating research studies and anyone with a financial or non-financial conflict of interest is excluded from the process. Financial conflicts of interest include receving a income from the treatment under review or financial support from producers of drugs being evaluated. Non-financial conflicts might include being an author of a study under review or involvement with a patient advocacy group.

The systematic reviews on hormonal treatment for gender dysphoria conducted in Sweden, Finland, the United Kingdom and elsewhere have consistently found that the supporting evidence that the risks outweigh the benefits is low quality. Supporters of affirming care point out that many treatments are only supported by low quality evidence. However, these treatments are usually low risk. Cross sex hormones and puberty blockers both carry signficant known and potential risks. Normal medical practice would require high quality evidence that the benefits outweigh the risks before using these treatments instead of non-invasive psychotherapy.

In his response to the petition the federal Minister of Health pointed out, correctly, that the Canadian Task Force on Preventive Health Care is an arm’s length agency and that the government does not submit topics for its consideration. In fact, anyone can submit a request that the Task force develop a new clinical guideline through its website. This point could technically have answered the petition but the Minister provided a lengthier response which demonstrates his lack of understanding of the issue. The first few paragraphs of the response are innocuous:

The Minister of Health has a responsibility to protect and promote the health of all Canadians, including of trans and non-binary people in Canada. Our Government is committed to working towards a more equitable, diverse and inclusive country, where everyone is free to be themselves and participate fully in society.

Everyone, regardless of their gender identity, has the right to be their authentic self, which includes having access to the care that they need to lead a happy and healthy life.

Gender dysphoria refers to the distress that trans and non-binary people experience resulting from a difference between a person’s gender identity and the person’s assigned sex at birth, associated gender role, and/or primary and secondary sex characteristics.

Gender-affirming care refers to culturally competent health care that is provided to an individual across their lifespan in support of their gender identity, which may include medical, surgical, social and/or psychological services and refrains from directing a person towards any particular identity. It is important to note that the provision of transition-related care, such as medical gender affirmation via hormones or surgery, does not alone ensure that the care provided is gender-affirming.

The response uses the ideologically loaded phrased “assigned sex at birth” and also refers to gender dysphoria as something that affects both trans and non-binary people.

The next paragraph attempts to address the issue of standards and guidelines but shows that the Minister is not able to distinguish between policies based on consensus and genuinely evidence-based standards:

Standards and guidelines are set by disciplinary professional associations and are based on the best available evidence at the time. There are several widely accepted practice guidelines/position statements on gender-affirming care that have been produced by a range of clinical organizations to provide information and support to their members (e.g., An affirming approach to caring for transgender and gender-diverse youth | Canadian Paediatric Society (cps.ca) and Canadian Psychological Association 2023 Position Statement on Promotion of Gender Diversity and Expression and Prevention of Gender-Related Hate and Harm).

The Canadian Pediatric Society document does not claim to be a clinical practice guideline or standard of care. It is the work of only two authors and was reviewed by a number of committees. There is no attempt to apply the principles of evidence-based medicine or any reference to the systematic reviews that have been completed in other countries. It is an “eminence based” document which simply cites articles that support its preferred model of treatment. There is no discussion of the possibility of regret or detransition. On the question of risk, the paper says that gender affirming hormone therapy “is considered safe for adolescents, but it can have associated short- and long-term health risks that are beyond the scope of this statement to review.”

The Canadian Psychological Association position statement is not a so much a clinical practice guide as a political statement which calls for the CPA to work for policy changes to eliminate “cissexist discrimination.” Most of the references are to publications by advocacy groups rather than actual peer reviewed research.

The government response then claims that the WPATH standards of care fill the need for an evidence-based standard of care and says:

The World Professional Association for Transgender Health (WPATH) offers guidelines called “Standards of Care” (SOC) to provide clinical guidance for health professionals to assist transgender and gender diverse children, youth, and adults with safe and effective pathways to care. WPATH’s eighth edition of the Standards of Care (SOC8) were released in September 2022. WPATH outlines how the guidelines were developed, and that the process followed recommendations on clinical practice guideline development from the World Health Organization and the US’s National Academies of Medicine. Notably, a team of independent researchers at Johns Hopkins University conducted the systematic reviews of research evidence that underpin the WPATH guidelines.

An article by Jennifer Block in the British Medical Journal quotes two experts on evidence-based medicine, Gordon Guyatt of McMaster University in Hamilton, Ontario and Mark Helfland of Oregon Science and Health University, on the WPATH SOC:

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.”

.The review by the John Hopkins researchers evaluated studies on the psychological effects of hormone therapy among transgender people. It found that the strength of the evidence of improved outcomes for quality of life, depression and anxiety was low and that the evidence of the effect on death by suicide was insufficient. Nevertheless, WPATH went ahead and made strong recommendations based on this low-quality evidence.

Neither the WPATH SOC8 nor the other documents the Minister refers to are evidence-based standards of care. Without a proper systematic review there is no basis for the Minister’s claim that Canadian treatment standards are based on the best available evidence.

The next paragraph of the Minister’s response takes advantage of a small lack of clarity in the wording of the petition to make large and unwarranted statements:

There is a lack of data available to confirm if there has been an increase in numbers of people experiencing gender dysphoria in Canada. However, younger people may be more willing to disclose their gender identity to organizations such as Statistics Canada. This may be due, in part, to improvements in the social supports, greater acceptance and visibility, increasing human rights protections, and other forms of supportive legislation for transgender, non-binary and other 2SLGBTQI+ people in Canada.

The preamble to the petition refers to an increase in the incidence of gender dysphoria in Canada. In fact, what the available data shows is a massive increase in the number of referrals to pediatric gender clinics, with the largest increase in adolescent girls. It is not possible to say whether this increase corresponds to an actual increase in the incidence of gender dysphoria because, in many cases, clinics do not do the kind of assessment required  to make a diagnosis. However, the response goes beyond the petition and asserts that the increase in transgender identification is due to an increase in social supports and acceptance. I discussed this view in a previous article and pointed out that the 1000% or more increases in caseloads at pediatric gender clinics over the last 10 years are far in excess or what could be expected from simple acceptance.

The last paragraph packs a massive amount of hypocrisy, mixed with veiled threats into a single sentence.

The Government of Canada stands firm against misinformation and disinformation regarding the care of trans people and reiterates the importance of shared decision-making between the patient and their health provider based on the best evidence available and the unique needs of individuals.

Any reference by a government to “misinformation and disinformation” is chilling. If the If the government were serious about  A government which was serious about fighting misinformation would be promoting transparent and non-partisan fact finding processes like systematic review. However, it is clear that for this government at least, misinformation and disinformation are simply labels which are used to discredit any facts that challenge the government’s preferred policies.

While the government claims to respect decision making between patient and health care provider, its actions have been in the opposite direction. The conversion therapy ban in the Criminal Code restricts the ability of health care providers to offer exploratory psychotherapy as an alternative to invasive, risky and poorly supported gender affirming care.

It would be reassuring to believe that the government’s response was dictated at the political level and that there are senior staff in Health Canada who actually understand evidence-based medicine and how it applies to gender medicine. However, we can’t be sure. Institutional capture by transgender ideology has been wide and deep.