HHS’s Peer-Reviewed Gender Dysphoria Report Answers Critics

 Last month, the U.S. Department of Health and Human Services released a peer-reviewed version of its previously published report on evidence and best practices for the treatment of pediatric gender dysphoria. Notably, the reviewers praised the report’s methodology and declined to challenge the finding of its umbrella review (a systematic review of reviews) that only “low certainty” evidence exists for benefits of hormonal and surgical treatments.

The peer review supplement—which features reviews by international experts in evidence-based medicine and identifies the report’s coauthors, including Manhattan Institute senior fellow Leor Sapir—addresses two of critics’ major pretenses for refusing to grapple with the report’s findings: the anonymity of the authors, and the previous lack of peer-review.

The report’s authors are politically diverse and were granted full independence from the Trump administration. But critics have pointed out that some of them had publicly criticized “gender affirming care,” suggesting that the report’s conclusions were predetermined and its findings suspect.

Having an informed perspective is not the same thing as having a conflict of interest. And practitioners of “gender-affirming care”—whose livelihoods depend on the continued existence of this practice—are rarely held to a similar standard when testifying as expert witnesses or when issuing position statements supporting such interventions.

Despite its authors’ perspective, the report stands on its scientific merits. Peer reviewer Jilles Smids—an expert in medical ethics, philosophy, and history of medicine from the Netherlands—wrote that the report is forthcoming about its perspective, which is informed by “established principles of evidence based medicine, responsible clinical practice, and medical ethics,” and grapples with “all extant considerations presented in favor of the gender affirmative care model.”

As Smids pointed out, critics of the report are free to identify methodological or logical limitations. As Lisa Selin Davis noted in Unherd, the report authors sought out peer reviews from the Endocrine Society and the American Academy of Pediatrics (AAP)—two organizations that support pediatric medical transition—but neither organization took them up on the offer. This didn’t stop the AAP, though, from issuing a joint statement with the American Medical Association (AMA) criticizing the report after the supplement was released.

“We reject characterizations of our approach to gender-affirming care as negligent or ideologically driven . . . . These claims, rooted in politics and partisanship, misrepresent the consensus of medical science, undermine the professionalism of physicians, and risk harming vulnerable young people and their families,” said David Aizuss, chair of the AMA Board of Trustees, and Susan J. Kressly, president of the AAP, in a joint statement.

This statement is Freudian projection. Organizations like the AAP and AMA have continued to promote pediatric medical transition despite its failure to meet the standards of evidence-based medicine and its unfavorable risk-benefit profile.

Consensus medicine is not evidence-based medicine, and the HHS authors note that pediatric medical transition was originally implemented within an “innovative practice” framework—which allows for “small scale” use—but was scaled up internationally without clinical trials. If medical societies had followed established norms and practices for developing clinical practice guidelines, Smids wrote, “there would have been no need for the current HHS report on [gender dysphoria].”

Peer reviewer Johan C. Bester, a professor of medical ethics at the Saint Louis University School of Medicine, cut to the heart of the debate. Clinicians’ ability to offer a particular treatment, he wrote, “simply hinges on this: is there evidence for benefit? Does the expected benefit outweigh the potential harms?” If it does not, the intervention “cannot be offered as treatment to patients.”

Bester’s point is often overlooked in the debate over pediatric medical transition. While we often dispute the relative weight to assign various medical-ethical principles when considering treatment options, such analyses presuppose that the treatment options under consideration have a favorable risk-benefit profile. But “There is no obligation on medical professionals to offer non-beneficial treatments, and there is no patient right to demand non-beneficial treatments,” Bester wrote.

Activists like Kellan Baker—senior advisor for health policy at the Movement Advancement Project, a think tank that focuses on LGBTQ issues—claim that the “standard of care” in youth gender medicine “is based on the same comparable quality of evidence as care across any other area of medicine.” This statement is patently false. If anything, a common refrain among the HHS peer reviewers is that the field is not held to the same standards as other fields of medicine. If another pediatric subspeciality rendered treatments with low-certainty evidence for benefits and credible indication of significant harm, it would be considered incompatible with scientific and ethical medical norms.

The HHS report is a singular achievement. It deserves praise for both its umbrella review of the evidence and its interdisciplinary weaving of clinical, institutional, philosophical, and ethical strands. And, like the U.K.’s Cass Review, it provides an opportunity to place gender-dysphoria treatment in the U.S. on strong scientific footing—the minimum standard that the afflicted deserve.

Joseph Figliolia is a policy analyst at the Manhattan Institute.

https://www.city-journal.org/article/hhs-peer-reviewed-pediatric-gender-care-report