Summary

This BMJ investigation asks whether the US claim of medical agreement on treating gender distress in young people is backed by evidence. Block looks at the three most-quoted US guidance documents (from WPATH, the American Academy of Pediatrics and the Endocrine Society) and interviews experts on how they were made. Research reviews behind these guidelines rated the evidence for teenagers as low or very low quality, yet strong recommendations were made, and the pediatrics statement was not based on a formal review of the research. Meanwhile Sweden, Finland and NHS England were restricting medical treatment. It documents real weaknesses in the US guidelines and showed a major journal took the debate seriously. But it is journalism: the reporter chose the sources and examples, some figures (such as 20–30% stopping hormones) come from limited studies, and some readers called it biased.

Key findings

• Ameriške medicinske skupine (WPATH, American Academy of Pediatrics in Endocrine Society) podpirajo zaviralce pubertete, hormone nasprotnega spola in v nekaterih primerih operacije za mladoletnike, medtem ko sta se Švedska in Finska preusmerili tako, da imata psihološko oskrbo na prvem mestu, operacije pa omejujeta na odrasle.
• Endocrine Society je uporabil formalni sistem ocenjevanja dokazov in dokaze za vsa svoja priporočila za najstnike ocenil kot „nizke“ ali „zelo nizke“, a kljub temu včasih podal močna priporočila. Gordon Guyatt, soustanovitelj tega sistema ocenjevanja, je dejal, da bi to moralo biti redko in jasno pojasnjeno.
• Smernice WPATH iz leta 2022 nimajo sistema ocenjevanja dokazov. Strokovnjak za smernice Mark Helfand je našel izjave, ki so „v neskladju“ z lastnimi raziskovalnimi pregledovalci smernic, ki so dokaze o učinkih hormonov na kakovost življenja, depresijo in anksioznost ocenili kot nizke kakovosti.
• Vodilni avtor izjave politike American Academy of Pediatrics iz leta 2018 je dejal, da njen postopek ni povsem štel za formalni pregled raziskav. Cochrane, vodilna skupina za pregled dokazov, je po strokovnem preverjanju zavrnila objavo predlaganega pregleda zaviralcev pubertete.
• Povzetek 61 raziskovalnih pregledov univerze McMaster, ki ga je plačala agencija Medicaid (javno zdravstveno zavarovanje) v Floridi, je ugotovil „veliko negotovost“ glede zaviralcev, hormonov in operacij pri mladih.
• Dve nedavni študiji (revizija ordinacije družinskega zdravnika v Združenem kraljestvu in lekarniški zapisi ameriške vojske) sta nakazovali, da lahko 20–30 % bolnikov preneha jemati hormone v nekaj letih, vendar sta merili prenehanje, ne obžalovanja ali detranzicije.
• Kliniki so opisali hitrejše medicinsko zdravljenje in manj ocen duševnega zdravja. V študiji na kliniki Seattle Children's je bilo dve tretjini najstnikov na hormonih v 12 mesecih od prvega obiska.

Conclusion

This investigative report from The BMJ concludes that despite claims of consensus, gender-affirming medical treatments for minors with gender dysphoria lack strong evidence-based support. Key findings include: (1) US medical organizations (WPATH, AAP, Endocrine Society) endorse gender-affirming care including puberty blockers, hormones, and surgeries, while several European countries (Sweden, Finland, France, UK) have moved to restrict medical interventions for minors, prioritizing psychological care; (2) systematic reviews commissioned by guideline bodies found evidence quality to be "low" or "very low," with experts criticizing the misapplication of "evidence-based" labeling to recommendations not meeting rigorous standards; (3) the surge in treatment of minors—particularly birth-registered females with no prior history of gender dysphoria—has outpaced research, with long-term outcomes unknown and detransition rates potentially as high as 20-30%; (4) clinical practice has shifted toward rapid medicalization, with concerns about inadequate assessment and perfunctory informed consent processes; and (5) prominent evidence-based medicine experts conclude that when rigorous systematic reviews find "we don't know," claims of certainty are not evidence-based, and consensus-based guidelines should not be called evidence-based.