Can Science Take Down Gender Doctors?

Yes, when they lie about it

“This is an area of remarkably weak evidence … we have no good evidence on the long-term outcomes of interventions to manage gender-related distress.”

–Hilary Cass (2024)

Evidence-based medicine (EBM) is a movement to impose scientific rigor on the practice of medicine and weed out treatments that can’t be proven to help patients. Gender medicine is a treatment that can’t be proven to help patients. Why hasn’t EBM laid waste to gender medicine already?

Because gender medicine is a scam and EBM isn’t designed to bust scams. When misused, EBM can actually inhibit the effort to expose intellectual fraud. But it’s playing a helpful role in recent court battles: tempting gender doctors to make demonstrably false statements.

In this post I’ll explain what EBM is. Then I’ll show how it’s been invoked in US gender medicine guidelines and the UK’s Cass Review. Finally I’ll analyze EBM’s limitations and superpowers when it comes to fighting predatory practices by doctors.

What Is Evidence-Based Medicine?

Until the late 20th century, doctors were not very programmatic in their approach to patients. “Expert opinion, experience, and authoritarian judgment were the foundation for decision making. The use of scientific methodology … [was] rare in the world of medicine.” But in the 1960s an effort to marry science and clinical medicine began to take shape. In 1992, a physician who trained internal medicine residents in Ontario, Gordon Guyatt, coined the term “evidence-based medicine.”

In a 2023 piece on gender medicine, Jennifer Block reported on how EBM should be used:

“Mark Helfand, professor of medical informatics and clinical epidemiology at Oregon Health and Science University, says, ‘An evidence based recommendation requires two steps.’ First, ‘an unbiased, thorough, critical systematic review of all the relevant evidence.’ Second, ‘some commitment to link the strength of the recommendations to the quality of the evidence.’”

In the evidence review, researchers judge studies by their rigor. Case studies and expert opinion are ranked at the bottom because of their susceptibility to bias. Randomized controlled trials (RCTs) are considered strong. The most reliable evidence is a systematic review of multiple high-quality studies. (More details here.)

The generally-accepted ranking method is called “the GRADE system (Grading of Recommendations, Assessment, Development, and Evaluations).” The point of GRADE is to communicate the quality of evidence to clinicians: high, moderate, low, or very low.

To be clear, “very low” is bad:

“The true effect [of the intervention] is probably markedly different from the estimated effect”

If the medical topic is mental health, the conditions being treated are defined by the DSM-5. The DSM is not a scientific document (chapter 13) – its diagnoses are generated by throwing favored experts on a committee together. So the entire process of EBM gets off on the wrong foot, as researchers choose studies based on a categorization that is not objective or based in the scientific method.

The DSM-5’s diagnosis for patients who express “gender dysphoria” is “gender dysphoria.”

The Medical Associations Do Science

Gender doctors claim their treatments yield mental health benefits for patients with “gender dysphoria,” but they shy away from running high-quality studies that would prove it. Nevertheless, many American medical societies back the interventions – even while pretending they care about evidence. 

Here’s a rundown of recent statements on gender from relevant medical institutions.

Gavin Grimm Amicus Briefs (2017-19)

Gavin Grimm was a teen girl who identified as a boy and wanted to use the boys’ bathroom. School officials wouldn’t let her. In 2015, the ACLU represented Grimm in suing the school district for anti-trans discrimination. The hard-fought case bopped between a federal district court in Virginia and the Fourth Circuit of Appeals for years; twice a party sought review by the US Supreme Court.

In March 2017, twenty medical and mental health orgs jointly filed an amicus brief on Grimm’s behalf, arguing in favor of classmate-assisted social transition. They included the American Academy of Pediatrics (AAP), the Endocrine Society (ES), and the American Psychiatric Association (APA). 

In November 2019, the coalition filed an amicus brief that was substantially the same. This time they had more sign-ons, including the American Medical Association (AMA).

The brief invokes evidence without citing evidence. For example, one of its headings reads “Exclusionary Policies … Are Contrary To Widely Accepted, Evidence-Based Treatment Protocols.” But the brief doesn’t claim the protocols are based on research, only that they are supported by “international medical consensus.”

To back up the claim that using sex-appropriate bathrooms harms trans people, the brief cites an APA “resolution” – not a study. To argue that “safer school environments lead to reduced rates of depression” in trans students, it cites studies on LGB students.

One more evidence-based argument:

“[T]here is no evidence of any harm to the physical or mental health of other children and adolescents when transgender students use facilities that match their gender identity.”

You think it’s bad for girls to change clothes in front of boys? Prove it. 

Since 2020, trans activists have filed over a dozen lawsuits attacking new bans on boys playing girls’ sports and PGM. The AAP, APA, ES, and AMA routinely file joint amicus briefs in support of the activists.

Endocrine Society Guideline (2017)

The Endocrine Society issued a guideline in November 2017 that recommended puberty blockers and cross-sex hormones for kids with, basically, a therapist sign-off.

The guideline claimed:

“This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation approach to describe the strength of recommendations and the quality of evidence.”

Block notes that the drafters rated all the evidence on adolescents as low or very low quality – and other issues:

“Guyatt … found ‘serious problems’ with the Endocrine Society guidelines, noting that the systematic reviews didn’t look at the effect of the interventions on gender dysphoria itself, arguably ‘the most important outcome.’ He also noted that the Endocrine Society had at times paired strong recommendations—phrased as ‘we recommend’—with weak evidence.”

American Academy of Pediatrics (2018)

In 2018, the AAP released a “policy statement” in support of PGM:

“In this policy statement, we review relevant concepts and challenges and provide suggestions for pediatric providers that are focused on promoting the health and positive development of youth that identify as [transgender or gender diverse] while eliminating discrimination and stigma.”

Drafted by a young medical resident named Jason Rafferty, the statement was festooned with citations. This created the impression that its “suggestions” were backed by evidence. But many of the citations did not support the sentences they ornamented, as scorchingly detailed by the sexologist James Cantor.

In February 2023, the AAP told Block that a “revision is under way” based on a “robust evidence review.”

In August 2023, the AAP’s board voted unanimously to “reaffirm” the policy statement. It also commissioned a systematic review of the evidence. The NYTimes quoted its chief executive:

“The board has confidence that the existing evidence is such that the current policy is appropriate. At the same time, the board recognized that additional detail would be helpful here.”

The AAP has not yet released the “revision” promised to Block or the “additional detail” telegraphed to the NYT.

American Psychiatric Association (2020)

The APA adopted a “position statement” in support of PGM in 2020. It did not claim to rely on scientific studies.

American Medical Association (2021)

In 2021, when the first PGM ban was enacted, the AMA issued a press release. It namechecked EBM without directly endorsing the evidence behind gender medicine (emphasis added):

“As physicians and leaders in medicine, the AMA is steadfast in its belief that every individual is entitled to high quality evidence-based medical care regardless of gender or sexual orientation and will continue to work diligently to expand access to medical services, reduce stigma for LGBTQ patients and break down discriminatory barriers. …

“[C]linical guidelines established by professional medical organizations for the care of minors promote supportive interventions based on the current evidence and that enable young people to explore and live as the gender that they choose.”

WPATH Standards of Care v. 8 (2022)

In 2022, the self-appointed trans health authority WPATH released the most recent version of its medical guidelines, SOC8. It used the term “evidence-based” over a dozen times while mostly avoiding claiming to be evidence-based. (The exception relates to “assessments” — more in a minute.) For example, trans people “would benefit from evidence-based information[.]”

We’ve since learned that the SOC8 wasn’t drafted based on science but rather on the desire to win lawsuits.

SOC8 describes its methodology:

“[SOC8] is based upon a more rigorous and methodological evidence-based approach than previous versions.” 

No one has suggested SOC7 was any better than SOC8, so kudos to WPATH’s attorney Jennifer Levi for that possibly-accurate spin.

SOC8’s explanation of its methodology continues:

“This evidence is not only based on the published literature (direct as well as background evidence) but also on consensus-based expert opinion.”

Expert opinion and “background” information are considered the lowest form of evidence. So that line is saying something like:

“The candy we distribute on Halloween includes not only candy that comes in a wrapper (full-coverage and partial-coverage) but also candy without a wrapper, which we selected by consensus.”

SOC8 and “Assessments”

I’ve written before about the myth that vaguely-defined mental health assessments make PGM more scientific or successful. (I also discussed it on TransMuted.) Its most vocal proponent is the psychologist Laura Edwards-Leeper. She chaired the committee that drafted SOC8’s adolescent chapter.

This chapter first states that the “most robust longitudinal evidence” for PGM comes from the famous Dutch studies, in which the kids were subject to mental health assessments. It goes on:

“Given this research … a comprehensive diagnostic biopsychosocial assessment during adolescence is … evidence-based … There are no studies of the long-term outcomes of gender-related medical treatments for youth who have not undergone a comprehensive assessment. Treatment in this context (e.g., with limited or no assessment) has no empirical support[.]”

Cass was well-aware of the Dutch studies when she found the evidence for PGM was “remarkably weak.” To the extent the subjects fared OK (this is disputed), it’s likely because those with mental health issues were screened out by the assessments — which skewed the studies’ outcome and is not a practice Edwards-Leeper advocates for.

When SOC8 claims “assessments” for teens are evidence-based, it’s not honestly appraising the research. It’s just propping up a model that its committee chair profits from and smacking down a competing model.

Cass Review (2024)

In April 2024, England’s National Health Service published “Independent Review of gender identity services for children and young people.” It’s known as the Cass Review after its author, a pediatrician named Hilary Cass.

The Cass Review used EBM principles to examine the scientific support for transitioning minors and found it “remarkably weak.” It focused on puberty blockers, overlooking the medical harms caused by cross-sex hormones and surgery. (It says understanding the downsides of steroids is “unlikely to have a major impact on treatment decisions.”) Maybe that narrow approach was wise; England has since banned puberty blockers as gender medicine.

Cass is respected across partisan lines in the UK as a trustworthy figure who embodies the nation’s finest virtues – a kind of British Matthew McConaughey. The NHS leveraged her reputation by branding the doc “The Cass Review” and sending her on a media tour. Then the Tories made her a baroness. Her stardom defied the tenets of EBM, which are all about sidelining reputation to focus on data. I point that out to say we can’t credit EBM for the UK’s recent policy changes.

Replace the Senate with a House of Lords. It will be more democratic.

The Limits of Evidence

Here’s why gender critics shouldn’t use EBM as an overarching framework for their argument.

1. Medical Practice Is More than EBM

Telling a healthcare professional that a mental health intervention isn’t supported by high-quality evidence might not scandalize them.

Not all treatments are supported by RCTs. It’s normal for doctors to rely on lower quality evidence in making recommendations because higher-quality studies don’t exist. They also regularly rely on their own experience, reasoning skills, and mentors.

In a sign of EBM’s low uptake, ProPublica found in 2017 that “it is distressingly ordinary for patients to get treatments that research has shown are ineffective or even dangerous.”

Lady Cass herself departed from strict scientific priniciples. The Review found:

“For some [children], the best outcome will be transition”

“Many benefited from access to medical pathways, which they said [once they were young adults], enabled them to lead the lives they wanted.”

They might be doing better – while being spared the medical harms – if they hadn’t transitioned. There’s no way to know because the relevant studies lack control groups. (The Review also interviewed young adults who had medically transitioned.) But Cass doubled down on this sketchy claim when interviewed by the New York Times in May:

“There are young people who absolutely benefit from a medical pathway, and we need to make sure that those young people have access …”

The “low quality” of evidence supporting PGM is shocking only in light of the heavy costs it imposes on the body and on society. But many people, even healthcare professionals, aren’t aware of those costs because gender doctors have controlled the narrative since the 1970s.

So you have to explain how gender medicine harms patients. You can’t just tell people — especially ones who are familiar with EBM — that the evidence for benefits is low quality.

2. EBM Launders Irrational Hypotheses

If you pray for a heart surgery patient, and they don’t know what you’re up to, they’ll recover more smoothly than if you don’t pray for them. That was proven by RCTs in 1988 and 1999.

I assume there’s something wrong with the studies. A true EBM nerd would make no such assumption. They’d investigate the protocols without considering the hypothesis. Maybe they’d find a flaw, maybe they wouldn’t. Either way they wouldn’t really have learned more about the power of prayer. In the latter case they’d conclude that there’s high-quality evidence supporting an impossible idea.

Critics of EBM have referred to this problem as “subservience to empiricism.” They explain that some medical practitioners feel “it places them in the position of focusing on evaluating the statistical purity of studies instead of understanding physiological processes and the mechanisms of disease.”

Like remote prayer, gender medicine rests on a non-rational premise. Its proponents claim that gender identity is a “soul” or a “transcendent sense of gender.” 

But once these doctors produce a study, EBM takes the idea seriously. Even if the study earns EBM’s worst grade, “very low,” it’s still in the company of a lot of other normal medical research. In fact a brilliant, accurate insight by a genius doctor could be rated “very low.” So “very low” isn’t a condemnation. When a study explores a mystical idea, “very low” is a cloak of jargon that makes it look more scientific than it is.

3. EBM Is Shackled to the DSM

If you want to talk about the evidence base for gender medicine’s mental health outcomes, you have to use the language of “gender dysphoria.” That’s what the studies focus on. EBM doesn’t give you the tools or authority to explain why a diagnostic category is bunk.

And if you’re accepting that GD is real, then shouldn’t it be treated? And what treatments have been studied for GD? The ones that gender doctors – the people who believe GD is real – want to study. You’re boxed in.

4. EBM Strips Out Red Flags

I used to relate to trans issues only as a lesbian. I worried about girls like me feeling peer-pressured to use T or date trans-identified men. Then in 2023 I spoke with someone who had worked at a gender clinic. As this person recounted what a crap job it was, I had an idea – for-profit colleges!

For years I’d litigated against a scammy for-profit college, which entailed interviewing and deposing many of its workers. The gender clinic ex-employee reminded me of them. Suddenly I started drawing connections between gender medicine and other predatory industries. That’s the perspective that drives many of my posts here.

The world is full of people who could help expose gender medicine, if only they realized what was going on. We can’t predict what details or voices will jolt them awake. So we need to shove everything out into public view, not just scientific studies.

5. EBM Encourages Studies

Studies are sacred in EBM. If at first your studies are low quality, then study, study again. EBM is not in the business of shutting down studies – of saying, You Have Studied Enough. That’s not what it’s for.

Consider the Cass Review. Cass questions the rationale for puberty blockers (especially for girls), notes that studies don’t show they reduce gender dysphoria, and raises concern about potential medical harms. Conclusion: “they should only be offered under a research protocol.”

Why risk the health of even one child for an idea that makes no sense? 

6. EBM Holds Us to a High Standard

We want to get the word out that “T” permanently impacts girls’ genitals and vocal cords in ways that can be painful. But no one has run RCTs on these subjects.

In court, our side has called detransitioners to the stand to talk about their own medical experiences. Psychiatrists have also taken the stand to talk about patients they knew who recovered from “gender dysphoria” without cross-sex hormones. Not scientific.

We don’t want to live in a world, or argue in a court, where every assertion must be backed by high-quality scientific evidence.

How EBM Trips Up Gender Doctors

Gender doctors don’t have high-quality studies to support their position. But they want to play the EBM game anyway. They square the circle by making it sound like they rely on strong evidence. When their wordsmithing crosses the line into lying, they risk losing everything.

In this section I’ll quote WPATH SOC8 drafters whose internal emails were exposed last month through public filings in the Alabama PGM lawsuit. The drafters have not been publicly identified. Most of my quotes are drawn from the supplemental report of James Cantor, a sexologist serving as an expert witness for the state.

1. Gender Doctors Know The Evidence Is Against Them

A drafter commented before SOC8’s 2022 publication:

“I am concerned about language such as ‘insufficient evidence,’ ‘limited data,’ etc…”

This person continued to accurately sum up outside criticisms:

“these groups [that oppose gender medicine in the US] already assert that research in this field is low quality (ie small series, retrospective, no controls, etc….).”

After SOC8’s publication, a WPATH leadership committee wrote to an organizational ally:

“we were not able to be as systematic as we could have been (e.g., we did not use GRADE explicitly). …

“Now that we have reviewed the evidence, we are painfully aware of the gaps in the literature and the kinds of research that are needed to support our recommendations”

WPATH also commissioned Johns Hopkins University to conduct systematic reviews of the literature on adolescent gender medicine, then suppressed them.

2. Gender Doctors Think They Need Evidence to Win Hearts and Lawsuits

Gender doctors are nervous about their lack of evidence. The first SOC8 drafter I quoted above explained their concern:

“I say this from the perspective of current legal challenges in the US. … My specific concern is that this type of language (insufficient evidence, limited data, etc…) will empower these groups and reinforce their erroneous assertions.”

Another email:

“Our concerns, echoed by the social justice lawyers we spoke with, is that evidence-based review reveals [there is] little or no evidence and puts us in an untenable position in terms of affecting policy or winning lawsuits.”

A SOC8 drafter wrote regarding the academic realm:

“I think we need a more detailed defense that we can use that can respond to academic critics. . . .we know that some of the studies we have cited in support of our recommendations will be torn about by organizations such as the Society for Evidence Based Gender Medicine.”

The post-publication email noted anxiety that might be related to healthcare administrators or insurance companies. In Cantor’s words:

“The document’s introduction includes a list of adversaries and obstacles which [Eli Coleman, chair of the SOC8 steering committee] felt were attacking trans health care, including ‘academics and scientists who are naturally skeptical’ and ‘continuing pressure in health care to provide evidence-based care.’”

3. Gender Doctors Might Be Overestimating the Importance of EBM

As an aside, I’m not sure gender doctors benefit much in court from exaggerating the evidence supporting their treatments.

The Federal Rules of Evidence were not drafted by Gordon Guyatt. They allow experts to testify, for example, about the prevailing attitudes of their field. Gender doctors sparkle on this subject. 

Judges in Arkansas and Florida – the only states in which we have trial rulings so far – seemed very impressed with the “medical consensus” among gender doctors to which gender doctors testified. 

The Florida judge lavished approval also on their “clinical evidence,” meaning their opinions based on personally treating patients. Not scientific.

The most important question in the PGM lawsuits is which side bears the burden of proof. The Supreme Court will likely decide that in the next year after hearing Skrmetti, an appeal of a preliminary order in Tennessee. Studies on medical interventions won’t play into the Supreme Court’s analysis.

4. Gender Doctors Cross the Line

Some gender doctors overstate the findings of gender science, risking their credibility about everything.

Jack Turban is a San Francisco psychiatrist who’s suffered embarrassing fact-checks in his writing for the public about gender research. Attorneys could use his past writing to show he cares about point-scoring more than accuracy. 

Jason Rafferty is the Rhode Island pediatrician who got pantsed by James Cantor. He’s being sued by a detransitioner in part for his role drafting the fraudulent AAP statement. As far as I know, he has not been invited to testify as an expert witness in any PGM lawsuits. 

Aron Janssen is a Chicago psychiatrist who lied about SOC8’s development in expert reports in PGM lawsuits. He’s slated to testify in at least four states. Attorneys for those states will try to discredit him based on those lies.

WPATH calls SOC8 evidence-based. In 2023, Guyatt came close to saying it wasn’t. Block:

“When there’s been a rigorous systematic review of the evidence and the bottom line is that ‘we don’t know,’ he says, then ‘anybody who then claims they do know is not being evidence based.’”

When Guyatt said that, it wasn’t widely known that systematic reviews of PGM had taken place. Now, thanks to the Alabama emails, we know JHU conducted multiple reviews. Perhaps Guyatt or another EBM bigwig will testify that WPATH’s claims of being “evidence-based” are outright falsehoods.

And then there’s Meredithe McNamara …

The Disinformation Expert

Meredithe McNamara is a pediatrician who teaches at Yale Med and serves as an expert witness in PGM lawsuits. She writes and speaks about “scientific disinformation.” She’s affiliated with Yale Law School’s “Integrity Project,” which “promot[es] sound science in child and adolescent health policy.” Most of its publications are defenses of PGM.

The Integrity Project published a takedown of the Cass Review that McNamara co-authored with Janssen, Turban, a law professor, and others. It’s titled: 

“An Evidence-Based Critique of ‘The Cass Review’ on Gender-affirming Care for Adolescent Gender Dysphoria”

McNamara also filed an 80-page Cass takedown as a supplemental report in the Alabama PGM lawsuit. 

Boldly pitting her own authority against Hilary Cass’s, McNamara charges:

“The Cass Review does not follow established standards for evaluating evidence and evidence quality.”

“The Cass Review misinterprets and misrepresents its own data.”

“The Review’s discussion of evidence quality is scientifically unsound”

“[The Review] confidently cit[es] pseudoscience in support of outdated and debunked notions around rare phenomena like regret after gender-affirming care.”

“[The Review] is rife with misapplications of the scientific method.”

McNamara triumphantly claims that SOC8 uses GRADE, which we know from the WPATH emails isn’t true. She accuses Cass of having a “fixation on over-treating.” She huffs:

“It is completely unscientific and inappropriate to expect a young person, regardless of their gender identity, [to] ‘try out’ life as a gender they do not identify with - as the Review supposes transgender youth should.”

The phrase “try out” in this context isn’t in the Cass Review. McNamara is misquoting her target. (Lawyers mock Yale for hiring law professors who live in the world of theory and can’t litigate. I suppose that goes for Yale Law School’s medical professors as well.)

McNamara never offers a definition of gender in either of her Alabama reports, but she gives us something better:

“In the truest scientific sense, gender and sex are multidimensional concepts with complex expressions that are related—and distinct from each other—in ways that modern science is still exploring.”

I think she wrote that after shopping for a chandelier on Anthropologie.com.

Alabama’s lawyers don’t need to thoroughly debunk this entire 80-page report. They just need to trawl it for its most unfair, inaccurate, or loony sentences, then use them to expose McNamara on the witness stand. 

Scientists seek truth. Lawyers hunt lies.

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