Canadian provincial healthcare systems use the World Professional Association of Transgender Health (WPATH) guidelines to assess the insurability of gender healthcare services. WPATH recently released their “Standard of Care version 8”, however, after approximately 10 years in the making, a systematic review of the evidence was not undertaken by WPATH. Independent systematic reviews of the evidence behind gender-affirmation care have been undertaken by several national healthcare systems around the world as concerns have increased about the exponential numbers of children and young people seeking gender transition.
There’s a growing divergence of medical opinion between WPATH (and the Canadian group CPATH) and several independent groups of medical professionals, including the National Institute of Healthcare Excellence of the UK, the Swedish National Board of Health and Welfare, the Finland National Health System and the Florida Boards of Medicine and Osteopathic Medicine. These jurisdictions have been the first to undertake independent, non-partisan, systematic reviews of the evidence supporting medical gender affirmation for children and young people presenting with gender-related distress.
After a review of the evidence and careful stakeholder consultation, all have implemented new safeguarding measures for children and young people seeking medical gender transition, noting the exponential rise of a new cohort of predominantly female adolescents who are presenting to clinics with gender-related distress.
The British Journal of Medicine published an excellent summary of the current state of medical care in this area. The weak evidence, the article states: “doesn’t just mean something esoteric about study design, it means there’s uncertainty about whether the long term benefits outweigh the harms”. Canadian health research methods expert, Gordon Guyatt of McMaster University, who co-developed GRADE, a systematic approach to rate the quality and certainty of research evidence, is quoted heavily in this piece.
The Cass Review is an Independent Review of Gender Identity Services for Children and Young People commissioned by NHS England and NHS Improvement in Autumn 2020. The Interim report was released in February and contributed to the shutdown of the Tavistock Gender Clinic “due to patient safety” in July of 2022.
The practical meaning of “assessment” is a key concept that needs serious definition and reflection under the gender-affirmation treatment protocol. There is a conclusion in the Interim Report that there are “different views about the purpose of assessment” and that this is problematic and needs to be addressed. We expect that the final report will provide direction on this fundamental question.
Of particular import in the Interim report is the recommendation for broader treatment pathways that recognize subgroups of young people presenting with gender dysphoria such as autistic and neurodiverse children as well as young people who may be suffering from trauma. The report also emphasizes the need for the development of a formal research program and outcomes tracking into adulthood.
Links to UK evidence reviews (National Institute for Health and Care Excellence)
Evidence review: Gonadotrophin releasing hormone analogues for children and adolescents with gender dysphoria
Evidence review: Gender-affirming hormones for children and adolescents with gender dysphoria
Canadian Gender Report predicted the Swedish U-turn on gender transitioning for children based on data provided by one of the pediatric gender services and several news reports that gave medical experts the leeway to voice their concerns about gender transitioning of children being a “medical experiment”.
An official independent evidence review was initiated in Sweden by the left-leaning Social Democrat party after they tried to lower the age for gender-affirmation surgeries to 15 from 18. Experts spoke up and the Medical Ethics group recommended a review of the evidence and coming up with new treatment protocols that would be evidence-based.
The result was that the Karolinska Hospital, a renowned research and teaching hospital that grants the Nobel Prize in Medicine, suspended all pediatric gender transitions outside experimental or national monitored settings, with all Swedish hospitals eventually following suit.
May 2021, the Astrid Lindgren Children’s Hospital in Sweden stopped using puberty blockers and cross sex hormones to treat patients with gender dysphoria outside the context of clinical trials. The Hospital’s guidelines stated that the available research provided “…low quality evidence that the treatments have the desired effect…” and that the treatments “…are potentially fraught with extensive and irreversible adverse consequences such as cardiovascular disease, osteoporosis, infertility, increased cancer risk, and thrombosis.”
Official Sweden evidence review:
The Swedish National Health and Welfare Board issued guidance for treating gender dysphoria (not gender identity) earlier this year.
Translated version (need to upload)
In 2020 the Finnish Health Authority issued new guidelines stating that “…psychotherapy, rather than puberty blockers and cross-sex hormones, should be the first-line treatment for gender-dysphoric youth. This change occurred following a systematic evidence review, which found the body of evidence for pediatric transition inconclusive.” The guidelines called gender reassignment of minors, “an experimental practice,” and said, “It is critical to obtain information on the benefits and risks of these treatments in rigorous research settings.”
Finland evidence review (see Finland systematic review Google translate attached)
Numerous medical boards
2019 Britain’s Royal College of General Practitioners issued a position statement saying, “There is a significant lack of robust, comprehensive evidence around the outcomes, side effects and unintended consequences of such treatment [i.e. puberty blockers and cross sex hormones] for people with gender dysphoria, particularly children and young people, which prevents GPs from helping patients and their families in making an informed decision.”
“ There are currently significant gaps in evidence for nearly all aspects of clinical management of gender dysphoria in youth. Urgent investment in research on the impacts of treatments for children and young people is needed.
“The fundamental standards of care and principles of oversight and regulation applied by the Care Quality Commission (CQC) in England and equivalent bodies in the Devolved Nations, should be applied to all providers of gender identity services, through regular service reviews and publication of results.”
The National Academy of Medicine in France approved a statement in 2022 urging the greatest caution in using puberty blockers and cross-sex hormones to treat minors “…taking into account the side-effects such as the impact on growth, bone weakening, risk of sterility, emotional and intellectual consequences and, for girls, menopause-like symptoms.” The National Academy warned that since there is no test to distinguish persisting gender dysphoria from transient adolescent dysphoria, there is a real risk of over-diagnosis.
Several US states have taken action to ban gender transitioning for children. While some of these states have done this with purely political motivations, there is one example of an excellent evidence review that was conducted by a group including a well respected Canadian health research methodology expert.
Florida Agency for Health Care
Florida’s Agency for Health Care Administration commissioned an overview of systematic reviews looking at outcomes “important to patients” with gender dysphoria, including mental health, quality of life, and complications. Two Canadian health research methodologists at McMaster University carried out the work, analyzing 61 systematic reviews and concluding that “there is great uncertainty about the effects of puberty blockers, cross-sex hormones, and surgeries in young people.” The body of evidence, they said, was “not sufficient” to support treatment decisions.
Fact checking of American Academy of Pediatrics gender affirming care policy (by Canadian Dr James Cantor)
Fact checking of US HHS policy:
Why are experts not speaking up in Canada? They’ve tried but our media has been very reluctant to give them a voice. A world-reknowned Canadian expert on gender dysphoria, Ken Zucker, was axed from his position leading the gender services at CAMH. He won a wrongful dismissal lawsuit and a financial settlement. Still, the message was clear – dissent from the unquestioned gender-affirmation approach will not be tolerated.
Aaron Kimberley came forward in 2020. Aaron is a transman who has transitioned himself and a RN with a mental health specialization who was working with transgender youth in BC. He was sanctioned for posting information on the listserv that questioned the “affirmation” treatment pathway. His clinic was effectively shut down to silence him. He was being honest with the families he met, telling them that gender transition doesn’t always solve all your issues. He has since started GD Alliance and is an advocate for more holistic care for young people struggling with gender-related distress.
Dr Joey Bonifacio is a pediatric gender clinician who used to direct the SickKids gender clinic. After leaving SickKids he had his own practice where he offered a multi-disciplinary approach including psychotherapy for young people who wished to transition their gender. He spoke out in the summer of 2022 in a National Post article calling for gender clinicians in Canada to “slow down”.
The Globe & Mail has not published a single article revealing the growing international concerns and lack of evidence supporting gender transition for children and young people. W5 is the only Canadian current affairs program to air a balanced documentary about gender transition. One documentary, aired once.
It is our view that Canadians expect caution and due diligence to be exercised when children are being submitted to experimental and life-changing medical treatments. Unfortunately, there is no evidence that this is the case. Canadian healthcare systems have adopted the unproven “gender affirmation” model and young people are able to self-direct their “gender journey”. This will continue to be the protocol until there is a independent review of the treatment protocols and evidence base in Canada because there are many activists, well-funded and well-positioned with policy and decision makers, who are pushing for more unfettered access to gender affirmation treatments regardless of the age of the patient.