INSTITUTIONAL CAPTURE
“In an investigative report for the British Medical Journal (BMJ), Dr. Gordon Guyatt, a highly respected figure in the field of medical research methods and evidence evaluation who pioneered the evidence-based medicine (EBM) movement, stated that the current guidelines in the United States for managing gender dysphoria in adolescents should not be considered evidence-based. He emphasized that these guidelines fail to offer cautious and conditional recommendations appropriate for such low-quality evidence. Guyatt further underscored his concerns in a social media post, labeling these guidelines as ’untrustworthy.’”
— Christina Buttons, Buttonslives
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One of the most well-worn slogans in gender medicine is that “gender-affirming care” is supported by robust evidence going back decades and that every major medical association recommends the medicalization of gender distress. Not so fast. It turns out these statements are both misleading and inaccurate.
Let’s take a closer look at the main medical organizations in the U.S. and evaluate evidence they cite in support of these radical interventions. The most comprehensive review of gender medicine ever conducted, The Cass Review (National Health Service, England, April 2024), included a systematic evidence review of guideline quality based on an analysis of 19 international guidelines (including five from the U.S.). Of these, only two (from Sweden and Finland, countries that have banned pediatric gender medicine) “scored higher than 50% for rigor of development [the adherence to the scientific method to ensure robust and unbiased experimental design, methodology, analysis, interpretation and reporting of results] due to their evidence-based approach and transparent reporting of this. They were also the only guidelines which included a formal ethics review and they both scored highly on stakeholder involvement.”
The Cass Review exposed the rampant corruption within and between medical organizations when it comes to pediatric gender medicine. One of the most striking aspects of this corruption is the flagrant “circular referencing,“ which creates the appearance of independent and broad consensus. Also known as “citation laundering,” the practice involves multiple organizations referencing each other’s (and their own!) research as sources despite low-quality or non-existent underlying evidence. The World Professional Association for Transgender Health (WPATH) and the Endocrine Society (ES), the two most influential guidelines in the US, referenced each other’s poorly-evidenced guidelines, and the other major medical associations then based their guidelines on the WPATH and ES guidelines. All these organizations are actively deceiving and betraying public trust by portraying their policies as “evidence-based.”
The institutions formerly known as credible are:
THE AMERICAN MEDICAL ASSOCIATION (AMA).
The AMA's stated mission is to "promote the science and art of medicine and the betterment of public health." Ironically, the AMA bases its official statement of support for sex-trait modification (aka “gender-affirming care”) for children on cherry-picked, inapplicable, and/or outdated sources. For example, to support the claim that sex-trait modification for children improves mental health, they cite an article in the Journal of Sexual Medicine that is based on a study in which the participants were 18 years or older. The AMA’s claim that gender medicine reduces suicide attempts, depression, and anxiety is based on a 2010 systematic review of adult patients after hormone therapy and sex reassignment, and a 2005 journal article on “sex reassignment” of adolescents and adults, which cites no evidence to support the claim.
THE ENDOCRINE SOCIETY
The ES’s stated mission is to “improve patient care and shape effective policy.” Their current gender-specific policies (2017) reference other national and regional guidelines as evidence of consensus, but those guidelines don’t indicate new analyses, but rather were based on their own original recommendations. The circularity of this approach is highlighted in The Cass Review (see page 130). The ES guidelines include an assessment of the quality of evidence supporting its recommendations: “low” or “very low.” Given that the ES is a national leader providing clinical practice guidelines and professional development, their promotion of experimental interventions for children based only on admittedly low-quality evidence is disturbing. The Cass Review rated ES’s latest guidelines 4 out of 7 for whether they should be recommended, with two appraisers recommending that the guidelines be followed only with modifications and one appraiser recommending that the guidelines not be followed at all.
THE AMERICAN ACADEMY OF PEDIATRICS (AAP)
The very powerful AAP identifies itself as “an organization of 67,000 pediatricians committed to the optimal physical, mental, and social health and well-being for all infants, children, adolescents, and young adults.” The organization has taken an activist role against sex-trait modification bans and for including boys in girls sports. Oddly, the AAP entrusted most of their policies on gender medicine to one man: Jason Rafferty. A disclaimer in their guidelines document says “Dr. Rafferty conceptualized the statement, drafted the initial manuscript, reviewed and revised the manuscript, approved the final manuscript as submitted, and agrees to be accountable for all aspects of the work.” In other words, Rafferty was empowered to submit his own work to himself for approval and then (drum roll please), he approved it.
All three appraisers for The Cass Review rated the AAP guidelines as not recommended, with scores of 12 out of 100 for rigor and 6 out of 100 for applicability (whether or not the study can be applied to the specific clinical setting and individual patient) — the lowest applicability score of any guideline evaluated. Rafferty misrepresents the studies he cites, including as evidence studies that looked at sexuality, not gender identity, and studies that recommended exhausting all other avenues of care before medicalizing. Dissenters within AAP have tried repeatedly to petition the organization to conduct their own systematic review (learn more about this sad saga from Jenny Poyer Ackerman, a member of DIAG’s Board of Directors). In 2023, AAP grudgingly agreed to do so (providing no timeline) while at the same time reaffirming their 2018 policy statement and consigning thousands of children to infertility and their parents to despair.
From 4th Wave Now: “Canadian psychologist and sexologist James Cantor fact-checked the studies cited in the AAP’s policy statement.[49] He found the AAP statement failed to reference outcomes from 11 studies that followed gender-dysphoric (GD) children as they matured. Every one of these studies, “…found the same thing: Over puberty, the majority of GD children ceased to want to transition.”[50] An affirmation-only approach makes no sense when research shows most children grow out of their gender dysphoria. Cantor concluded, “Not only did AAP fail to provide compelling evidence, … AAP’s recommendations are despite the existing evidence.”[52])
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AMERICAN ACADEMY OF CHILD AND ADOLESCENT PSYCHIATRY (AACAP)
The AACAP’s mission is to “promote the healthy development of children, adolescents, and families through advocacy, education, and research, and to meet the professional needs of child and adolescent psychiatrists throughout their careers.” In 2019 they released the AACAP Statement Responding to Efforts to ban Evidence-Based Care for Transgender and Gender Diverse Youth which claims to support evidence-based care. Two of the three appraisers for The Cass Review rated the AACAP guidelines as not recommended with a score of 3 out of 7, a lackluster 44 out of 100 for rigor and an abysmal 7 out of 100 for applicability.
AMERICAN PSYCHIATRIC ASSOCIATION (APA)
The APA “is to be the premier psychiatric organization that advances mental health as part of general health and well-being.” (We’re waiting.) APA publishes the influential Diagnostic and Statistical Manual of Mental Disorders (DSM) which in the fifth edition (DSM5) set out the criteria for diagnosing gender dysphoria (based on regressive sex stereotypes and mostly useful as a source for insurance reimbursement billing codes). APA supports sex-trait modification, going as far as recommending whatever medical interventions WPATH likes. They state “No mental health evaluation is necessary to receive medical treatment.” As is common, they group gender non-conforming people (tomboys, for example) with those who have adopted a “trans” identity. (Note: The APA was not analyzed by The Cass Review.)
SOCIETY FOR ADOLESCENT HEALTH AND MEDICINE (SAHM)
SAHM is a nonprofit professional society “committed to the promotion of health, well-being and equity for all adolescents and young adults by supporting adolescent health and medicine professionals through the advancement of clinical practice, care delivery, research, advocacy, and professional development.” They support “protecting access to gender-affirming clinical care for transgender and nonbinary adolescents and young adults.” Their guidelines appear to be more concerned about protecting practitioners than protecting adolescents. All three appraisers for The Cass Review rated the SAHM guidelines as not recommended (they received two scores of 1 out of 7 and one score of 2 out of 7) and scored a miserable 17 out of 100 for rigor and 7 out of 100 for applicability.
AMERICAN PSYCHOLOGICAL ASSOCIATION (APA)
APA’s mission is “to promote the advancement, communication, and application of psychological science and knowledge to benefit society and improve lives.“ Their most recent guidelines were published in 2015. All three appraisers for The Cass Review ranked APA’s gender guidelines as not recommended, further ranking them 24 out of 100 for rigor and 18 out of 100 for applicability. The APA continues to issue policy statements on the need for sex-trait modification, ignoring The Cass Review and criticizing any opposition as motivated by bigotry.
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The above organizations are very powerful, and have circled their wagons (and their referencing!), to reinforce one another’s deception and cover-ups. Their corruption and misinformation campaigns have leaked outward and led to other formerly respected institutions falling eagerly into line. Rather than investigate whether what they were being fed was accurate, the following orgs swallowed it whole and regurgitated it:
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American Society of Plastic Surgeons — On Aug. 12, 2024, the ASPS released a statement saying, in part "ASPS has not endorsed any organization's practice recommendations for the treatment of adolescents with gender dysphoria. ASPS currently understands that there is considerable uncertainty as to the long-term efficacy for the use of chest and genital surgical interventions for the treatment of adolescents with gender dysphoria, and the existing evidence base is viewed as low quality/low certainty," making them the first major U.S. medical association to break ranks.
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WPATH/USPATH is left off this list, as they have never been credible and thus, we have generously given them their very own page.