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Thank you to Our Duty Canada for composing this letter.
An Open Letter to the Alberta Medical Association (AMA)
Regarding the February 1st Statement from the AMA
Section of Pediatrics on gender-affirming treatments March 2024
On February 1, 2024 your association released a statement in response to
Alberta Premiere Danielle Smith’s proposed changes to the treatment of
trans-identified children and adolescents, those struggling with gender
ideation. We ask that you consider and respond to our questions and
concerns regarding your statement and explain how the official position
described therein is consistent with your profession’s fundamental
principle to first “do no harm.”
We are a group of concerned parents, most of whom have children
struggling with gender ideation and grappling with the largely unrestricted
social and medical options being presented to them in Canada. We believe
that no child has the necessary cognitive and psychosocial maturity to
provide informed consent to the use of off-label synthetic hormones and
surgical procedures, often referred to as “gender-affirming healthcare,”
that have irreversible and damaging effects on their health and fertility.
We also carefully follow the results of peer-reviewed research in this area,
which, to date, has NOT yielded strong evidence of the safety or efficacy
of gender-affirming medical treatments. Therefore, we work to increase
public awareness and pressure our social, medical and political
organizations to conduct themselves from an evidence-based perspective.
We have identified several areas of concern in your recent statement and
we address them herein. In summary, your statement contains
generalizations that are not supported by sound evidence; false statements
about the safety and efficacy of the off-label drugs you recommend for
children and adolescents; reference to your steadfast opposition to
safeguarding children and adolescents through proper regulatory
processes and networks; and finally, a strong disregard for age-appropriate
decision-making and consent to medical treatments and surgical
procedures that have irreversible and damaging effects, and which
increasing numbers of youth are living to regret.
Your statement first asserts that “transgender youth have higher rates of
mental health issues and suicidality because of the stigma attached to
their status. The mental health of these children and youth will be markedly
worse when denied care.” The fact is, however, that recent peer-reviewed
research, such as this 20-year Finnish study, does NOT show that gender
affirming healthcare improves the mental health outcomes of children and
adolescents. For example, and perhaps most importantly, this research
does NOT find decreased suicide rates in youth who have accessed
gender-affirming medical treatment.
Your statement further asserts that “the effects of puberty-blocking agents
are not irreversible; and once treatment stops, puberty goes forward.
Treatment allows the patient time to determine their options without
permanent effects.” This assertion is particularly disturbing for two
reasons: (1) it blatantly misleads readers about how puberty blockers are
actually used in trans-identified children and adolescents, and (2)
consequently, it evades the full truth about the actual impacts of these
off-label drugs. In regard to (1), your assertion is premised on cases where
puberty blockers are used for brief periods of time and then stopped so
that natural puberty can progress.
However, this is not how puberty
blockers are actually being used in the majority of trans-identified children
and adolescents. In reality, puberty blockers are most often followed by
cross-sex hormone treatment (up to 98% of the time) and these minors
never go through natural puberty. Further, the long-term effects of puberty
blockers when they are followed by cross-sex hormones are
well-documented and dire, as even the president of WPATH confirms in
this linked video and with this statement, “Every single child or adolescent
who was truly blocked at Tanner Stage 2 has never experienced orgasm, I
mean it’s really about zero.” The pituitary gland is actually rendered
indefinitely dormant with GnRH Analogues (Puberty Blockers), which is why
several countries, most recently England, have corrected their course and
banned their use for gender affirming healthcare. Medical associations owe
it to the public to provide COMPLETE and TRUTHFUL information, which
your statement does NOT do.
Your statement goes on to point out that “Bottom surgery in Canada is
already limited to patients over 18 years.” Once again, you assert a
half-truth that is misleading to readers when you state that “bottom surgery”
is limited, but you remain silent about bilateral mastectomies (“top
surgery”). The fact is that bilateral mastectomies ARE being performed
on patients UNDER 18 YEARS old in Canada. We know this first-hand
because it has happened to our own children, and we know that this
procedure is completely irreversible. Asserting half-truths and omitting
information is not conducive to maintaining the trust of the public.
In light of the recent release of the WPATH Files, we find the following part
of your statement to be an effort to escape the duty to be transparent that,
as a regulatory body for the entire province of Alberta, is crucial to the
AMA’s role and responsibility: “Requiring a private registry of physicians to
provide gender-affirming care has the feel of surveillance, to which we
object. It is an unnecessary bureaucratic process given the current
existence of effective referral processes and networks.” First, what you
refer to as “surveillance” is understood by the Albertans to whom you are
accountable as the transparency you are charged to uphold. Second, you
fail to explain that your referral process is based on the WPATH guidelines,
which have been largely discredited. The fact is that these guidelines, for
“gender-affirming healthcare,” are not evidence-based, but experimental.
A 2023 article in the prestigious British Medical Journal confirms this. As
parents, we are paying close attention to this, and we are asking that our
medical professionals do the same. Statements like the one you have just
made show us that you are NOT paying attention and that you are NOT
following the overwhelming and growing body of evidence.
When professional medical associations cease to be guided by
evidence-based research and principles, and cease to be open and honest
with the public, then the public– rightly and understandably– becomes
alarmed and will, in turn, support the intervention of governments and
ultimately the courts. While we do respect the doctor/patient relationship,
your lack of adherence to the evidence is a symptom of a problem to which
you, as a medical association, have contributed. Your statement is shining
evidence of this.
There is, however, one part of your statement with which we could not
agree more: “Children and youth have the right to the appropriate medical
care.” Children and adolescents DO have the right to safe, evidence-based,
non-experimental medical care that protects them from long-term harm
such as loss of sexual function and infertility. This right is enshrined in the
United Nations Convention on the Rights of the Child. Moreover, children,
adolescents and their families ALSO have the right to provide informed
consent to drugs and surgical procedures that are recommended to them.
This requires doctors and medical associations to be informed and
evidence-based, transparent and accountable. Your statement shows a
shocking disregard for these responsibilities, which the AMA SHOULD hold
sacred. Full stop.
We strongly recommend that your organization cease to follow the
guidelines put forth by the heavily discredited WPATH, stop promoting
medical negligence and harm while operating from a non-evidence-based
perspective, and change course now as progressive European countries
including Sweden, Finland, England, Norway and France have already
done.
We ask that you explain your comments from an evidence-based
perspective. If you cannot, we must assume that they, along with your
official position, are ideologically driven, in which case we call for complete
retraction or substantial correction to the AMA’s original statement. Should
you fail to respond, we will understand that as further dismissal of the
parents, children and adolescents, and citizens to whom you are
responsible, and we will proceed accordingly.
In Support of Children and Families,
Our Duty Canad
Reproduced in full – Find the original here.
“A common claim by Americans who oppose state restrictions on “gender-affirming care” is that Sweden, Finland, and the U.K. have not done away with hormonal interventions—and therefore that Republican lawmakers who seek such restrictions are going beyond Europe, and presumably against what European health authorities recommend. Jack Turban, a prominent voice in the affirmative-medicine movement and a notorious source of misinformation on this issue, has said that “not a single country” in Europe “has banned gender-affirming care for trans youth.” The claim is true in a narrow and technical sense, but highly misleading.
In the past few years, European health authorities conducted systematic reviews of evidence for the benefits and risks of puberty blockers and cross-sex hormones. The findings from these reviews—that the certainty of benefits is very low—guided the hand of policymakers there to restrict access to hormones. Currently, minors in these countries can access puberty blockers and cross-sex hormones only if they meet strict eligibility requirements as set out in the Dutch protocol and only in the context of a tightly controlled research setting.
As I’ve explained in pastwritings, the research from the Dutch clinics is championed even by American proponents of “affirmative” medicine as the gold standard in pediatric gender medicine. These advocates either don’t know or are deliberately misleading the public about the discrepancy between the Dutch protocol and what is actually happening in American clinics. The American approach effectively puts distressed teenagers in the driver’s seat of making risky and irreversible medical decisions. It assumes that “gender identity” is innate and immutable, that some kids are just born “trans” and can know this from as young as toddlerhood. It also uses the “minority stress” model to explain away co-occurring mental-health problems, which appear in roughly three-quarters of patients presenting at pediatric gender clinics.
In effect, once a child declares that he is trans, the role of doctors is to “affirm” that declaration medically. Parents are to consent to treatments or get out of the way. Mental-health professionals are there only to help the child cope with the stress that comes from being in a minority, since, as Turban puts it, “most of society is awful.”
One source of confusion, therefore, concerns what, exactly, white-gowned activists like Turban mean when they say “gender-affirming care.” As Hilary Cass noted in her report to the U.K.’s National Health Service, the American affirmative model removes the main guardrails put in place by the Dutch protocol, resulting in a lack of medical “safeguarding.” At least in its official policy, Europe is decidedly not practicing what Turban considers “gender-affirming care.”
To be sure, the problems with the American affirmative model should not conceal the fact that the Dutch study itself rests on a very shaky empirical foundation. The study’s flaws were discussed at length in a recent peer-reviewed article, but two in particular should be mentioned before considering the European systematic reviews.
First, the Dutch study’s lead author, Annelou de Vries, has admitted that “resolution of gender dysphoria” was its “main finding.” But this finding was based on a highly questionable use of the Utrecht Gender Dysphoria Scale—a measure originally developed for diagnostic purposes, not to assess treatment outcomes. The scale is sex-specific, which means that biological males and biological females are given different versions of it. Among other differences, the female version includes questions on menstruation while the male version includes questions about erections. In their follow-up assessments, the Dutch team gave boys who had undergone hormonal treatments the girls’ scale and girls who had undergone hormonal treatments the boys’ scale. Thus, biological males were asked whether experiencing menstruation caused them distress. Since even boys who “transition” do not get periods, those who answered the questionnaire reported a low level of distress. In other words, the plummeting scores in gender dysphoria that the Dutch team reported as their “main finding” was not necessarily due to actually resolved dysphoria, but more likely to switching the scales.
Second, replication is a bedrock of scientific analysis, yet the only attempt to date to replicate the Dutch study, conducted in the U.K., failed. Preliminary results from the study, which began in 2010, were reported as very unimpressive, with adolescents after one year of puberty suppression showing an “increase in internalising problems and body dissatisfaction, especially natal girls.” Moreover, the cohort that received puberty blockers showed no statistically significant difference from the cohort that received only psychotherapy. As Michael Biggs has pointed out, the full picture of the study’s findings became public only after a prolonged campaign to force the researchers to publish their findings.
Contrary to what American activists imply, the systematic reviews of evidence in Sweden, Finland, and the U.K. did not find that the Dutch study, on which the Dutch protocol is based, constitutes high-quality evidence. One of the core questions in the systematic review by the U.K.’s National Institute for Health and Care Excellence (NICE) was this: “In children and adolescents with gender dysphoria, what is the clinical effectiveness of treatment with GnRH analogues [puberty blockers] compared with one or a combination of psychological support, social transitioning to the desired gender or no intervention?” Using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) system, NICE assessed the Dutch study for seven reported metrics of mental health impact: gender dysphoria, depression, anger, anxiety, body image, global functioning, and psychosocial functioning.
It found that evidence for benefits across all seven measures was of “very low” certainty. NICE’s conclusion about all the studies on puberty blockers, including the Dutch, was unequivocal: “Studies that found differences in outcomes could represent changes that are either of questionable clinical value, or the studies themselves are not reliable and changes could be due to confounding, bias or chance.” NICE conducted a separate systematic review for cross-sex hormones (which the Dutch study did not independently cover) and found that “[a]ll the studies . . . are uncontrolled observational studies, which are subject to bias and confounding and were of very low certainty using modified GRADE. A fundamental limitation of all the uncontrolled studies included in this review is that any changes in scores from baseline to follow-up could be attributed to a regression-to-the mean” (because patients tend to report for care at the peak of their distress).
The systematic reviews by Sweden’s Committee for Medical and Social Evaluation (SBU), meantime, likewise found that the evidence for the mental-health benefits of hormones, including from the Dutch study, was very uncertain, because of the “moderate to high risk of bias” in these studies. The studies exhibit numerous methodological shortcomings, including confounding factors, lack of control groups, and high rates of attrition. “The identified scientific basis regarding hormone treatment of children and adolescents with gender dysphoria,” SBU concludes, “is limited and it is not possible to draw any conclusions with moderate or high reliability. For most outcomes examined in this report, the evidence is insufficient and conclusions cannot be drawn.” SBU also reported “low confidence” in the assessed health risks of hormonal interventions in minors. In essence, Sweden recognizes this as a medical experiment with no high-quality, reliable data on long-term benefits or risks.
The results from the evidence review in Finland are harder to interpret because most of the studies evaluated involved adults, and the review did not rate the quality and reliability of the studies. In other words, the review did not try to assess the degree to which even the positive findings in the Dutch study were causally related to the hormonal treatments. Nevertheless, on the basis of this review, and a study published by Finnish gender clinicians shortly thereafter finding that “medical gender reassignment is not enough to improve functioning and relieve psychiatric comorbidities,” the country’s Council for Choices in Health Care (COHERE) issued new recommendations in 2020. Even for patients whose gender issues appeared first in childhood and intensified in adolescence (a pathway that is required for hormonal eligibility under the Dutch protocol but optional under the American-affirmative one), COHERE recommends that “the first-line treatment for gender dysphoria is psychosocial support and, as necessary, psychotherapy and treatment of possible comorbid psychiatric disorders.” In the same document, COHERE emphasizes that “gender reassignment of minors is an experimental practice.” This includes minors transitioned under the Dutch protocol.
Yes, Sweden, Finland, and the U.K. still allow a tiny subset of minors with gender issues access to puberty blockers and cross-sex hormones. But they are doing so under tight restrictions and against the findings of their own systematic reviews—or, as in the case of Finland, in full recognition that this constitutes medical experimentation on minors.
A good case can be made that Republicans who seek to ban these interventions entirely are being more faithful to the findings of the European evidence reviews. The real debate between red states in the U.S. and European health authorities is not about whether there is good evidence for pediatric gender transition. There isn’t. Rather, the debate is about whether children as young as eight with a strong desire for “gender affirming” drugs have the ability to understand fully and give informed consent to the long-term consequences of these interventions—and even if they can, whether this justifies enlisting them in an uncontrolled medical experiment.”
This excerpt from Leor Sapir’s article – The Deposition of Jack Turban – One of America’s leading gender clinicians proves that he doesn’t understand evidence-based medicine.
“Ramer asked Turban to explain the GRADE method (Grading of Recommendations Assessment, Development and Evaluations), a standardized EBM framework for evaluating quality. “GRADE generally involves looking at the research literature,” Turban explained. “And then there’s some subjectivity to it, but they provide you with general guidelines about how you would—like, great level of confidence in the research itself. Then there’s a—and then each of those get GRADE scores. I think it’s something like low, very low, high, very high. I could be wrong about the exact names of the categories.” Turban is indeed wrong: the categories are high, moderate, low, and very low. It’s surprising that someone involved in the debate over gender-medicine research for several years, and who understands that questions of GRADE and of quality are central, doesn’t know this by heart.
Ramer asked Turban what method, if any, he uses to assess quality in gender-medicine research. Turban explained that he reads the studies individually and does his own assessment of bias. GRADE is “subjective,” and this subjectivity, Turban said, is one reason that the U.K. systematic reviews rated studies that he commonly cites as “very low” quality. Turban’s thinking seems to be that, because GRADE is “subjective,” it is no better than a gender clinician sitting down with individual studies and deciding whether they are reliable.
I asked Guyatt to comment on Turban’s understanding of systematic reviews and GRADE. “Assessment of quality of evidence,” he told me, “is fundamental to a systematic review. In fact, we have more than once published that it is fundamental to EBM, and is clearly crucial to deciding the treatment recommendation, which is going to differ based on quality of evidence.” Guyatt said that “GRADE’s assessment of quality of the evidence is crucial to anybody’s assessment of quality of evidence. It provides a structured framework. To say that the subjective assessment of a clinician using no formal system is equivalent to the assessment of an expert clinical epidemiologist using a standardized system endorsed by over 110 organizations worldwide shows no respect for, or understanding of, science.”
At one point, Ramer pressed Turban to explain his views on psychotherapy as an alternative to drugs and surgeries. Systematic reviews have rated the studies Turban relies on for his support of puberty blockers and cross-sex hormones “very low” quality in part because these studies are confounded by psychotherapy. Because the kids who were given drugs and improved were also given psychotherapy and the studies lack a proper control group, it is not possible to know which of these interventions caused the improvement.
Turban seemed not to grasp the significance of this fact. If hormonal treatments can be said to cause improvement despite confounding psychotherapy, why can’t psychotherapy be said to cause improvement despite confounding drugs?
The exchange about confounding factors came up in the context of Ramer asking Turban about an article he wrote for Psychology Today. The article, aimed at a popular audience, purports to give an overview of the research that confirms the necessity of “gender-affirming care.” Last year, I published a detailed fact-check of the article, showing how Turban ignores confounding factors, among other problems. Four days later, Psychology Today made a series of corrections to Turban’s article. Some of these corrections were acknowledged in a note; others were done without any acknowledgement. In the deposition, Ramer asked Turban about my critique, to which Turban replied that he “left Psychology Today to do whatever edits they needed to do,” and that, when he later read the edits, he found them “generally reasonable.”
In sum, though Turban says that “there are no evidence-based psychotherapy protocols that effectively treat gender dysphoria itself,” the same studies he cites furnish just as much evidence for psychotherapy as they do for puberty blockers or cross-sex hormones—which is to say “very low” quality evidence.”
The quality of evidence that Gender Affirming Care works is “Very Low”. In other words those who argue for Gender Affirming Care are arguing from a base of low quality, probably confounded evidence that doesn’t say what they think it says. It just another example of how the pseudo-science of gender identity is propagated by believers – even medical doctors – over the principles of evidence based medicine. Make sure you go and read the full article, it is a wild ride.
The gender cult and associated gender religious members are pushing bullshit and now, finally, the stink is starting to seep out.
bleatmop
Mystro
The Arbourist
Dead Wild Roses 
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