Erin Reed Health Trans Rights

The Myth Of “Low Quality Evidence” Around Transgender Care

Recent discussions among legislators and think tanks opposed to gender-affirming care highlight a recurring claim: "There is no high-quality evidence." It's time to address this misconception.
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By Erin Reed / Erin in the Morning

If you’ve been following Republican legislators and think tanks recently, you might notice a recurring talking point they are using against gender-affirming care for transgender youth: “There is no high-quality evidence for gender-affirming care, and so it should be banned.” This is a blatant deception – there is plenty of strong evidence around gender affirming care. It is recognized as the standard of care for transgender youth by institutions like the World Professional Association for Transgender Health and the American Medical Association.

The argument that gender affirming care “lacks high quality evidence” hinges on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system, a method for assessing the quality of evidence in scientific research. Within the GRADE system, evidence is ranked from “very low quality” to “high quality.” Typically, research is categorized as either observational studies or RCTs (Randomized Controlled Trials). In order to receive a “high quality evidence” score under the system, RCTs are typically necessary. Observational studies, on the other hand, are given “low quality” rankings in this system save for a few rare exceptions (such as strong dose response curves).

Virtually all of the research on gender-affirming care consists of observational studies. In fact, there are over 50 studies examining gender-affirming care from various perspectives. The majority of these studies report large reductions in suicidality, depression, and anxiety. Though there is plenty of strong evidence for gender affirming care, it is observational in nature – and for good reason! Conducting RCTs for gender-affirming care is highly unethical and impossible. The physical effects of hormones are extremely evident, making blinding for such trials unfeasible. Furthermore, it would be unethical to pretend to treat a transgender person with hormones while withholding them – no such study would ever get approved given the massive weight of evidence in the favor of gender affirming care.

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Gender-affirming care isn’t unique in this regard. Some studies suggest that over 90% of medical care lacks “high-quality evidence” as classified by the GRADE system. However, this doesn’t equate to “90% of medical care is untested, experimental, or questionable.” The GRADE system explicitly does not bar medical care that relies heavily on individualized approaches and is backed by a wealth of observational evidence. Additionally, over reliance on the GRADE system might not be appropriate for medical treatments where blinding isn’t feasible or where withholding treatment would be considered unethical. This encompasses almost all pediatric medicine and a significant portion of adult medicine.

Here are just some examples of medication and medical procedures with no “High Quality Evidence” under the GRADE system:

Yet, there’s no movement to ban these treatments or medications, despite their ranking under the GRADE system. No one labels gallbladder surgery as “experimental.” Similarly, antidepressants aren’t labeled as “experimental drugs”; they’re part of an individualized treatment approach that prioritizes patient-centered care. Yet if we interpreted the GRADE standards the same way conservative lawmakers and think tanks do, many other procedures would also be challenged.

The GRADE system itself specifically notes that low quality evidence under it’s system is not meant to create a situation where RCT’s are required for medical care. Instead, lower GRADE scores can often lead to strong recommendations on medical care (and indeed, explains why we still allow 90% of medical care despite lower GRADE evidence quality scores):

Although higher quality evidence is more likely to be associated with strong recommendations than lower quality evidence, a particular level of quality does not imply a particular strength of recommendation. Sometimes, low or very low quality evidence can lead to a strong recommendation.

There is an abundance of evidence around gender affirming care that has led to the recommendations under the current standards of care. A recent article in the respected medical journal The Lancet, dated July 26, emphasizes that gender-affirming care serves as preventative healthcare. This care is linked to enhanced quality of life and is essential for the well-being of transgender youth. Numerous studies indicate its role in positive psychological outcomes, with some pointing to a significant 73% reduction in suicide rates. Furthermore, Cornell University has compiled over 50 studies supporting the benefits of gender-affirming care. As a result, describing gender-affirming care as an “unhealthy decision” is inaccurate. It’s a medically backed approach rooted in research, greatly benefiting transgender individuals who need it.

Mischaracterizing the evidence around gender affirming care as “low-quality” is a deceptive practice that relies on a layman understanding of the term. There is no level of evidence that will ever be acceptable to those seeking to ban gender affirming care, as controlled trials where trans youth are put through conversion therapy or denied medication are not ever going to ethically happen – especially given suicide risks among this patient population. Stating that gender affirming care lacks evidence is not a statement rooted in reality, and all attempts in the future to raise this disinformation should be met with swift rebuttal.

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Erin Reed

Erin Reed is a trans queer news and history content creator, lgbtq+ and repro legislation tracker, and activist trying to change the world to be a better place.

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