In the spring, the Department of Health and Human Services published a careful, 409-page systematic review of the evidence and ethical considerations for pediatric medical transition. But one thing was missing: the names of the authors.
The official explanation of this omission was unhelpfully cryptic: “Names of the contributors to the review are not initially being made public, in order to help maintain the integrity of this process.” The report’s many critics pointed out that this left readers unable to evaluate their credibility or conflicts of interest. Others went further: “That’s one more reason why I can tell you this is an ideological, political document and not a scientific one,” Casey Pick, director of law and policy at the Trevor Project, told the journal Science. “Scientists stand by their work.”
Good news: The names of the authors have now been released, along with a supplement to the report that includes peer reviews by experts in fields such as psychology, endocrinology and evidence-based medicine, along with the responses of the authors. It is fair to say that their work has withstood scrutiny, with minor updates.
The names include two bioethicists, Farr Curlin of Duke University and philosopher Moti Gorin of Colorado State University, and two psychiatrists, Kristopher Kaliebe of the University of South Florida and Kathleen McDeavitt of Baylor University. They also include MIT philosopher Alex Byrne, who has written extensively about the philosophy of gender, and Evgenia Abbruzzese, a health care researcher who founded the Society for Evidence-Based Gender Medicine. Rounding out the pack is Michael K. Laidlaw, an endocrinologist; Yuan Zhang, an evidence-based medicine specialist; and Leor Sapir, who researches pediatric gender issues for the Manhattan Institute.
Critics will note that many of these contributors question the evidence for pediatric medical transition, though that was fairly obvious from the report itself. But these are not ideological cranks; they are thoughtful researchers. Their core finding — that the evidence for these interventions is highly uncertain — echoes the results of systematic reviews in other countries. None of the peer reviews of the HHS report ultimately rebut that conclusion.
Reasonable people can dispute what to do about that fact. Critics of the “gender-affirming” model argue that the evidence does not reach the bar required to justify tampering with puberty, given known side effects such as infertility. Then there are unknown risks, such as what it does to developing adolescent brains and bodies. Many proponents acknowledge that more and better research is needed, but they argue the preponderance of the studies that are available suggests these treatments help.
Far too many people have behaved unreasonably in this debate. Some who favor these therapies have attacked anyone who suggests their data is too weak to justify current medical practice, and more troublingly, may have delayed or suppressed publication of research that failed to show clear benefits. Meanwhile, some critics have resorted to demeaning or hostile rhetoric. Indeed, the Trump administration’s executive order that gave birth to the HHS report was titled “Protecting Children from Chemical and Surgical Mutilation.”
This is an empirical question involving vulnerable children, not a political football match. Both sides need to acknowledge the uncertainties, lay out the arguments for intervening or not and support the kind of rigorous, comprehensive research program that should have been used to validate these treatments — before they were given to thousands of children.
The most contestable conclusion of the HHS report, and the place where critics are apt to get the most traction, is that “it is not ethical to subject adolescents to hormonal and surgical interventions … even in a research trial, until and unless the state of the evidence suggests a favorable risk/benefit profile for the studied intervention.” But as long as there is a chance that puberty blockers and hormones can help deeply distressed children with gender dysphoria, many parents will seek them — in another state, in another country or over the internet if they have to. It would be much better if they got them in the context of a study that can establish the benefits (or lack thereof) once and for all.
The HHS report has jump-started a much-needed conversation. Scientists should continue it.
The post What we still don’t know about pediatric medical transition
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