The "godfather of evidence-based medicine" shocked and appalled skeptics of pediatric gender medicine by adopting activist rhetoric last month that contradicted his own team's research.
These were excellent articles, the Unherd one and this one. You mention that Dr. Guyatt has been accused of having a history of overemphasizing patient autonomy. Do you know if these any of these other instances were also heavily political or activist influenced? For example, would he have responded to the Marcolino et al 2022 systematic review that did not find good evidence for using ivermectin to treat Covid infections as a way to reduce mortality or ventilator use by also saying this should result in more patient autonomy in getting ivermectin if they wanted it, especially for their children? In other words, is there evidence that Dr. Guyatt consistently responds this way to all SRs with weak outcomes, or are only certain ones - high profile, politicized, or highly activist influenced - getting this response?
I think that as a matter of policy, he does have a history of putting particular emphasis on patient autonomy. He’s maybe a bit of a medical libertarian.
Even as a libertarian, he needs to put more emphasis on the fact that these are children, even when they are teenagers, and cannot meaningfully consent. Maybe he gives a lot of weight to parental rights to consent for their children, although I am not sure that this reasoning then can still be construed as respecting "patient autonomy" in the context of medical ethics. Is there such a thing as surrogate autonomy? Or should children's bodily autonomy be protected from their parents' misguided decisions until they are truly able to consent for themselves? And of course, if it's all about a libertarian perspective on patient autonomy, we have to ask if it should be covered by insurance. From a strictly libertarian perspective, clearly not.
I agree. And I would also argue that parents, teenagers, and even adult are not making free decisions in the libertarian sense if they are being emotionally manipulated or bullied into a treatment pathway, not being told by their doctors how weak the evidence is, and having medical associations falsely claim the evidence is strong. You're also not making a free choice about your medical interventions if you're not being adequately assessed and given a proper diagnosis. Despite what activists like to claim, there is no evidence that gender dysphoria is a root cause condition from which all other mental health conditions stem and that it can't be a symptom or distortion created by another mental health condition or sociological/cultural issue that has nothing to do with someone's gender identity.
The Atlantic just published a big article about medically assisted death in Canada that touches on many of the same ethical debates. It says, "When autonomy is entrenched as the guiding principle, exclusions and safeguards eventually begin to seam arbitrary and even cruel."
The article contrasts euthanasia in Canada to Europe, where there are more legal limitations on who is eligible. It seems our North American culture has a big impact on medical ethics. Without clear legal guidelines, that field of medicine selects for extremists doctors who support the procedure even in edge cases.
Here is a quote from one of the MAiD doctors: “Once you accept that people ought to have autonomy—once you accept that life is not sacred and something that can only be taken by God, a being I don’t believe in—then, if you’re in that work, some of us have to go forward and say, ‘We’ll do it.’ ”
Yes, that was an excellent article. Essentially, when the greatest good is defined as giving people what they say they want, then any guardrails against abuse begin to crumble and fall away.
Ultimately, I think it's nihilism. What we "want" should not be the primary basis of medical care, not to mention medically assisted suicide. Our wants change. Our wants can be irrational. Our wants should not be the tail that wags the dog.
Thanks for this level of detail. I note the letter says "It is disingenuous to cast health care based on low-certainty evidence as bad care or as care driven by ideology, and low-certainty evidence as bad science."
OK, should we use the words 'risky' and 'unethical' in place of 'bad' to fix this? Do some people find the moral judgement of being called 'bad' uncomfortable?
Personally, I don't have this problem, as I don't consider the sexological alchemy of the gender clinic to be either 'health care' or 'science'.
The 'bodily autonomy' argument is highly misleading because very few people carry out their own gender surgeries. The gender clinics form part of a medical and legal system in which only certain 'choices' are permitted and funded. This necessarily involves pre-ordained choices made for us, and so 'autonomy' is socially constructed by those people that make the rules.
Guyatt needs to realize that "driven by ideology" is exactly what it is, not just because we have only low-certainty evidence for the effectiveness of the interventions. Without the foundational assumption of an innate, immutable "gender identity", for which there is not a shred of scientific evidence (not even of low certainty), the field would not exist, and the whole house of cards of the justifications for these interventions collapses.
This article talks about "potential harms" of gender surgeries (which are real). What is missed in all the articles I have seen about Guyatt is that removal of healthy organs is not listed as a harm. I think if you talk to the young woman who had their breasts removed at 13- they would say it is a considerable harm. And that harm is not potential, it is built into the surgery.
Guyatt's own GRADE matrix would require him to reject something with harm and low to very-low evidence of benefit. Not counting removing breasts as harm allows him to get around this.
I decided not to get into all that, but there's this debate over whether not having breasts is definitely a harm if the person asked to have them removed and then never says they regretted it.
If that is the case, why is there any controversy over doing body dysmorphia surgeries on adults or children? If the goal of those surgeries is, for example, to remove a healthy leg- then it should not be counted as harm.
The studies on desistance range, but they are all over 50% if there are no interventions. So even if you are going to weight the harm, I do not understand how over 50% of a clear harm is trumped by low to very-low benefit.
Wow, that’s amazing. I guess I’m biased because I’m female and the idea of replacing sensitive erogenous zones (not to mention nursing capacity) with scars (and possibly complications) seems an obvious harm.
Would be interested in more information about that debate—would have ramifications for female detransitioners.
So that you know how biased I am, the proudly displayed chest scars of Ellen/Elliot Page peaked me. It might not affect other people the same way—maybe those without breasts are less horrified?
I am sure I do not feel it in the same visceral way, but I am still shocked by this. I know of no other procedure where the loss of a healthy - important organ - is not considered harm. Under this logic body dysmorphia surgeries should not be at all controversial. Of course, those surgeries are very controversial, but somehow this life long harm to children is shrugged off. I do not understand it.
Perhaps this is another case of "trans exceptionalism": when the rules for everything else just don't apply to anything trans. Patient evaluation is good, except for someone claiming to be trans. Evidence matters, except for gender medicine. Bad outcomes are bad, except for transitioners, for whom it is "worth" it.
It is all predicated on the evidence-free assumption of the existence of an immutable "gender identity". If you believe in that, "transness" becomes a real medical condition that requires treatment, regardless of the lack of good evidence that such treatment improves the observable symptoms. If we assume that someone's "true self" is at odds with their body, altering the body becomes imperative for personal wholeness, no matter the observable harms and the lack of evidence for the improvement of symptoms.
I don't think any other medical field relies on such a strong, yet evidence-free foundational belief about the condition it treats, which is why the rules are different for "gender medicine".
I seriously wonder sometimes if an unexamined dislike of homosexuals is not at play here. Not the garden variety “homophobia” but something deeper that only gets activated when the prospect of a child growing up to be homosexual is at play.
If you would have told me that Gordon Guyatt was going to appear on the “Beyond Gender” podcast with Stella O’Malley and Mia Hughes (both branded as transphobes by TRAs) after condemning SEGM due to activist pressure, I would not have believed it. That he would then acknowledge on said podcast that he didn’t agree with everything on the disclaimer statement he and some of his coauthors issued (namely, that GAC is “medically necessary”) is truly mind-blowing.
The letter penned by these two researchers reads an awful lot like it was created (or at least edited) by activists who pressured and threatened them into writing it. Absent said pressure - I think they’d default to a line of thinking like Dr. Montante: produce truthful reports and leave the rest up to ethicists, medical bodies etc.
David Sackett, and not Gordon Guyatt, is generally recognized as the “father of evidence-based medicine”. That said, Guyatt has always been a tall figure in the movement. His caving to the crazed and depraved gender activists is not a good look and will diminish his standing in the field moving forward.
Sackett introduced the “EBM Venn diagram”. The 3 components are “the scientific evidence”, “clinical judgement” (often taken to mean a clinician’s accounting for a patient’s unique characteristics and individual co-morbidities), and “patient values and preferences”. “EBM” is the intersection of those 3 spheres on the Venn diagram. For Guyatt to suggest that “values and preferences” should take precedence particularly when “scientific evidence “ is lacking, is beyond the pale, and belies a misunderstanding of the EBM concept that is simply not possible for someone of his stature and experience in this field.
It’s a sad day when a giant in the field of EBM is sacrificed at the altar of woke in the service of people who are hell-bent on irreversibly mutilating children.
A bit off topic but Benjamin, is there any data on number of trans athletes beating out their assigned gender competition in sports. It’s been difficult to prove this athletic superiority argument.
Hi Ben - I support your work and would be keen to read your September 4th article for Unherd (US edition). However, as a UK subscriber, I can't easily access occasional articles of interest from Unherd (US). This is a global debate, with international ramification. Any way you can take this up with Unherd (US)? Thanks, Peter.
These were excellent articles, the Unherd one and this one. You mention that Dr. Guyatt has been accused of having a history of overemphasizing patient autonomy. Do you know if these any of these other instances were also heavily political or activist influenced? For example, would he have responded to the Marcolino et al 2022 systematic review that did not find good evidence for using ivermectin to treat Covid infections as a way to reduce mortality or ventilator use by also saying this should result in more patient autonomy in getting ivermectin if they wanted it, especially for their children? In other words, is there evidence that Dr. Guyatt consistently responds this way to all SRs with weak outcomes, or are only certain ones - high profile, politicized, or highly activist influenced - getting this response?
He rather famously said people should just go ahead and eat red meat if they like. https://cancerletter.com/conversation-with-the-cancer-letter/20191004_2/
I think that as a matter of policy, he does have a history of putting particular emphasis on patient autonomy. He’s maybe a bit of a medical libertarian.
Even as a libertarian, he needs to put more emphasis on the fact that these are children, even when they are teenagers, and cannot meaningfully consent. Maybe he gives a lot of weight to parental rights to consent for their children, although I am not sure that this reasoning then can still be construed as respecting "patient autonomy" in the context of medical ethics. Is there such a thing as surrogate autonomy? Or should children's bodily autonomy be protected from their parents' misguided decisions until they are truly able to consent for themselves? And of course, if it's all about a libertarian perspective on patient autonomy, we have to ask if it should be covered by insurance. From a strictly libertarian perspective, clearly not.
I agree. And I would also argue that parents, teenagers, and even adult are not making free decisions in the libertarian sense if they are being emotionally manipulated or bullied into a treatment pathway, not being told by their doctors how weak the evidence is, and having medical associations falsely claim the evidence is strong. You're also not making a free choice about your medical interventions if you're not being adequately assessed and given a proper diagnosis. Despite what activists like to claim, there is no evidence that gender dysphoria is a root cause condition from which all other mental health conditions stem and that it can't be a symptom or distortion created by another mental health condition or sociological/cultural issue that has nothing to do with someone's gender identity.
The Atlantic just published a big article about medically assisted death in Canada that touches on many of the same ethical debates. It says, "When autonomy is entrenched as the guiding principle, exclusions and safeguards eventually begin to seam arbitrary and even cruel."
The article contrasts euthanasia in Canada to Europe, where there are more legal limitations on who is eligible. It seems our North American culture has a big impact on medical ethics. Without clear legal guidelines, that field of medicine selects for extremists doctors who support the procedure even in edge cases.
Here is a quote from one of the MAiD doctors: “Once you accept that people ought to have autonomy—once you accept that life is not sacred and something that can only be taken by God, a being I don’t believe in—then, if you’re in that work, some of us have to go forward and say, ‘We’ll do it.’ ”
Yes, that was an excellent article. Essentially, when the greatest good is defined as giving people what they say they want, then any guardrails against abuse begin to crumble and fall away.
Ultimately, I think it's nihilism. What we "want" should not be the primary basis of medical care, not to mention medically assisted suicide. Our wants change. Our wants can be irrational. Our wants should not be the tail that wags the dog.
Thanks for this level of detail. I note the letter says "It is disingenuous to cast health care based on low-certainty evidence as bad care or as care driven by ideology, and low-certainty evidence as bad science."
OK, should we use the words 'risky' and 'unethical' in place of 'bad' to fix this? Do some people find the moral judgement of being called 'bad' uncomfortable?
Personally, I don't have this problem, as I don't consider the sexological alchemy of the gender clinic to be either 'health care' or 'science'.
The 'bodily autonomy' argument is highly misleading because very few people carry out their own gender surgeries. The gender clinics form part of a medical and legal system in which only certain 'choices' are permitted and funded. This necessarily involves pre-ordained choices made for us, and so 'autonomy' is socially constructed by those people that make the rules.
Guyatt needs to realize that "driven by ideology" is exactly what it is, not just because we have only low-certainty evidence for the effectiveness of the interventions. Without the foundational assumption of an innate, immutable "gender identity", for which there is not a shred of scientific evidence (not even of low certainty), the field would not exist, and the whole house of cards of the justifications for these interventions collapses.
This article talks about "potential harms" of gender surgeries (which are real). What is missed in all the articles I have seen about Guyatt is that removal of healthy organs is not listed as a harm. I think if you talk to the young woman who had their breasts removed at 13- they would say it is a considerable harm. And that harm is not potential, it is built into the surgery.
Guyatt's own GRADE matrix would require him to reject something with harm and low to very-low evidence of benefit. Not counting removing breasts as harm allows him to get around this.
I decided not to get into all that, but there's this debate over whether not having breasts is definitely a harm if the person asked to have them removed and then never says they regretted it.
If that is the case, why is there any controversy over doing body dysmorphia surgeries on adults or children? If the goal of those surgeries is, for example, to remove a healthy leg- then it should not be counted as harm.
The studies on desistance range, but they are all over 50% if there are no interventions. So even if you are going to weight the harm, I do not understand how over 50% of a clear harm is trumped by low to very-low benefit.
Wow, that’s amazing. I guess I’m biased because I’m female and the idea of replacing sensitive erogenous zones (not to mention nursing capacity) with scars (and possibly complications) seems an obvious harm.
Would be interested in more information about that debate—would have ramifications for female detransitioners.
So that you know how biased I am, the proudly displayed chest scars of Ellen/Elliot Page peaked me. It might not affect other people the same way—maybe those without breasts are less horrified?
I am sure I do not feel it in the same visceral way, but I am still shocked by this. I know of no other procedure where the loss of a healthy - important organ - is not considered harm. Under this logic body dysmorphia surgeries should not be at all controversial. Of course, those surgeries are very controversial, but somehow this life long harm to children is shrugged off. I do not understand it.
Thanks for more details!
Perhaps this is another case of "trans exceptionalism": when the rules for everything else just don't apply to anything trans. Patient evaluation is good, except for someone claiming to be trans. Evidence matters, except for gender medicine. Bad outcomes are bad, except for transitioners, for whom it is "worth" it.
It is all predicated on the evidence-free assumption of the existence of an immutable "gender identity". If you believe in that, "transness" becomes a real medical condition that requires treatment, regardless of the lack of good evidence that such treatment improves the observable symptoms. If we assume that someone's "true self" is at odds with their body, altering the body becomes imperative for personal wholeness, no matter the observable harms and the lack of evidence for the improvement of symptoms.
I don't think any other medical field relies on such a strong, yet evidence-free foundational belief about the condition it treats, which is why the rules are different for "gender medicine".
I seriously wonder sometimes if an unexamined dislike of homosexuals is not at play here. Not the garden variety “homophobia” but something deeper that only gets activated when the prospect of a child growing up to be homosexual is at play.
If you would have told me that Gordon Guyatt was going to appear on the “Beyond Gender” podcast with Stella O’Malley and Mia Hughes (both branded as transphobes by TRAs) after condemning SEGM due to activist pressure, I would not have believed it. That he would then acknowledge on said podcast that he didn’t agree with everything on the disclaimer statement he and some of his coauthors issued (namely, that GAC is “medically necessary”) is truly mind-blowing.
https://x.com/_CryMiaRiver/status/1965155081038561553
The letter penned by these two researchers reads an awful lot like it was created (or at least edited) by activists who pressured and threatened them into writing it. Absent said pressure - I think they’d default to a line of thinking like Dr. Montante: produce truthful reports and leave the rest up to ethicists, medical bodies etc.
David Sackett, and not Gordon Guyatt, is generally recognized as the “father of evidence-based medicine”. That said, Guyatt has always been a tall figure in the movement. His caving to the crazed and depraved gender activists is not a good look and will diminish his standing in the field moving forward.
Sackett introduced the “EBM Venn diagram”. The 3 components are “the scientific evidence”, “clinical judgement” (often taken to mean a clinician’s accounting for a patient’s unique characteristics and individual co-morbidities), and “patient values and preferences”. “EBM” is the intersection of those 3 spheres on the Venn diagram. For Guyatt to suggest that “values and preferences” should take precedence particularly when “scientific evidence “ is lacking, is beyond the pale, and belies a misunderstanding of the EBM concept that is simply not possible for someone of his stature and experience in this field.
It’s a sad day when a giant in the field of EBM is sacrificed at the altar of woke in the service of people who are hell-bent on irreversibly mutilating children.
A bit off topic but Benjamin, is there any data on number of trans athletes beating out their assigned gender competition in sports. It’s been difficult to prove this athletic superiority argument.
Oooh, thanks! Definitely looking forward to the Q&A.
Hi Ben - I support your work and would be keen to read your September 4th article for Unherd (US edition). However, as a UK subscriber, I can't easily access occasional articles of interest from Unherd (US). This is a global debate, with international ramification. Any way you can take this up with Unherd (US)? Thanks, Peter.
Try to see if you can access it through web archive: https://archive.is
Just put in the URL of the article, that's how you can access most content behind a paywall.
Hm, I don’t know. But go to my website, you should be able to use the link there: www.Benryan.net.