Spotlight OPS - From evidence-based medicine to denial-based medicine
- La Petite Sirène
- 2 days ago
- 5 min read
Jacques Robert, emeritus professor of medicine, Bordeaux, France
A group of Canadian physicians and non-physicians from McMaster University, led by Professor Gordon Guyatt, worked on the benefits and risks of certain medical treatments for adolescents showing signs of pubertal sexual anxiety. They developed, according to the rules of the art, systematic reviews of studies published on the subject [1-3]. It should be noted that Professor Guyatt is one of the renowned initiators of evidence-based medicine. The conclusions of their studies are clear and are not questioned: “only low certainty evidence exists […] regarding the benefits of the gender-affirming care interventions addressed in our systematic reviews”. This group recently intervened, in an open letter published on the McMaster University website, to criticize the use that doctors could make of these systematic reviews [4]. A very complete analysis of this affair, carried out by Jesse Singal, a journalist publishing on the Substack platform, is available on the Observatoire La Petite Sirène website [5]. I’m just adding here some personal comments on the open letter by Guyatt et al.
At a first glance, the group of Guyatt et al. denies other physicians the right to derive from their work a therapeutic course of action that is not the one they advocate: “Authors of scientific articles have a responsibility to attend to how their contributions will be used and to modify their presentation in the articles, or other communications, accordingly”; and further: “We therefore feel compelled to make explicit our view regarding how our findings should and should not be used”. This is an unacceptable claim. Either their work is reliable and their systematic reviews well done, and each therapist has the right to draw the conclusions that seem best to him; or their work is questionable and only the conclusions of the authors are allowed to be followed, conclusions that we cannot therefore know if they are justified. The freedom to prescribe appropriate care is the privilege of physicians, who have the right to draw practical conclusions from well-done studies that may not be in accordance with those of the authors of these studies. This is a matter of appreciation and no one can claim the right to demand that recommendations be accepted by other doctors when they do not consider them appropriate and justified.
The authors of this letter then fear that their studies will lead to “denial of care to trans, nonbinary, and gender-diverse”. However, it was never proposed to deny care to these people. The doctors and psychologists who treat them are perfectly aware that gender dysphoria, also known as ‘pubertal sexual anxiety’ in adolescents, is a suffering that must be alleviated. Claiming that those who have not reached the same conclusions as the authors of these studies would refuse to provide care to their patients is unacceptable. In fact, through a semantic shift, the authors only subsequently reveal that it is ‘gender-affirming’ care that would be unacceptable to refuse, as if other therapeutic approaches were not possible. Gender-affirming treatments are hormonal treatments (‘puberty blockers’, ‘cross-sex’ hormones) and surgical treatments, whose safety has never been proven and whose long-term side effects are formidable. There is no need to invoke evidence-based medicine to apply the intangible Hippocratic principle ‘primum non nocere’.
Further on, the letter's authors claim that “following the principles of evidence-based decision-making, clinicians should always have a high respect for the autonomy of patients and their advocates”. This call for respect for autonomy is particularly inappropriate in this case. How much ‘autonomy’ does a patient have who is prescribed ‘gender-affirming’ care that will last for several years, or even, for ‘cross-hormones’, a lifetime? How much autonomy does a patient have who depends on taking a medication whose side effects are uncontrollable? The dependence of a diabetic on his or her treatment is a serious issue that a diabetologist always has in mind when explaining to a young patient what to expect. Certainly, the therapist must, in the last resort, respect the wishes of his patients, even if they refuses treatment, but he must also inform them of the loss of autonomy that they will suffer, and this applies to an essential treatment (insulin for diabetics), as well as to a treatment that is not essential to the life or physical health of the patient (cross-hormones for pubertal sexual anxiety). We could safely replace ‘autonomy’ in the letter with ‘demand’, ‘desire’, or even ‘whim’, which would be more justified terms.
Guyatt et al.’s letter concludes, that in the absence of strong evidence to determine whether a treatment is justified, the patient’s claim must be accepted and the treatment requested prescribed. This is medically exorbitant, and it is doubtful that other similar situations exist. However, we see very often that the doctor complies with the request of the person who has become his client instead of his patient, particularly in the prescription of sick leave. We agree that “it is profoundly misguided to cast health care based on low-certainty evidence as bad care”, and that non–evidence-based data is not ‘bad science’ Certainly, “enlightened individuals often legitimately and wisely choose such interventions”, but what about ‘unenlightened’ people? Adolescents who are still searching for themselves and are prey to influencers of all kinds? Believing that the person who is suffering knows what treatment they need is an illusion.
Finally, let us point out another semantic shift in the letter from Guyatt et al.: “forbidding delivery of gender-affirming care […] on the basis of low certainty evidence is a clear violation of the principles of evidence-based shared decision-making and is unconscionable”. Who is talking about ‘forbidding care delivery’? Competent therapists, doctors, psychologists, who treat these patients do not prohibit anything: they propose on a case-by-case basis, and associations like the Society for Evidence-based Gender Medicine (or the Observatoire La Petite Sirène in France) issue recommendations, but cannot ‘forbid’ experienced practitioners from any prescription that they deem appropriate, depending on the patient: age, physiological and psychological state, existence of an intercurrent pathology; and more specifically for adolescents: relationships with parents, with classmates, etc. Each patient is unique and our goal, as therapists, is to relieve his/her suffering without creating new ones. Is it too much to ask to respect the doctor’s choice when he proposes a therapy (or an absence of therapy), when only ‘low-certainty evidence’ is available?
Jacques Robert, emeritus professor of medicine, Bordeaux, France
References
1. Miroshnychenko A, Roldan Y, Ibrahim S, Kulatunga-Moruzi C, Montante S, Couban R, Guyatt G, Brignardello -Petersen R. Puberty blockers for gender dysphoria in youth: A systematic review and meta-analysis. Arch Dis Child 2025; 110(6): 429-436.
2. Miroshnychenko A, Ibrahim S, Roldan Y, Kulatunga-Moruzi C, Montante S, Couban R, Guyatt G, Brignardello -Petersen R. Gender affirming hormone therapy for individuals with gender dysphoria aged <26 years: a systematic review and meta-analysis. Arch Dis Child 2025; 110(6): 437-445.
3. Miroshnychenko A, Roldan YM, Ibrahim S, Kulatunga-Moruzi C, Dahlin K, Montante S, Couban R, Guyatt G, Brignardello -Petersen R. Mastectomy for individuals with gender dysphoria younger than 26 years: A systematic review and meta-analysis. plastic Rebuild Surg 2025; 155(6): 915-923.
