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Evidence Based Medicine, Science Based Medicine... I just want Based Medicine
In 2021 the Society for Evidence-Based Gender Medicine (SEGM) contracted McMaster University to do a series of systematic reviews of gender medicine, and what better place than McMaster, home to Dr. Gordon Guyatt, the father of Evidence Based Medicine himself? For quite a while the working relationship seems to have indeed been working, perhaps not completely without a hitch as Dr. Guyatt will later tell us, but 3 systematic reviews, assessing the evidence for puberty blockers, cross-sex hormones, and bilateral mastectomies, have been published earlier this year. Their results are consistent with all other systematic reviews published to date: the evidence for various forms of gender affirming care is of low to very low quality.
In February 2025 The BMJ published an article titled Medical journal editors must resist CDC order and anti-gender ideology. This was a response to the much-criticized Trump CTRL+F grant cuts, dataset changes, and orders for CDC scientists to remove themselves from studies that so much as mention "gender" or any other 2SLGBTQIA+ related terminology. The BMJ swears up and down that such terms are "medically relevant" and therefore "evidence based", and so the Trump administration has no place in dictating how science is conducted.
One of the responses to the article praises the BMJ for it's "anti-gender ideology" stance, but declares that this is just an empty gesture, as the journal has published the studies sponsored by SEGM, which has been designated as an "anti-LGBT hate group" by the SPLC. On top of that, Dr. Guyatt and his staff faced direct activist pressure of various sorts.
In August, McMaster University published a stetement about their systematic reviews, expressing concern that their studies are being misused to pass policy which takes away autonomy from the patient, something that goes against the principles of Evidence Based Medicine, as they understand it. They announced that they will not be working with SEGM anymore, and that they will be donating Egale Canada to help fund their efforts to prevent gender affirming care bans.
Following the publishing of the statement, there is now an open letter demanding an apology, and a retraction of the SEGM-funded studies.
...A renowned institution, a respected leader, some activist pressure, and a repudiation of their previous work: a story that we're quite familiar with by now... or is it?
Earlier this week Dr. Guyatt was interviewed on the Beyond Gender podcast about his work with SEGM and his statement about the systematic reviews. Throughout the conversation it becomes clear that there is no evidence-based argument against SEGM and their work, rather it's a disagreement of values. As already noted in the his statement, Dr. Guyatt holds patient autonomy in extremely high regard, and his main issue is with his work being used to justify blanket bans. This mirrors the shift in the discourse that I talked about before. Not being able to argue that The Science Is Settled, activists have to retreat to a more defensible position and settled on autonomy with a sprinkling of Trust The Experts, although they're kind of trying to have it both ways...
During the interview Dr. Guyatt is asked how he would define "medical necessity", at first he's confused, and then rejects the very concept outright, which is interesting in the light of the following exchange taking place at the end of the episode:
Narrator: To date, Dr. Guyatt has not yet jumped off a bridge. He noticed no irony in the contrast between his complaint about his studies, that to date he still stands behind, being used to justify policy he disagrees with, and his downplaying of how his signature, on a statement he vehemently disagrees with, could be used.
Credit to Mia Hughes, not just for the interview, but for already collecting most of the links.
Ok, some extra thoughts.
This isn't the first time we got a politically charged statement from a suppesedly neutral political institution. Off the top of my head there was the AMA declaring gun violence to be a public health crisis, or similar statements from the American College of Physicians, complete with a trendy hashtag, and of course, who can forget "Racism is an ongoing public health crisis"? This is, however, the first time someone from any of these institutions was publically cross-examined, and the results were devastating. Do the other statements have better backing? I personally doubt it, we can always quibble about it and construct elaborate "steelmen", but it doesn't matter. My opinion is that all these statements should be rejected by default, and and treated as political, and not based on science or their understanding of the public good, at least until similar cross-examinations take place.
This also touches on Trump's dreaded funding cuts. We've had a number of people here complaining about them, claiming that Trump should have used a more precise approach. It can't be done. Any presumption-of-innocence approach would yield no significant outcome, as institutions could hire activists faster than you could get them fired. If you want people to stop cheering as he torches your institutions, do something to save them yourself. Show people that they're self-correcting and can be trusted by the public, and if they aren't then make them become self-correcting.
Finally, on a different topic, it's interesting to compare Guyatt's autonomy-valuing approach to the results of other people's non-autonomy-respecting approaches. Though I'm Rat-adjacent, I've never been a proper Rat. Rather, I hail from the "Skeptic" community - Sagan, James Randi, those sorts of people. Randi himself, and many of his followers, spent a lot of their time debunking evidence-free treatments, often calling for their banning and/or strict regulation. One of them, Dr Steven Novella, even formulated a broader criticism of the entire Evidence Based Medicine framework, and founded his own blog Science Based Medicine blog in response. The issue he and his collegues identified, is that EBM can be hacked as it focuses too much on clinical trials, rather than the entirety of evidence, and prior plausibility. For the curious here's his introduction post explaining their approach, and here's a post series about some spat about cancer treatments which provides a more specific example (and extra links outlining the differences between the approaches).
Given the direct contrast to EBM, and the opposition to patient autonomy when the treatment is not grounded in sound science, what do you think would be their response to the transgender care phenomenon? Oh, that's right, a complete caving to the trans activists in violation of all their principles. Credit where credit is due, I suppose, AJ Eckart, the pro-trans author they hired after dropping Harriet Hall, has been awfully quiet ever since the Cass Review dropped, so someone must have decided they backed the wrong horse.
The sad conclusion of all this seems to be: the romantic notion that Science™ can be trusted as a process seems to completely wrong. Science is only as a good as the people doing, and the people doing it at the moment don't seem much good. If a conflict between their scientific principles, and their political principles arises, scientists seem to reliably choose politics.
This is, like, just a non sequitur, no? Something something, list of grievances, declaration that $Thing can't be done, because something something, the other side can recruit or something? Is the implication here just the @gattsuru comment? No bother firing (upon) them one-by-one; no bother even considering any other possible pathway either; really gotta just go for a mass casualty event?
Well, it's not really a logical proof, just a statement on how I see no other practical way to do any of this.
Even if I put my mind to it, it doesn't seem trivial. Is opening fire on anyone who ever published and/or signed one of these statements be acceptable? Between online journals, scholarly databases, and LLMs this could probably automated, but does Trump have levers to pull that target with this level of precision? Would it hold up in court? Wouldn't the backlash / objections to it nbe effectively the same, as people like Guyatt start crying that theybjust wanted to do science, and didn't even read what they were signing?
I find this to be, frankly, borne of ignorance and lack of creativity. That is, similar to what I wrote here, it scans to me like "Joe Sixpack" bloviating on Middle East politics. Perhaps some of that is epistemic helplessness, seeing for example the classic hapax legomenon about Afghanistan, then just casually coming to the conclusion that all is hopeless and we should just nuke 'em all and turn the sand into glass. There's no sense of theory of war/politics involved, no understanding of the concepts behind consolidating gains, just shooting from the hip without much thought.
Even here in your latest comment, you seem to grasping for something to 'work' (you don't use the word, but ISTM that it's what you're going for), but there's no sense of what 'working' is. There's not even really a well-formed goal. Just a vague sense of these people seem bad, and it seems complicated, and I don't know what to do, so I'll just go in blastin'.
Sure, guilty as charged. Academia is not my world, and to the extent I'm familiar with it, the system I know is not even located in your country. There very well may be effective tools that have more subtlety than a megaton bomb. I'd love to be educated on what they are, and how they work.
I'm a little bit hurt by the second charge, but sure, you're a smart guy, and I wouldn't be surprised in the slightest, if you could come up with something that would blow my idea out of the water.
Not quite.
It's not "just a vague sense of these people seem bad". It's a very specific sense of these people using deliberate infiltration (the response in BMJ citing the SPLC designating SEGM as a "hate group") and harrasment (activists accosting Guyatt and his staff at their place of work, and online) tactics to yield concessions from institutions (cutting off the working relationship with SEGM), that contradict their stated principles (McMaster's statement claiming transgender care is medically necessary), which they can then use to their advantage in future fights (any other university considering work with SEGM will either come across the scandal when vetting the organization and get cold feet, or in the event they don't, activists can forward it to them once any such future relationship is discovered. The "medically necessary" statement can also be used to persuade and/or sue any healthcare insurer or provider refusing these treatments). This isn't a singular case, it's a blueprint they worked off for years. I'd say that's quite specific, and not vague at all.
Something needs to be done to break that chain, and ideally roll back their previous victories. Is it complicated? I don't know, if I was the King of Academia, I think I could solve the issue effectively, and without resorting to nuclear fire, but I'm not, and such a position doesn't seem to exist to begin with. Again, I'm all ears if there's a clean, subtle, and effective solution. I won't even insist on it's quick results, if I can be reasonably assured of it's effectiveness.
This seems pretty apart from a core problem within academia.
Uh, likewise? That's sort of just a general phenomenon that exists in a variety of places?
Yeah, uh, the same?
I'm really struggling to see how any of this is actually about academia qua academia. There's almost nothing here about the typical workings of academia, interactions with the federal government, levers that could be pulled, specific goals to be accomplished.
Big picture, it seems like most of this is that there is some influence on academia's decision-making, and that influence is political in nature and bad. ISTM that the goal would be some form of reducing that influence or the effectiveness thereof, rather than detonating all of academia, itself. Would that at least be a reasonable statement of a plausible goal?
Wait, when you said "these people" you meant academics? I thought we're talking about progressives. I don't think academics are bad, though I'm extremely frustrated with their complicity. In fact, the reason I'm all Something Must Be Done about this whole thing, is that I think academia is pretty important to society.
Yeah, but the reduction has to be pretty drastic (even if it takes time). The levels of their dominance over the institution seems to be fairly massive.
Perhaps this was all just a bit of confusion. I was responding to your bit:
where the internal link was to funding cuts to academia, with the context being whether or not there were goal-oriented, somewhat tailored ways of approaching it compared to what I've perceived in these fora as calls for 'indiscriminate chemotherapy'. So, I guess, I'm not really sure what you're meaning or going for.
I think I already linked it, but it might not have been worth the time to read it before, but here is some context, with links to prior discussions where I was pushing back against the 'indiscriminate chemo' calls, culminating in the more recent cuts being targeted and linked to institutional behavior.
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Is Science-Based Medicine opposed to the likes of elective plastic surgery? I think there's a great deal of difference between "opposing patient autonomy" in the sense of being against allowing patients too much discretion to pick quack treatments that they can cure them of a particular ailment, vs "opposing patient autonomy" in the sense of being against patients undergoing elective procedures for reasons other than medical need, but whose efficacy to do the things they physically achieve is not in scientific doubt. Mastectomy's ability to reduce or remove somebody's breasts is pretty settled at the empirical level. A defense of gender-affirming care on the basis of autonomy has nothing to do with the "I should be allowed to heal my cancer with snake oil if I think that will work best" kind of autonomy. It's about the broader kind of bodily autonomy - "it is my right to have my breasts reduced much as it is my right to get my ears pierced" - and I don't see why SBM would have anything to say about that, good or bad. It's a moral question, not a scientific one.
Sure, I can concede the difference, but transgender care gets dinged either way. The signed-but-not-read statement says it's "medically necessary", activists say it's "life-saving", "do you want a happy little girl, or a dead little boy?", etc. What do you think is the drama around these systematic reviews, if it isn't about showing that they're ineffective treatments.
This is quack medicine, no two ways about it.
Well, that standard party line for transgender care gets dinged. I, for one, am strongly pro-transgender-care myself, but I consider that position a subset of my broader transhumanism, and therefore I think that disingenuously wedging gender reassignment in particular into the Overton window through spurious "medically necessary" rationales was one-step-forward-two-steps-back.
Well, I've long argued that transgenderism is just a facet of transhumanism (much to tje chagrin of self_made_human), but that's beside the point. The SBM people weren't defending it on transhumanist grounds.
I would find it difficult to imagine a comprehensive transhumanism that doesn't implicitly include transgenderism. From some years back I remember "morphological freedom" as a transhumanist talking point, and there's no particular way to cash that out that doesn't validate transgenderism. If one of one's goals is complete personal and bodily autonomy, well, you get transgenderism thrown in for free.
I don't think I agree with this position as a normative good, but it is an intellectually consistent one, in a way that I think some of the transgenderism arguments today are not. Morphological freedom also includes, for instance, transracialism for free, even though progressive orthodoxy validates transgenderism but not transracialism.
Perhaps a transhumanist might argue that morphological freedom and individual autonomy extends to the right to make your physical body anything you desire, including everything from sexual organs to skin colour to species, but does not confer a right to be included in any particular community you desire? So an elective community of people identifying as natal-woman or natal-black or what have you might still have the right to constitute itself as such, and forbid transgender or transracial people from joining it. If I imagine a transhumanist utopia, I could imagine a group like that existing in something like the Culture; though I also suspect that in a realistic liberal-transhumanist context, that group would be a tiny minority of weird people, tolerated but largely ignored by most of society, in which transhumanism and radical morphological freedom has dissolved most such concerns or identities.
Yes and no. You get one of the material objects that the trans advocates want for free but they make wider ontological claims. i.e. "men should be allowed to have gender reassignment surgery and be feminine men" is something morphological freedom would endorse but trans activists may not.
Wouldn't they? Isn't that a textbook example of queering the gender binary?
There are a lot of different mutually exclusive factions that make up the trans coalition. You might have transwomen who demand to be considered ontologically categorized the same as natal females support a cisman wearing a dress to queer the gender binary but would strongly object to any insinuation that they were doing basically the same thing. Morphological freedom alone can't explain this conflict, you need additional axioms.
To be sure there are people who call themselves trans who might fully endorse and live by this maximally vague morphological framework, but I'd argue they are a vast minority, especially among vocal activists.
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Well, I would argue that mouthing along to incorrect arguments for something which you would have more principled reasons to support anyway is a significantly lesser sin relative to mouthing along in support of something you wouldn't support at all if you were ideologically consistent. (Though, to be sure, it's still bad form, and reduces SBM's intellectual credibility a nonzero amount.)
Lying. It's called lying. And explicitly telling scared, confused parents that if they don't allow their child to medically transition they are thereby condemning them to death by their own hand, when you know full well that this is complete bullshit, is so transparently manipulative and emotionally abusive that anyone who does it should have their license to practise medicine revoked.
The fact that Chase Strangio told SCOTUS that "there is no evidence to support the idea that medical transition reduces adolescent suicide rates" during oral arguments as part of Skrmetti should mean that the "dead son or living daughter?" line gets finally put away forever. If there was good evidence that applying these interventions sooner rather than later really helped children, I would have expected Strangio to know about it and deploy it during Skrmetti.
It's so telling that Strangio had no choice but to admit that to avoid perjuring herself.
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This assumes the primary objective of the SBM people is to defend transgender care, rather than their actually stated one of informing the piblic about which medical treatments are scientifically backed.
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Anyone starting to wonder what the point of "academic freedom" is? It certainly doesn't do what it says on the label, and mostly seems like a way to keep commies on state pensions while they burn the commons of our society.
This is still not the place for drive-by culture warring.
Your last warning for this exact behavior was last month. Your last ban was further back—but it was also the exact same behavior.
Three day ban, this time. Please show some restraint.
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The purpose of a system is what it does.
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Jesse Singal has a two-parter about this kerfuffle which I started reading but haven't finished yet (no paywall FYI).
Of particular interest here, the second half is an interview with Guyatt that's possibly even more revealing than the one in the OP.
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Nullius in verba the motto of the Royal Society. Of course these days, even they would tell you to "Trust The Science."
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The central myth and in my view issue of modern discourse is this idea that science, more specifically empiricism, has metaphysical and moral value, and can be used to make claims in such fields. It absolutely can't. Empiricism cannot make value judgements and be used as a cudgel to force metaphysical arguments about what a man or woman is. The second you begin to cross that line, your vaunted neutral, empirical viewpoint falls apart.
Unfortunately if we truly accepted this as a society, we would basically have to rewrite our institutions from the ground up anyway, a truly harrowing task. We'll see if empiricism is defeated anytime soon.
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