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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.
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.
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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