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Not all randomized control trials are blinded randomized control trials. All you need for a randomized control trial is to randomly assign a group of patients that gets the treatment and a group that doesn't. As far as I know, no long-term randomized control study of gender transition has ever been conducted, in either children or adults.
Non-RCT's are if anything even worse than euphemisms like "moderate-quality" make them seem, reading something like Scott's ivermectin post might help give a sense for it. That's why fields like nutrition, where long-term randomized control trials are impractical, are so terrible despite far more quantity and quality of research than a small field like gender dysphoria.
No, it's way worse than that, the high/moderate/low quality ratings were based on the cited meta-study and seem if anything too lenient. Reading the meta-study, many of the studies only looked at physical outcomes like "is puberty suppressed", they made no attempt to measure psychological outcomes to determine whether suppressing puberty actually provided any benefit. This is the supposed single "high-quality" study. It isn't a randomized control study, it compares patients who have been given puberty blockers to ones who just started the assessment process. (It also compares to a "cisgender comparison group", such comparisons tend to be even more worthless.) Among other potential problems, this means the results are very plausibly just regression to the mean or benefits from the other mental-health care provided. If you think the parents of children with worse self-reported "internalizing, suicidality, and peer relations" are more likely to seek treatment than the parents of children who are currently doing fine, which the study itself shows, then improvement over time is the expected result even if you don't do anything. And then here are the detailed explanations of why they considered the other studies to be even worse.
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