Trans Health Care “Skeptics” Lost a Key Ally—Now They’re Having a Meltdown

Colleagues call Gordon Guyatt the “godfather” of evidence-based medicine.

Guyatt, a distinguished professor of medicine at McMaster University in Canada, has had sweeping influence on medical research: GRADE, the framework he helped pioneer to assess the evidence behind clinical recommendations, is a standard at more than 100 medical organizations, including the WHO. Before Guyatt, medicine relied much more on the judgment calls of senior clinicians; today, standardized research is increasingly central.

Guyatt was also, until August, a reluctant icon of the movement against trans health care. 

His was by far the biggest name associated with the Society for Evidence-Based Gender Medicine (SEGM), a group known^[2] for^[3] casting^[4] doubt^[5] on the safety and efficacy of gender-affirming care by framing it as risky and supported only by “low-quality” evidence within the GRADE framework.

Guyatt spoke at SEGM’s 2023 conference; he is a co-author on the group’s recent reviews of the evidence base for transgender health care, which in turn underpin a chapter of the Department of Health and Human Services’ anonymously written report^[6] painting it as a threat.

His work has been cited not only by Trump’s HHS but in other prominent attacks on transgender health care, including an amicus brief in support of Chiles v. Salazar^[7], the upcoming Supreme Court case seeking to overturn Colorado’s conversion therapy ban for minors.

In short, it was the prevailing assumption on all sides that Guyatt was not in favor—or at least quite skeptical—of transgender health care.

But in August, Guyatt and four colleagues at McMaster made waves with a letter^[8] distancing themselves from SEGM and arguing that their work had been “misrepresented and misinterpreted.” 

“It is profoundly misguided 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. Many of the interventions we offer are based on low certainty evidence, and enlightened individuals often legitimately and wisely choose such interventions.”

Using GRADE to justify bans, Guyatt and his colleagues wrote, was “a clear violation of the principles of evidence-based shared decision-making.”

A media sphere, particularly on Substack, of trans health care “skeptics”—as with vaccines, “skeptic” offers a plausible deniability and respectability that “opponent” does not—has dissected the letter nonstop, trying to understand the apparent loss of a key ally.

Some asserted that Guyatt was “tamed^[9]” or “bending the knee^[10]” to activists; others that he was “turning his back^[11]” on science. A Manhattan Institute writer drafted a different statement he wished Guyatt had made. A surgeon who faced Justice Department prosecution for leaking trans youth medical records—charges dropped in the Trump administration’s first week—said clinicians like Guyatt “place their own selfish interests above the principles of the profession.”

Guyatt was somewhat less dramatic. Speaking to me on a video call, the bespectacled doctor emphatically called it “an unconscionable use of our work to deny people gender-affirming care”—insisting that, until student activists at McMaster spoke out about the collaboration, he hadn’t been fully aware of SEGM’s involvement with the university’s research on transgender health care.

In retrospect, Guyatt says, he believes the group “behaved very badly,” obfuscating its stance on medical interventions in transgender youth care, changing tack and public position depending on its audience.

In an extensive response, SEGM disputed that characterization, defended its reviews, and rejected the idea that its work was ideologically motivated. SEGM said it had demanded corrections to the McMaster statement, which it alleged was “informed” by “external pressures”—and that it was in fact McMaster researchers who, by weighing in on how the reviews were used in policy and politics, “may be operating outside of the widely established boundaries of evidence-based medicine.”

“McMaster has not been able to produce any evidence that SEGM misused the systematic reviews,” the group said, emphasizing that it had no influence over the “team composition, nor the research process, nor the conclusions” of the reports. The view of Guyatt’s research team, SEGM said, “appears to be that patient autonomy affords patients the right to demand any treatment, regardless of its risk-benefit profile or any other considerations.”

“What nonsense,” said Guyatt, who reviewed the SEGM statement. “We never say anything remotely close to that.”

SEGM, Guyatt said, “can make up new rules of evidence-based medicine, but we are the folks who have articulated it, and our articulation is widely accepted.”

McMaster said it had no plan to alter or update the statement.

A key argument advanced by opponents of gender-affirming care is that its treatments are only supported by “weak” or “low-quality” evidence, as the SEGM^[12]–affiliated^[13] reviews^[14] and others^[15] have^[16] found^[17].

The thing is, so are a lot of standard—and essential—medical interventions. Cancer drugs have a notoriously^[18] low-quality evidence base, including many FDA-approved treatments^[19]. Almost all nutritional guidelines^[20] are supported by what Guyatt’s system labels poor evidence. About five million youth have asthma in the United States—yet the evidence for medical guidelines for pediatric asthma care is regularly^[21] rated^[22] “poor” or “weak,” as are many^[23] of the treatments^[24], which have indisputably saved countless lives. 

This is not surprising. A March study^[25] in the journal of the American Academy of Pediatrics found that 10.6 percent of treatment recommendations in its clinical practice guidelines were “based on the highest-quality evidence.” In a 2020 paper in the Journal of Clinical Epidemiology, the proportion of treatments “supported by high-quality evidence” was just under 10 percent. 

For self-described skeptics of transgender health care, the words “weak” and “low-quality” do indispensable work. To medical academics like Guyatt, they’re professional terms of art, based on a shared understanding of narrow, specific implications. To most others, they mean “stay away.”

Low-quality, in Guyatt’s GRADE methodology^[26], means there may be a lot more individual variability than is captured in the data, leaving physicians to rely on observational evidence and clinical experience. The gold standard for evidence-based medicine is randomized controlled trials; high-quality evidence^[27] generally comes from studies with very large numbers of participants who are blinded, meaning they don’t know whether they’re receiving the treatment—a setup that isn’t always possible or ethical^[28]. Many medical practices, as a result, are only supported by smaller studies without the same kinds of control groups: “low-quality” evidence. (GRADE also includes other levels of evidence.)

It’s a fundamental misunderstanding of evidence-based medicine, Guyatt says, to ban care on the basis that supporting studies are “low-quality.” Just this year, Guyatt was involved in a systematic review for treatments of severe bleeding^[29]. It also found low-certainty evidence—but nobody is remarking on those treatments, let alone trying to ban them.

SEGM said it wants “youth suffering with gender dysphoria” to get “the same care that all other youth receive,” arguing that “no other area of medicine…operates in such a way.”

The evidence underpinning gender-affirming health care is “not different from most of medicine,” Guyatt said, and the field, from his point of view, looks about like any other in medicine, with a similar range of quality, caution, and care in medical practice—if possibly under more scrutiny.

But the way the media and legislators responded to Guyatt’s systematic reviews on transgender health care was different. His work was cited^[30] in the Supreme Court’s majority ruling in the Skrmetti^[31] case^[32], which has led to bans on trans health care treatments in several states. Opponents said Guyatt’s research supported the idea that the treatments were a “bad idea^[33]” and “cast grave doubts^[34]” on their safety.

Guyatt found that “extremely disturbing.” The point of the reviews, he said, was to inform patients without limiting treatment options.

Patient choice and values, Guyatt emphasized, are a key part^[35] of evidence-based medicine. “It is inappropriate to put zero value on autonomy,” he said to me, or to deny patients an informed chance to choose medical care that’s harder to study and assess.

“It is a fundamental principle of evidence-based medicine that one should respect patients’ values and preferences,” Guyatt said. “People seeking gender-affirming care are entitled to that respect.”

While it lasted, the Society for Evidence-Based Gender Medicine seemingly relished its association with Guyatt.

A small group of clinicians—many unaffiliated with universities and other institutions—SEGM sits^[36] “outside of the mainstream,” according to leading medical groups. Its focus on evidence that can be construed to support conversion therapy and bans on gender-affirming care has always raised questions about its claims to be “free from political, ideological, religious, or financial influences.”

The group’s X account has an article pinned^[37] about “doubts” in gender medicine that references Guyatt 19 times, without comment from him, and suggests he is lead author on the reviews. (He is not.) Its work is frequently cited by states banning^[38] transgender healthcare for minors: SEGM co-founder William Malone provided expert testimony for Idaho’s gender-affirming care ban in which he compared the treatment to lobotomies^[39] and accused^[40] national physicians’ associations of being “captured” by “gender ideology.”

Malone has repeatedly^[41] asserted^[42] that “no child is actually born in the wrong body.” On X, he has endorsed^[43] Robert F. Kennedy Jr. and his “MAHA” movement and retweeted^[44] other right-wing content; another SEGM member was found^[45] to be the operator of a transphobic Twitter account that posted speculation about trans people’s genitalia. When asked member’s rhetoric, SEGM said, “we are not monitoring or censoring social media accounts of individuals volunteering their time to SEGM.” The group also said its members “categorically reject any insinuation that SEGM seeks to harm members of the LGBTQ community,” and that “many of the professionals collaborating with SEGM are themselves” LGBT.

Many of the group’s members, like Malone, would replace trans medical care with interventions to “resolve any trauma or thought processes that have caused them to desire an opposite-sexed body”—which, given the lack of any published studies showing benefits for gender dysphoria, hardly constitutes evidence-based gender medicine. Its president practices “gender exploratory therapy,” a label used by some^[46] anti-trans conversion therapists for their work.

Epidemiologist Gideon Meyerowitz-Katz, of the University of Wollongong in Australia, who has written about the evidence^[47] base^[48] for gender-affirming care, said SEGM’s embrace of dubious therapies belies its name. “If you are unwilling to apply the same level of scrutiny to your own preferred treatments,” he said, “how can you call yourself evidence-based?” 

“We strongly refute the allegation that SEGM is not evidence-based,” the group said in its response.

But it means something else for Guyatt, the highest-profile researcher ever to have been publicly associated with SEGM, to critique and disavow the group.

He has also repeatedly critiqued the gender-affirming care guidelines of the World Professional Association for Transgender Health and the Endocrine Society, a professional association for endocrinologists, particularly over their use of strong language—”we recommend”—around low-quality evidence. Guyatt is not, he emphasizes, an expert in transgender or pediatric health care.

In Guyatt’s mind, his association with SEGM began and ended with his attendance at their 2023 conference, when he knew little about them, and which he spent, he said, “fighting with them” over the role of patient autonomy in evidence-based medicine. 

“As far as I am concerned,” Guyatt recounted telling people affiliated with SEGM in a recent conversation, “you are not evidence-based.” 

It was a burn that only the guy who coined the term “evidence-based medicine” could give.

SEGM feels that it, and McMaster, are facing unfair backlash. “Every independent evaluator in this field…has been subject to the same unconscionable treatment from groups of activists who want to thwart scientific inquiry into the field of youth gender medicine,” SEGM said in its response.

Absent any reason to expect a different result, Guyatt said, there would be no legitimate reason for outside groups to commission more reviews of the trans health care evidence base like the one that he helped conduct.

Guyatt’s reviews for SEGM have come in for criticism: Two reviewers who (unlike Guyatt) previously served as paid consultants to SEGM, one of whom was also retained^[49] by the state of Florida for expert assistance with a report the state used to ban gender-affirming care. Another methodologist involved had previously written a separate report^[50] for a conservative think tank on transgender health care, with predictable conclusions.

“If you can’t do the randomized trials, [the evidence] is always going to be low-certainty,” Guyatt said, but that doesn’t mean halting care.

“It is clear to me, anyway, what should be done is not banning the care,” he said, “but ensuring that it be delivered carefully, cautiously and conscientiously,” with safeguards and “better observational studies than have been done up to now.”

“There are people who have real benefits [from this care],” said Guyatt. “To deny it to people, to make people suffer unnecessarily, that’s another type of harm.”

When I asked Guyatt what had compelled him to speak out more forcefully, he pointed to a variety of factors: the alleged misuse of his research, SEGM’s general conduct, and the recent rise of a student group protesting McMaster’s association with SEGM. 

Guyatt called the group “extremist” and critiqued its methods, which included flyering, posting critiques of the researchers on social media, protesting research events, and now circulating an open letter^[51], which a spokesperson characterized as a “typical awareness campaign.” 

But despite Guyatt’s sense of the “terrible behavior” of the McMaster activists, and his disagreements with their positions, he said he was “glad that I’ve had the nudge to rethink my views on my responsibilities as a scientist.” 

For most of his career, Guyatt says, he felt his responsibility was only to “put out good science.” But campaigns like SEGM’s, critiques from the student activists, and the present climate, have changed his mind: Right now, he says, “it’s being used for nefarious purposes.”

“Putting out good science is not enough,” Guyatt said. “I have a responsibility to how it gets used.” 

Additional research by Anna Rogers.