The Society for Evidence-Based Medicine calls for an interim update based on existing systematic evidence reviews
Extrait :
We welcome the American Academy of Pediatrics (AAP) decision to update treatment recommendations for gender dysphoric youth based on the results of a systematic review of evidence the AAP plans to commission. This is an important step on the path to creating evidence-based treatment recommendations for managing youth gender dysphoria in the United States and Canada. However, we are concerned by the AAP decision to reaffirm its current policy for treating minors with puberty blockers, hormones and surgery pending the yet-to-be commissioned systematic review, and by the lengthy timeline for any updates to the policy this approach implies.
Systematic reviews of evidence, when performed correctly (the steps are outlined below), involve a rigorous process that typically takes a year or more to complete. Once a systematic review of evidence has been completed, updating treatment guidelines using a credible process takes several more months to a year. This suggests that an update won't be available for 1-2 years or more. In the meantime, tens of thousands of youth will continue to be treated according to AAP's non-evidence-based recommendations, exposing them to potentially non-beneficial or even harmful interventions.
According to the principles of evidence-based decision-making, when making treatment recommendations, one has to leverage the best available evidence, which is typically found in systematic reviews of evidence. Several systematic reviews have recently been completed by European public health authorities; three of these reviews are available in English. These independent systematic reviews of evidence found the practice of youth gender transition to either not be clearly beneficial, or net-harmful. It is incumbent on the AAP to leverage these systematic evidence reviews to urgently issue an interim update to its 2018 policy. In parallel with the the interim update, the AAP can initiate and complete its own rigorous systematic evidence review.
In addition to the unreasonably lengthy timeline for the urgently-needed updates implied by the AAP's announcement, we find several statements in the AAP press release concerning. One such statement is the assertion that “policy authors and AAP leadership are confident the principles presented in the original policy, Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents, remain in the best interest of children.” Not only is it inappropriate to start a research process with a pre-ordained conclusion, but this conclusion also contradicts the findings of the current systematic reviews of evidence.
Another concerning statement is that “the decision to authorize a systematic review reflects the board’s concerns about restrictions to access to health care with bans on gender-affirming care in more than 20 states.” Conducting a systematic review of evidence to influence a political process, rather than to pursue knowledge about the outcomes of a medical intervention, distorts the purpose of evidence-based medicine and creates the appearance of a compromised process.
We call on the AAP leadership to issue an interim update to its 2018 policy based on the systematic reviews already conducted by public health authorities in Europe. For the process to be credible, the AAP should include a range of stakeholders with diverse views on the topic, from those who support gender transition of minors, to those who have voiced concerns about the practice. Once the immediate gap in the AAP’s current guidelines is addressed via an interim update, the AAP can embark on its own independent comprehensive systematic review of evidence, after which it can issue a final policy update.
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