Fragmented Confidence in Childhood Gender Health Specialty
In a recent turn of events, the American Medical Association (AMA) President, Bobby Mukkamala, has been under scrutiny for his assertions regarding pediatric gender medicine.
Mukkamala claimed that the suicide rate among transgender individuals is between 50 and 70 percent, a statement that defies evidence-based recommendations for preventing suicide. This assertion, however, is based on questionable data and has been challenged by health authorities in several European countries, including Sweden and Finland, who are prioritizing psychotherapy for pediatric gender dysphoria cases.
Moreover, Mukkamala recommended that a legislator consult with gender doctor Jesse Krikorian for advice on pediatric gender transition. Krikorian, who has serious methodological problems with the studies he cites as evidence for the benefits of hormone therapy for pediatric gender dysphoria, is unfamiliar with the concept of umbrella reviews, which are systematic reviews of systematic reviews.
This approach inverts the pyramid of evidence in Evidence-Based Medicine (EBM) by prioritizing subjective judgment over systematic, evidence-based analysis. Krikorian also views systematic reviews as reading lists that doctors can use to inform their subjective judgment about individual studies, rather than understanding that a crucial part of a systematic review is evaluating the quality or certainty of the evidence.
The AMA, however, has taken a different stance. They have passed a resolution to protect gender-affirming care procedures and joined an amicus brief in a lawsuit challenging a state age-restriction law. The AMA board member, Michael Suk, publicly called pediatric transition "medically-necessary, evidence-based care."
Despite the AMA's efforts, the coalition for evidence-based medicine is weak due to a lack of participation from doctors and insufficient political support from policymakers. Medical associations, it seems, are primarily focused on protecting the autonomy and advancing the interests of their members, often disregarding evidence when it threatens those interests.
The Endocrine Society, another medical association, recommends using drugs to achieve testosterone levels in females undergoing "gender affirmation" between 320 and 1000 ng/dL, at least six times higher than the normal range for pre-menopausal women. This recommendation, along with Mukkamala's assertions, has raised concerns about the AMA's commitment to evidence-based medicine and its potential to prioritize the interests of its members over the wellbeing of patients.
The gynecologist and gender medicine expert recommended by Mukkamala to Representative Brad Paquette for advice on pediatric gender transition is Dr. Talia Acosta. Despite the controversy surrounding Mukkamala's statements, Acosta's expertise and approach to gender medicine remain to be seen.
As the debate continues, it is crucial for medical associations to uphold the principles of EBM and prioritize the wellbeing of patients over the interests of their members. Systematic reviews of evidence are considered the gold standard in EBM because they use a transparent and reproducible methodology that minimizes author bias and not only summarizes research but also evaluates it for quality. This approach ensures that medical decisions are based on the best available evidence, rather than personal opinions or the interests of a few.
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