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Editor's Choice

Caring for young people with gender dysphoria

BMJ 2023; 380 doi: (Published 09 March 2023) Cite this as: BMJ 2023;380:p553

Rapid Response:

Evidence in the media

Dear Editor

About 30 years ago I wondered out loud why we didn’t start doing breast screening sooner. Shouldn’t we be screening earlier for life threatening conditions? And then I went and read the evidence, and realised that I wasn’t so smart after all. I learned about lead time bias, the need for control groups, and overdiagnosis, but, fundamentally, the fact that well intended doctors can still do harms. When Dr Spock recommended that children sleep on their fronts, lest they choke on their vomit, he did so because it sounded sensible and he wanted children not to to die (1). When we told pregnant women to avoid peanuts it was because we thought it would reduce the incidence of life threatening allergies (2). When we gave class 1-C anti arrhythmic drugs after myocardial infarction it was with the intention to reduce deaths. (3) All of these interventions did harm: babies are more likely to die if put to sleep prone, pregnant women who avoid peanuts have an increased risk of allergies in their children; routine use of flecanide post myocardial infarction - having been thought to reduce fatal arrhythmia - increases, rather than decreases, deaths.

Standing up for evidence based medicine is what doctors should do: the alternative is to use stuff that doesn’t work. I’ve been writing about the need for high quality evidence in medicine for over a quarter of a decade. Over that time I have become quite used to criticism, anger, and sometimes legal threats. This can be upsetting: but it is also to be expected. We should not seek to be popular but to do the right thing. As they say: Demand Evidence and Think Critically. Do you have good enough evidence for your assertions? What are the uncertainties? What are the potential biases and unintended consequences? Are you sure you are not doing more harm than good? This should be routine. This should be unremarkable. This should be normal, good, medicine.

And yet. In the last few years something strange has happened. Rational discussions about gender dysphoria have become exceptional. The profession seems to have been unable to reasonably discuss the fact that there are significant uncertainties about the best medical response to gender dysphoria in young people, without accusations of transphobia following shortly after. Complaints to universities about researchers who have stated this lack of evidence have resulted in staff being investigated rather than supported in speaking up. Doctors who offer interventions but overstate benefits, and/or fail to investigate the potential for harm should make us pause. That should happen whether they are offering tracheal transplants, re-implantation of ectopic pregnancies, amputation for body dysmorphia - and everything else. Overpromising, or failing to be honest, is just as problematic. For stating that human sex is immutable and binary - key facts for anyone contemplating medical interventions - one risks being accused of spreading hate. For a profession with a history of repeatedly failing to investigate its well-meaning interventions well enough, this is a deeply troubling response. In decades of writing, I have never encountered such resistance to publishing pieces stating, respectfully and cautiously, that I think we have an evidence problem here.

I think that gender ideology, colliding with medicine, holds much potential for harm. Plenty of doctors will tell me, behind closed doors, that they have similar views. Most will say that they dare not speak up - even when they see social media by medical professionals offering surgical interventions to distressed young people as routinely straightforward. They are worried about complaints, investigations, and accusations. This is profoundly disturbing. Medicine often encounters difficult problems, and none are made better by ignoring evidence - or a lack of it.

1) Bovbjerg ML. Rethinking Dr. Spock. Am J Public Health. 2011 Oct;101(10):1812; author reply 1812-3. doi: 10.2105/AJPH.2011.300336. Epub 2011 Aug 18. PMID: 21852654; PMCID: PMC3222341.

2) Abrams EM, Sicherer SH. Maternal peanut consumption and risk of peanut allergy in childhood. CMAJ. 2018 Jul 9;190(27):E814-E815. doi: 10.1503/cmaj.180563. PMID: 29986856; PMCID: PMC6041250

3) Echt DS, Liebson PR, Mitchell LB, Peters RW, Obias-Manno D, Barker AH, Arensberg D, Baker A, Friedman L, Greene HL, et al. Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial. N Engl J Med. 1991 Mar 21;324(12):781-8. doi: 10.1056/NEJM199103213241201. PMID: 1900101.

Competing interests: MM is a Director of Beira's Place, a woman only rape and sexual assault support centre and is a freelance writer and broadcaster. Her full DOI is at

30 May 2023
Margaret M McCartney