Scott Leibowitz, a gender clinician and author of @wpath SOC-8, writing in @medpagetoday makes some pretty astonishing claims about the recently published @HHSGov report on pediatric gender dysphoria.
Here are four examples🧵
Here are four examples🧵
Regret and Bans
According to Leibowitz, the report "heavily emphasizes concern for regret to justify its extreme positions supporting gender care bans."
FACT: The report explains that while "proponents and critics alike consider the question of regret as central to the ethics of PMT," in fact "regret alone... is not a valid indicator of whether an intervention is medically justified." Patients can regret justified medical interventions or be satisfied with unjustified ones. See Section 13.4.
The report does not recommend or condemn bans; it explicitly says that it "does not issue legislative or policy recommendations" (p. 10).
According to Leibowitz, the report "heavily emphasizes concern for regret to justify its extreme positions supporting gender care bans."
FACT: The report explains that while "proponents and critics alike consider the question of regret as central to the ethics of PMT," in fact "regret alone... is not a valid indicator of whether an intervention is medically justified." Patients can regret justified medical interventions or be satisfied with unjustified ones. See Section 13.4.
The report does not recommend or condemn bans; it explicitly says that it "does not issue legislative or policy recommendations" (p. 10).
Psychotherapy
Leibowitz: "the definition of 'appropriate' psychotherapy [the report] employs is questionable, especially considering the apparent lack of input from experienced clinicians in the field, whose public perspectives are conspicuously absent from the publication."
FACT: the word "apparent" is doing a lot of work here. More importantly, it is ironic for Leibowitz to complain about lack of balance among the report's authors. Leibowitz was co-chair of the Adolescent chapter of WPATH SOC-8, a guideline that was developed with a strictly enforced litmus test: only "affirming" clinicians supportive of medical interventions were invited to participate. The HHS report discusses this issue at length (Section 10.3).
Leibowitz: "the definition of 'appropriate' psychotherapy [the report] employs is questionable, especially considering the apparent lack of input from experienced clinicians in the field, whose public perspectives are conspicuously absent from the publication."
FACT: the word "apparent" is doing a lot of work here. More importantly, it is ironic for Leibowitz to complain about lack of balance among the report's authors. Leibowitz was co-chair of the Adolescent chapter of WPATH SOC-8, a guideline that was developed with a strictly enforced litmus test: only "affirming" clinicians supportive of medical interventions were invited to participate. The HHS report discusses this issue at length (Section 10.3).
Conflicts of Interest
Leibowitz: "Professionals with decades of direct clinical experience working with youth are paradoxically dismissed as inherently biased."
FACT: Evidence-based medicine recognizes the existence of financial as well as non-financial (e.g., intellectual) conflicts of interest. The latter engender attachment to a specific viewpoint in a way that can bias one's assessment of evidence. WPATH itself claimed to rely on COI management strategies laid out by the National Academy of Medicine and the World Health Organization, both of which would consider Leibowitz's personal involvement in pediatric gender medicine as a COI relevant to guideline development. Note that this does not mean clinicians like Leibowitz should never be involved in developing guidelines, only that their COIs must be declared and managed (which, in the case of SOC-8, they were not). The report explains these issues in 10.3.
Leibowitz: "Professionals with decades of direct clinical experience working with youth are paradoxically dismissed as inherently biased."
FACT: Evidence-based medicine recognizes the existence of financial as well as non-financial (e.g., intellectual) conflicts of interest. The latter engender attachment to a specific viewpoint in a way that can bias one's assessment of evidence. WPATH itself claimed to rely on COI management strategies laid out by the National Academy of Medicine and the World Health Organization, both of which would consider Leibowitz's personal involvement in pediatric gender medicine as a COI relevant to guideline development. Note that this does not mean clinicians like Leibowitz should never be involved in developing guidelines, only that their COIs must be declared and managed (which, in the case of SOC-8, they were not). The report explains these issues in 10.3.
Golden Mean Fallacy
Leibowitz favors a "nuanced middle ground" between prohibitionists (ban it all) and affirmers (total deregulation), implicitly putting the HHS report in the former category.
FACT: The report carefully describes the evidence and clinical reasoning for ALL pediatric presentations and medical pathways, including the one/s he believes justify medical interventions. Because Leibowitz does not engage with the report's evaluation of the evidence for the (presumably more cautious) Dutch approach, his claims amount to a golden mean fallacy.
Leibowitz favors a "nuanced middle ground" between prohibitionists (ban it all) and affirmers (total deregulation), implicitly putting the HHS report in the former category.
FACT: The report carefully describes the evidence and clinical reasoning for ALL pediatric presentations and medical pathways, including the one/s he believes justify medical interventions. Because Leibowitz does not engage with the report's evaluation of the evidence for the (presumably more cautious) Dutch approach, his claims amount to a golden mean fallacy.
No Substantive Engagement
Like other critics of the HHS report, Leibowitz does not identify any specific claims he believes are false.
Does he disagree with the findings of extant systematic reviews of the evidence, analyzed in the HHS report's umbrella review (Chapters 5-8)?
Does he take issue with the ethical analysis (Chapter 13), which he mischaracterizes (see "Regret" post above)?
Does he dispute the systematic reviews of clinical practice guideline quality (utilizing the AGREE II tool) that found SOC-8 to be unfit for clinical use?
In what sense, exactly, is the report's analysis of psychotherapy (Chapter 14) "questionable"? In its recognition that the evidence in support of psychotherapy for treatment of gender dysphoria is weak? In its explanation for how psychotherapy for common comorbidities is stronger?
Like other critics of the HHS report, Leibowitz does not identify any specific claims he believes are false.
Does he disagree with the findings of extant systematic reviews of the evidence, analyzed in the HHS report's umbrella review (Chapters 5-8)?
Does he take issue with the ethical analysis (Chapter 13), which he mischaracterizes (see "Regret" post above)?
Does he dispute the systematic reviews of clinical practice guideline quality (utilizing the AGREE II tool) that found SOC-8 to be unfit for clinical use?
In what sense, exactly, is the report's analysis of psychotherapy (Chapter 14) "questionable"? In its recognition that the evidence in support of psychotherapy for treatment of gender dysphoria is weak? In its explanation for how psychotherapy for common comorbidities is stronger?
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