The Disaster At McMaster, Part 1

Scholars are being “traumatized,” a long-running collaboration is being torched. . . what is going on?

Earlier this month, five scholars from the Department of Health Research Methods, Evidence, and Impact (HEI) at McMaster University published a statement criticizing the Society for Evidence-Based Gender Medicine (SEGM), an organization they had partnered with for several years. All five scholars had been listed as co-authors on three SEGM-funded systematic reviews concerning youth gender medicine that were published earlier this year.

Here’s the bulk of their post, which is centered on the possibility of their work being used by conservatives to justify bans or restrictions on youth gender medicine:

Authors of scientific articles have a responsibility to attend to how their contributions will be used and to modify their presentation in the articles, or other communications, accordingly. We, five authors of recent systematic reviews related to gender-affirming care, are concerned that the conclusions of our work — that only low certainty evidence exists (as determined by the GRADE [Grading of Recommendations, Assessment, Development, and Evaluation] approach) regarding the benefits of the gender-affirming care interventions addressed in our systematic reviews — will be misused. Specifically, we are concerned that the assessments of the certainty of evidence using established and standard methodology are interpreted as evidence supporting denial of care to trans, nonbinary, and gender-diverse (TGD) individuals, including youth. We are concerned our findings will be used to justify denying care such as puberty blockers and hormone replacement therapy to TGD individuals. Indeed, our prior work has been used in exactly this highly problematic way.

We therefore feel compelled to make explicit our view regarding how our findings should and should not be used. Following fundamental principles of humane medical practice, clinicians have an obligation to care for those in need, often in the context of shared decision-making. It is unconscionable to forbid clinicians from delivering gender-affirming care.

Moreover, following the principles of evidence-based decision-making, clinicians should always have a high respect for the autonomy of patients and their advocates. The high respect for autonomy becomes particularly important when the certainty of the evidence is low or very low. In such circumstances, clinicians should work with patients to ensure that care reflects the experience, goals, and priorities of those needing care — that is, their values and preferences.

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. Thus, forbidding delivery of gender-affirming care and limiting medical management options on the basis of low certainty evidence is a clear violation of the principles of evidence-based shared decision-making and is unconscionable. The appropriate use of our work is in ensuring patients receive needed care and in helping TGD patients and their clinicians in decision-making.

We write this in the hope that all those who use our work to inform the care of TGD patients receiving gender-affirming care, and those using our work in consideration of policy decisions, prioritize the delivery of compassionate and conscientious care that fully respects the autonomy of the TGD patient.

We acknowledge concerns that have been raised.¹ Our research agreement with SEGM ended in 2024. When the agreement started in 2021, the organization appeared to us as non-trans, cis-gender researchers to be legitimately evidence-based.

We will no longer accept funding from SEGM. As recommended by community advocates, we have also personally made a donation to Egale Canada’s legal and justice work, noting their litigation efforts aimed at preventing the denial of medically necessary care for gender-diverse youth.

Gordon Guyatt, MD, MSc
Romina Brignardello-Petersen, DDS, MSc, PhD
Sara Ibrahim, BHSc, PhD student
Yetiani Roldán-Benitez, MD, MSc
Rachel Couban, MA, MISt

1 https://www.bmj.com/content/388/bmj.r253/rr-0

The systematic reviews these authors had co-authored all came to the same conclusion: The evidence base is weak, meaning we don’t know whether youth gender medicine treatments benefit the youth who seek them and are worth the potential trade-offs.

Which raises an obvious question: How could these signatories publish those articles and then turn around and describe the treatments in question as “medically necessary”? How can a treatment be medically necessary if no one knows whether it works as advertised?

I can’t say for sure, but I think the answer has something to do with browbeating, bullying, professional threats, and lies.

What’s happening at McMaster University is important for the future of evidence-based medicine (which I’ll define momentarily) and independent scientific inquiry more broadly. In this article I’m going to provide some background and reporting on the current situation, and Part 2, which will go up a bit later today, will consist of an in-depth interview I did with Gordon Guyatt earlier this week [update: it’s up]. I found the interview striking on a number of fronts, including the bluntness with which he described the calculation that led him to publicly part ways with SEGM; his repeated use of the term traumatized and its variants to describe the effect of all of this on his younger colleagues; and his belief that members of the trans community were “in ecstasy” after he and his colleagues published the above statement. Perhaps most surprisingly, Guyatt denied even knowing, until recently, that the systematic reviews he co-authored were funded by SEGM in the first place.

Why Evidence-Based Medicine Matters

McMaster University, which is based in Hamilton, Ontario, is an epicenter of evidence-based medicine (EBM), a system designed to evaluate and improve the quality of medical research and practice. This work takes place at the aforementioned Department of Health Research Methods, Evidence, and Impact. HEI’s superstar scholar is Gordon Guyatt, who is considered one of the godfathers of EBM. Guyatt introduced the term itself in 1991 (according to one source) and has developed key concepts within the field, including the GRADE framework (that’s Grading of Recommendations, Assessment, Development, and Evaluations), which is a systematic tool for evaluating the strength of both medical research and clinical recommendations.

Guyatt has always been generous with his time, and on the few occasions I’ve interviewed him, I’ve learned a great deal. His movement’s bête noire is GOBSAT, or “good old boys sitting around a table” — that is, doctors who have strong opinions about which treatments work, but who are basing those opinions on little more than their own clinical observations, hunches, and the observations and hunches of their friends. Human judgment is flawed, and as it turns out, doctors’ observations and case studies aren’t nearly enough to establish that a given treatment is effective or has a favorable cost/benefit profile. That’s why Guyatt and his movement have sought to create systematic tools that, while not eliminating the effect of human bias — which would be impossible — have the potential to greatly attenuate it. The goal, at the end of the day, is to create a much more credible basis for medical decision-making than GOBSAT.

A particularly important tool in the EBM article is the systematic review, which, as one article puts it, “typically involve[s] a detailed and comprehensive plan and search strategy derived a priori, with the goal of reducing bias by identifying, appraising, and synthesizing all relevant studies on a particular topic.” Systematic reviews, or SRs, are far more effective ways of accurately assessing the strength of evidence surrounding a given area of medical research than other methods, which often involve the cherry-picking of individual studies with little regard for their quality.

It would be difficult to find an area of healthcare more in need of the EBM approach than youth gender medicine. For years, practitioners have published and relied on extremely weak studies that can’t, in fact, tell us much about the effectiveness of these treatments. When pressed about the evidence, they will simply gather together a bunch of cherry-picked studies with little regard for their quality and say “See? Look at these studies!” If there is one thing EBM (and the broader metascience movement) has taught us, it’s that you really can’t do that. A GOBSAT problem has emerged in youth gender medicine, with a small group of influential clinicians (plenty of whom, to be fair, aren’t “boys” these days) insisting that their treatments work, but not really having the evidence to back up these claims.

SEGM was founded in 2019 by Zhenya Abbruzzese, who had a background in healthcare research and healthcare economics, and by Will Malone, an endocrinologist. According to its website, its goals include advocating for higher-quality research in this area and disseminating accurate information about the state of the evidence for youth gender medicine. In 2021, McMaster and SEGM began a collaboration to produce systematic reviews about youth gender medicine. According to the agreement, the two sides would jointly develop a set of research questions. After that, McMaster’s scholars would have full autonomy to undertake the systematic reviews and publish them where they wanted to. SEGM, like any funder, would be kept in the loop, but the idea was for the SRs to be truly independent, and according to both sides, firewalls were put in place to prevent SEGM from interfering in the research. (When it comes to agreements between funders and researchers, nothing here is unusual.) Eventually, the two sides agreed on five systematic reviews. These efforts were led by Romina Brignardello-Petersen, an experienced McMaster scholar.

It takes a long time to publish a systematic review, and the McMaster team got to work. Earlier this year, their reviews on puberty blockers, hormones, and double mastectomies (given to individuals younger than 26) as treatments for gender dysphoria were published — those are the ones I also linked to above. These weren’t surprising results, but they represented progress: The more we know about what we don’t know, the better. No one who actually cares about trans and gender-questioning people could actually want a situation where weaknesses in the evidence base for gender medicine remain undiscovered, or where doctors who benefit from administering these treatments can make false or premature claims about their efficacy.

SEGM, though, has proven problematic for McMaster. In my view, that’s not really because of anything SEGM has done — though as you’ll see, Guyatt disagrees with me — but because of a yearslong smear campaign against the organization that echoes, a bit, my own experiences having covered this subject for about a decade. This campaign culminated in the Southern Poverty Law Center’s decision to label SEGM a “hate group” in 2024.

The SPLC’s Strange Campaign Against SEGM

The SPLC has long been a beloved and respected institution among American liberals. Growing up, my household received the print magazine Intelligence Report, and I remember lying on my bed, morbidly fascinated by the SPLC’s investigations into the evil white supremacists who called for the murders of blacks, Jews, and other minorities.

For about a decade now, though, critics have been airing what appear to be well-founded concerns and complaints about the SPLC’s lack of rigor and tendency to deploy accusations of bigotry in a promiscuous manner. In 2017, for example, a Politico feature noted that “Critics say the group abuses its position as an arbiter of hatred by labeling legitimate players ‘hate groups’ and ‘extremists’ to keep the attention of its liberal donors and grind a political ax.”

Along the way, the organization had been sued by the British Muslim activist Maajid Nawaz, a critic of radical Islam, after he was included on a list of “anti-Muslim activists.” Rather than defend this decision in court, the organization opted to pay him a $3.4 million settlement and issue an apology. The apology itself is revealing: Richard Cohen, then the head of the organization, said in an apology, “Given our understanding of the views of Mr. Nawaz and [his organization] Quilliam, it was our opinion at the time that the Field Guide was published that their inclusion was warranted. But after getting a deeper understanding of their views and after hearing from others for whom we have great respect, we realize that we were simply wrong to have included Mr. Nawaz and Quilliam in the Field Guide in the first place.” You can view his video apology here. Whatever one thinks about Nawaz, this clearly demonstrates that the SPLC, in at least some instances, will tar someone with a reputationally damaging label before fully investigating them or their work. The SPLC either deleted Cohen’s apology (it used to live here) from its website, or allowed it to be deleted in an update. In fact, the term Nawaz now does not appear on the SPLC’s website. The entire incident has been disappeared, which is not how this sort of thing is supposed to be handled.

Criticism of the SPLC has come from just about the entire respectable political spectrum — these concerns do not represent crankery. The socialist writer Nathan Robinson, for example, published a long, thorough 2019 critique of what he sees as the organization’s scaremongering approach in his magazine Current Affairs.

To evaluate the SPLC’s claim that SEGM is a hate group, it probably makes sense to first look at how the SPLC presently defines the term:

[A]n organization or collection of individuals that — based on its official statements or principles, the statements of its leaders, or its activities — has beliefs or practices that attack or malign an entire class of people, typically for their immutable characteristics. An organization does not need to have engaged in criminal conduct or have followed their speech with actual unlawful action to be labeled a hate group. . . . Hate groups vilify others because of their race, religion, ethnicity, sexual orientation, or gender identity — prejudices that strike at the heart of our democratic values and fracture society along its most fragile fault lines.

I have been familiar with SEGM for years, have interviewed many clinicians and researchers affiliated with it, and attended a 2023 conference the organization held in New York City where Guyatt was probably the most prominent invited speaker. The idea that SEGM is a hate group does not track with anything I have seen. SEGM also has a rather extensive website, and readers can poke around there and see if they can find any material that would match the above definition. I’ve reached out to the SPLC repeatedly since November in the hopes of getting on the phone with someone who can explain this decision, but I have never heard a peep back.

We do have two hints: First, SPLC attorneys were on the team that represented the plaintiffs in Koe v. Noggle, a case challenging Georgia’s ban on youth gender medicine. Here and in other such cases, SEGM’s work has been cited to argue that there is a lack of evidence for youth gender medicine. My sense is that activists see SEGM as a particularly nettlesome threat. It stays out of the culture-war fray on other trans issues and is more difficult to write off as partisan or radical than other organizations. As a result, SEGM has probably become the single most effective organization at spreading the message that the evidence base for youth gender medicine is paltry — a message that trans activist groups and their allies, such as the SPLC, do not want disseminated. The SPLC was both litigating one of these cases and had the power to instantly and potentially permanently discredit an organization that provided fuel for proponents of bans in every case concerning youth gender medicine. I am speculating, but wouldn’t this be tempting?

The second hint is less speculative: The SPLC put out a lengthy, multipart report called Combating Anti-LGBTQ+ Pseudoscience, or CAPTAIN, in late 2023. The contributors are listed as “R.G. Cravens, PhD, Editor; Quinnehtukqut McLamore, Postdoctoral Scholar, University of Missouri at Columbia; Lee Leveille, Co-Developer of Health Liberation Now!; Emerson Hodges; Sophie Wunderlich; and Lydia Bates.” SEGM features fairly heavily. I’ve been trying to get in touch with Cravens, via multiple channels, over the last week (to no avail), in addition to my attempts to reach the SPLC. I also contacted an acquaintance I have who works at the SPLC, and she assured me my interview request had been passed on to him. Nothing.

There’s a lot I would ask him if I had the opportunity, because the CAPTAIN report appears to be a rather irresponsible, inaccurate document. In many cases, it simply repeats long-debunked activist lines. To take one of many examples, the authors write at one point that “Prior to publication of the DSM-5, identifying as transgender was considered a mental disorder, just as homosexuality had been considered a mental disorder prior to the publication of the DSM-2 in 1973.” This is completely false, and it suggests the authors either are unfamiliar with the DSM-IV or intentionally misinterpret it. (This is a zombie rumor that just won’t die — see this post of mine from 2019. For various reasons, some activists want to undermine work done on gender-questioning youth in the DSM-IV era, when the condition in question was called gender identity disorder. In the DSM-5, the condition was indeed renamed to gender dysphoria, in part to make it sound less “pathologizing.” But the criteria themselves are largely the same. In neither edition would merely “identifying as transgender” net someone a diagnosis. This is not a close call. This is one of those “Do we inhabit a shared objective reality with regards to words printed on a page?” types of situations.)

The authors of the CAPTAIN report also make sweeping, sometimes disorganized and difficult-to-follow claims about SEGM’s supposed ties to other groups and supposedly shady finances. This work, too, is extremely sloppy and misleading in places. In one section, for example, the authors present this chart:

Then they continue:

Analyses of additional financial records^{[15] [16]} from 2021 reveal that SEGM’s total revenue nearly quadrupled from the previous year to nearly $800,000, and that funding appears to have come primarily from donor advised funds. The largest contribution, which came from Fidelity Investments Charitable Gift Fund, totals over $350,000. Notably, Fidelity and Vanguard Charitable Endowment Program (which also donated to SEGM in 2021) have a history of directing money to anti-LGBTQ+ groups, such as the Alliance Defending Freedom and the Family Research Council.^[17]

Most people don’t know what a donor advised fund (DAF) is. They will read this and think that there is a charity or foundation affiliated with Fidelity — a massive financial-services firm — that is funding SEGM to the tune of six figures in one year.

That’s incredibly misleading. A DAF is a tax-advantaged “charitable investment account for the sole purpose of supporting charitable organizations you care about,” as Fidelity explains. After you invest, “those funds can be invested for tax-free growth, and you can recommend grants to any eligible IRS-qualified public charity.”

So the above chart really just means that in total, if you take the donations of everyone who used a Fidelity DAF and requested money be granted to SEGM, that added up to around $360,000. It’s unclear what this is supposed to indicate, exactly, or why it should be considered alarming, unless the SPLC is arguing that financial service firms should prevent people who want to donate to SEGM from doing so.

I have a DAF through Charles Schwab. Sure enough, if I wanted to donate to SEGM, which I wouldn’t do for the same reasons I wouldn’t donate to any group involved with an issue I cover in depth, I could:

Oh my God! Charles Schwab funds SEGM? Of course it doesn’t. Charles Schwab offers its DAFers a wide variety of charities they can donate to.

You know who else is listed as a potential organization to donate to?

Oh my God! Charles Schwab funds the SPLC, the organization that defamed that innocent British Muslim activist??

This is all complete nonsense. It is, like much of the CAPTAIN report, designed to spin the illusion of some sort of vast conspiracy. The cherry on this very strange sundae can be found in Vanguard Charitable’s 2024 annual report, which lists its 20 most popular charities:

Much more disturbingly, the CAPTAIN report includes a chapter titled “ ‘Sterilization’ Rhetoric and Trans Kids” in which R.G. Cravens and his authors spread serious medical misinformation:

Question: When people argue that children are at risk of “sterilization,” what do they really mean?

Answer: Opponents of gender-affirming care for children will often use this extreme or even violent language to create fear and disgust. Not only is this medically inaccurate terminology, but the procedures they’re suggesting (“bottom surgery” or gender-affirming surgeries done on a patient’s genitals) are only done on consenting adults, in consultation with an expert medical team: not young children.

Q: So, if children aren’t getting these procedures, then how could they possibly be ‘sterilized’ or become ‘infertile’?

A: Gender-affirming care for children always consists of consultation with doctors and licensed mental health professionals. After deliberation among doctors, parents or guardian(s), and the child themselves, the most frequent route taken is the prescription of puberty blockers; these medications are associated with common myths about infertility, but such claims lack scientific evidence.

This is another instance in which either the authors are simply unfamiliar with the basics of this debate, or they are being intentionally dishonest. The debate over fertility really has nothing to do with “bottom surgery,” even if the occasional whackjob will claim bottom surgery is being given to 8-year-olds (I can’t say I have seen this claim much). Rather, it is well-established, for reasons having to do with extremely basic, ninth-grade biology, that if a young person goes on blockers at a young age, followed by cross-sex hormones, they will likely be rendered infertile (or sterile, to use one of the closest synonyms). To say puberty blockers are “associated with common myths about infertility, but such claims lack scientific evidence” is, in the context of youth gender medicine, scientific misinformation.

The CAPTAIN report clearly seeks to pathologize wholly legitimate questions about the evidence base for youth gender dysphoria, and to muddy the waters by pretending these critiques have something to do with eugenics, Nazis, white supremacy, and a bunch of other evil ideas. And while there are certainly far-right bigots in the world, including some whose concern for youth seeking gender medicine is driven by a broader disgust for trans people, the CAPTAIN report makes no effort to meaningfully separate legitimate questions from bigotry. It would be like if a right-wing think tank argued that there are no legitimate concerns over police reform because a small number of fringe individuals seek to shoot cops and burn down police stations.

For what it’s worth, in a mid-July email to Guyatt, SEGM co-founder Zhenya Abbruzzese defended SEGM against the many claims circulating about it, and accused the SPLC of having legitimated those claims:

The volume and absurdity of the falsehoods spread about SEGM and in individuals and activities associated — and importantly, not associated — with SEGM is staggering. It ranges from mischaracterizations of funding for the McMaster engagement as right wing/hate-fueled (the donor publicly self-identified is a liberal woman in her late 60s, a longtime supporter of Clinton, Obama, and the Democratic Party), to baseless claims that SEGM engages in political lobbying or calls for bans, to the absurd allegations that we are [a] Christian org that promotes conversion therapy. None of these allegations have any truth behind them, yet they continue to be repeated with aggressive persistence — and unfortunately are often taken at face value because SPLC white-washed them with their name which still carries much currency. I myself used to donate to SPLC.

(This and other emails I cite in this article were sent to me by Guyatt. He said during our interview he would forward emails from his interactions with SEGM that demonstrated why he was so unhappy with the organization. Whether or not it was intentional on Guyatt’s part, the full threads in question included a lot of other correspondence pertinent to this story, though no smoking gun of the sort he suggested I would find.)

Again, it would be extremely useful to be able to run Abbruzzese’s claims by the SPLC, which has an obvious ethical obligation to defend its work given how consequential it can be.

The Pressure Hits McMaster

The fact that the CAPTAIN report is so shoddy doesn’t matter. At the end of the day, the SPLC did designate SEGM a hate group, and it seems inevitable that this brought significant heat to McMaster University. From that point on, SEGM’s many opponents could accuse McMaster of having “partnered with a hate group,” which is exactly what they have done.

I do not know the full story of how the pressure ramped up, culminating in Guyatt and his colleagues denouncing SEGM and donating to a Canadian LGBT trans charity. I do know that earlier this year, according to Guyatt, the McMaster administration pressured his department to distance itself from SEGM, including by asking him and other high-ranking HEI faculty to remove their names from as-yet-unpublished systematic reviews. Two other individuals affiliated with McMaster, neither of whom wanted to be named, told me that they were aware of meetings (also earlier this year) in which younger faculty members were told not to work with SEGM and warned about the damage doing so could cause to their careers. (Neither McMaster’s media contact nor Alfonso Iorio, chair of HEI, returned emailed requests for comment or interviews.)

By at least as early as February, it appears the political pressure was starting to directly interfere with the scientific process of completing the systematic reviews. On February 19, Guyatt and Romina Brignardello-Petersen, who was leading McMaster’s SEGM-funded effort, sent an email to everyone who was set to be an author on at least one of the systematic reviews in progress.

“Unfortunately,” the duo wrote, “we have been made aware that — despite our efforts to be as neutral as possible, and to highlight that decision-making should be informed by other factors as well — our work is being misused and may be causing harm.” That is, conservatives were using it to support conservative policies, such as bans on youth gender medicine.

Their suggested response to this alleged harm:

Although we believe we should not make any changes to the results and conclusions of our review, we feel strongly that we need to add the following statement to the discussion:

“Following the principles of evidence-based decision-making, clinicians should always have a high respect for the autonomy of patients and their advocates — in the case of adolescents, their parental advocates. The high respect for autonomy becomes particularly important when the certainty of the evidence is low or very low. Forbidding management options on the basis of low-certainty evidence is a clear violation of the principles of evidence-based shared decision-making and is unconscionable.”

For the mastectomy paper, we would contact the journal and add this when we get the galley proofs. For social gender transition and binding & tucking, we would add it now that we are resubmitting after their respective rounds of peer review. For the puberty blockers and gender-affirming hormone therapies, we would ask the journal to publish an erratum. As I said above, we would make no other changes.

Please let us know as soon as possible if you have any concerns with this, as you know this is somewhat time sensitive. Feel free to reply only to us (Gordon and me) or to the whole group. We would be happy to chat if needed.

Best,
Romina & Gordon

According to someone with knowledge of the situation, this sparked some dissent. I don’t know the details of the subsequent debate, but it’s not hard to guess why some of the scholars would be reluctant to paste this language into all of their SRs. For one thing, this is simply unusual language to include in a systematic review in the first place. SRs are supposed to be “just the facts” documents that do not veer into the area of clinical recommendations. In general, the idea is to evaluate the evidence in as much of a vacuum as possible, and then, once you know where the evidence stands, you can proceed to figuring out what the policies and clinical recommendations should be.

Now, the evidence cannot, on its own, dictate exactly how doctors and patients should approach the treatments in question. Doing so is also a values question, and EBM practitioners generally recognize the four values considered to be foundational to medical ethics: beneficence, non-maleficence, autonomy, and justice. Figuring how to apply these principles to a given evidence controversy can be fiendishly complicated, especially because the values can and do often conflict. A patient might really want a given treatment (autonomy), but the doctors might know that there’s no real good reason to think it works (beneficence and non-maleficence). Patients and doctors themselves, being human, might have trouble fully understanding and responding appropriately (itself a subjective concept!) to probabilistic estimates, long-term risks, and so on. So even in situations where the evidence for or against a treatment is solid, there is no easy or mechanistic way to untangle any of this.

This brings us to another problem with the paragraph in question: to say that bans are “a clear violation of the principles of evidence-based shared decision-making and. . . unconscionable” is an extremely strong claim that simply ignores the fact that doctors are supposed to also weigh those other principles as well. It elevates one particular understanding at the expense of others that might be equally valid — it says “This is the proper weighing of the values.” Again, setting aside the fact that these sorts of claims aren’t supposed to find their way into a systematic review in the first place, there’s a whiff of GOBSAT here, of “This is just the way we do things.” Long after the bulk of these systematic reviews had been completed, Guyatt and Brignardello-Petersen were asking their colleagues — including some much younger, less established ones — to cosign a statement that 1) didn’t belong in a systematic review, traditionally speaking, and 2) which they might not have personally agreed with. (There is a long-standing debate between Guyatt and SEGM about how to weigh these competing values that is itself a complicated story for another day — you’ll see it pop up in my interview with him.)

In any case, this language did not end up in the three systematic reviews that were done or close to done at the time, or in any academic journal. Instead, it became part of the statement that the authors posted to the HEI website disavowing future engagement with SEGM.

Speaking of as-yet-unpublished SRs: In April, things escalated further. On the 17th, Brignardello-Petersen emailed Zhenya to tell her that she, Guyatt, and another colleague would be pulling their name off of an almost complete systematic review on social transition that seemed on track to be published in the Archives of Sexual Behavior, a peer-reviewed journal edited by the sex researcher Ken Zucker.

They wrote:

Dear Zhenya,

I am writing to provide an important update about the SGT [social gender transition] SR.

You are already aware of the serious concerns some of us have about our work being misinterpreted and causing harm. As we were ready to resubmit the Social Gender Transition manuscript (after 3 rounds of review), we came to realize that this risk may be even higher if we proceed with publication in the journal Archives of Sexual Behavior (suggested by one of our content experts).

The Editor in Chief, Dr. Kenneth Zucker, is linked to several controversies related to his work as well as his editorial leadership. The retracted paper about rapid onset of GD, for which SEGM paid for open access, makes it more difficult for our work to not be perceived or portrayed as aiming to harm.

From the methods perspective, the work is very outdated — it was the first review we started working on and the peer review process has taken a very long time. An update is necessary and we do not have the capacity to undertake this.

Respecting how hard all team members have worked on this review, I have offered for anybody in the team to take the lead on publishing this and to provide them with everything we have done. The names of those who no longer want to be listed as authors, however, should be excluded. This includes Gordon, Yetiani, and me (the ones informed about the issue until now).

If nobody wants to proceed with publication, we will give all the materials to you as a report, so you can use them as you see fit.

I understand these may be disappointing news and I thank you for understanding where we are coming from.

We will be happy to chat and answer any questions you may have, and will keep you updated about whether any team member has decided to move this forward to publication.

Best,
Romina

PS, 3 manuscripts (Mastectomy, PB, CSH) are already published, and binding and tucking is on the journal’s end, and we are expecting an acceptance soon.

According to one of the emails Guyatt shared, Abbruzzese responded by attempting to explain to Brignardello-Petersen and Guyatt that Zucker had been the subject of a smear campaign. This has definitely been true in the past, but this time around the “accusation” is particularly wild.

Archives had published a paper called “Rapid Onset Gender Dysphoria: Parent Reports on 1655 Possible Cases” by Suzanna Diaz and Michael Bailey, himself a controversial sex researcher. Immediately, a group of activists and activist-scholars were furious that this theory, which they treat as debunked and bigoted, was getting yet more airtime.

As Abbruzzese wrote:

With regard to the situation involving the retraction of the “ROGD article,” to be clear, SEGM was not involved in the production of the research in any way; we merely covered the open-access fees, as we have done dozens of times before. Doing so aligns with our mission to promote scientific debate, as few researchers engaged in critical inquiry on this subject have institutional support — particularly in contrast to those promoting gender-affirming models, which are typically well-supported and published open-access. This imbalance introduces yet another form of bias: a readership bias, wherein open-access articles often reflect a singular perspective, while critical or alternative views are paywalled (if published at all).

Once SEGM became aware of allegations concerning the article for which we funded open-access publication, we conducted a thorough investigation. The nature of the allegations shifted repeatedly. Initially, the claim was that no IRB had been obtained. When it became clear that the authors and the editor (Ken) had fully complied with the journal’s official requirements regarding IRB approval, the allegation shifted to claim that survey participants (parents of affected children) were not informed that their responses would be published. In reality, the survey webpage included a clear disclaimer that the survey’s purpose was to publish the results, and the parents participated with full knowledge (and hope) that the results would be published. When that was pointed out, the criticism shifted again — this time it was that the disclaimer’s failure to specify that the intended publication would be in an “academic journal” rendered it invalid.

I asked Zucker and Bailey if they endorsed this account and they both said yes. You can read more about this trainwreck here and here. The paper has since been republished here.

The social transition paper is now in limbo. For various reasons — not least the fact that the authors who pulled their names off were leading methodologists who did the data analysis and so forth — it is difficult to drag a paper over the finish line under such circumstances. The final systematic review, on breast binding and genital tucking, is in a similar boat, I am told. If and when these papers do get published, it’ll be in spite of a great deal of what certainly appears to be political interference sparked by the campaign against SEGM.

The Bigotry Bunch

Making matters worse was an Instagram account called @segm_x_mcmaster that appears to have popped up in June. Its bio reads: “🏳️‍⚧️Fighting McMaster U’s partnership with SEGM, an anti-trans pseudoscience hate group.” Whoever is running it is absolutely furious at the collaboration between SEGM and McMaster and seeks to inflict as much reputational damage as possible on everyone involved with it in any way.

While Guyatt and Brignardello-Petersen are singled out — the account proudly posted two videos of them being confronted in person — SxM seems to have targeted just about any scholar who has participated in the systematic reviews. Stuff like this is the norm:

I can tell you from experience: It’s not fun to be called a bigot. And if you question youth gender medicine in any way, and you have even a moderately sized platform, you will be called a bigot. Consider that an iron law. Maybe there are exceptions, but I’m unaware of them.

If you were a young scholar at McMaster with your whole career ahead of you to think about, would you want to find yourself on Instagram looking like this?

As far as I’m aware, SxM is breaking no law and violating no university policy. They’re allowed to be a crazy activist Instagram page. But at some point, as things escalate, someone has to step in and explain that no, activists don’t get to dictate what science gets done. And instead, it appears that McMaster did the opposite: better do what the activists say. It’s just a really depressing dereliction of duty, and it’s likely to have consequences for evidence-based medicine for years to come. How could you send a louder signal to activists that if they want to disrupt politically disfavored research, there’s an easy road map for doing so?

Now: Guyatt insists he has genuine, serious concerns with SEGM, as we’ll see in the interview transcript. And surely Brignardello-Petersen, too, would deny that she was simply caving to political pressure (she didn’t respond to my request for comment). But that’s the problem with allowing things to devolve to this point: It’s impossible to know. Maybe Guyatt had a genuine come-to-Jesus moment and just couldn’t abide SEGM anymore. Maybe Brignardello-Petersen really does think her work — conducting careful systematic reviews of the evidence for highly controversial medical treatments — is “harmful.” But when there’s 1) so much reputational and professional damage going on, and 2) when there’s no sign that the bosses of the researchers in question had their backs, why should we believe this? Why should we believe anything anyone says, when it’s already clear that if they speak — and research — freely, there will be hell to pay?

Where’s The Beef?

I had difficulty getting a straight answer out of Guyatt about exactly what was wrong with SEGM. He kept saying that SEGM favored bans on youth gender medicine, which SEGM has consistently denied. He couldn’t provide evidence; the emails he forwarded to me did not support this claim.

Here the strongest point an SEGM skeptic might make is the amicus brief the organization filed in Skrmetti. The document is called “Brief of Amicus Curiae Society for Evidence-Based Gender Medicine (SEGM) in Support of No Party but Suggesting Affirmance.” “SEGM’s brief is neither in support of, nor in opposition to, Tennessee Senate Bill 1 (SB1),” note the authors. “Our aim is to help the Court by summarizing the key dilemmas facing this understudied area of medicine, given the failure of the medical establishment to self-regulate in this area of medicine, which in turn, has created a safeguarding threat to tens of thousands of youths seeking help. We hope our analysis will aid the Court in making a better-informed, just decision.” Clearly SEGM’s contribution was meant to nudge the court toward affirming Tennessee’s right to enact the ban, but it’s worth keeping in mind that that’s what was at issue in this case: whether states have a right to enact these bans, not whether bans are the correct approach.

SEGM cofounder Will Malone elaborated on this in a statement: “Although in the U.S., constitutionally, it is the states that regulate the practice of medicine, many clinicians and researchers who collaborate with SEGM do not support state-level bans and wish the medical establishment would engage in thoughtful self-regulation, guided by ethical application of currently available medical evidence,” he said. “SEGM itself has not taken a position on state restrictions. In the SCOTUS amicus brief, SEGM clearly leaned into our position of concern — to suggest otherwise would be disingenuous. However, we are neutral about how the states should regulate this area of medicine. In fact, we were the only group among nearly 100 to have provided a neutral amicus brief—in support of neither party. We invite everyone to read our brief and familiarize themselves with SEGM’s positions.”

Now, as you’ll see in the interview, all this might be beside the point — Guyatt was pretty open with me that the mere perception that SEGM is bad was enough for him to cut ties with the organization, even if it had operated in an unimpeachable manner. It was a public-relations nightmare. But for what it’s worth, some of his correspondence with Abbruzzese, who wrote to him at great length defending her organization, reminded me of the paragraph he attempted to have inserted into the SRs: He seemed intent on demanding Abbruzzese and her organization look at the values question in exactly the same way he did.

Yesterday, he wrote to her:

[]I don’t buy your incapacity to make it known far and wide that core to your mission includes a deep commitment to patient autonomy and access to appropriate care and a fierce opposition to legislative efforts to restrict access. There are oodles of ways nowadays to get messages out. Given the current perception, if you started every presentation at meetings with a strong statement of these positions people would take notice and the word would get out quickly.

But there is no rulebook, in EBM or elsewhere, stating that patient autonomy should trump other, competing concerns in a situation like this. This just happens to be Guyatt’s view, which is his right — but SEGM doesn’t share it. As Abbruzzese put it in an email to me, “autonomy is not the sole consideration in public health. The balance of harms and benefits associated with any given treatment is another key consideration.”

For what it’s worth, when I followed up with Guyatt on this, he was clear that in some cases he puts other values ahead of patient autonomy: “Jesse, no physician is obliged to provide care that they are confident is not in the patient’s best interests,” he wrote. “Indeed, in my opinion, we should not provide such care. In my own practice, I am repeatedly faced with elderly patients with cognitive impairment who express an unequivocal desire to return to living [at] home alone when it is clear to me this is unsafe. I cannot participate in facilitating meeting their expressed preferences and indeed after following the rules regarding their capacity, participate in denying their wishes.” (There’s more on these autonomy and capacity questions in Part 2.)

Clearly Abbruzzese and her colleagues at SEGM feel that McMaster pulled the rug out from under them. She argued in an email to Guyatt that McMaster had been fully aware of the group’s stances all along, and that this had even come up early on in the collaboration:

Not only was our position of concern disclosed from the start, but it formed the entire basis for our collaboration and research plan. Because no evidence-based guidelines for the treatment of youth with gender dysphoria existed, SEGM’s goal was always to support the development of a trustworthy, evidence-based treatment guideline for young people with gender dysphoria. But this was impossible without first producing rigorous systematic reviews. . . . SEGM approached McMaster with a request to conduct systematic evidence reviews across the core components of the “gender-affirming” protocol: social gender transition; puberty blockers; cross-sex hormones; and surgery. We asked whether having a position as a funder would compromise the integrity of the work or its conclusions — whatever they might be. We were explicitly assured by McMaster’s Department of Health Research Methods, Evidence, and Impact (HEI) that having a position does not amount to bias, and that McMaster was expert in managing any real or perceived conflicts of interest (COIs) through a rigorous COI management process. We accepted McMaster’s proposed research agreement, its terms of COI management, and supplied the necessary funding.

This is exactly the sort of thing I would have liked to have asked McMaster about, but again, no one there responded to my inquiry.

Part 2, my interview with Gordon Guyatt, should be published within a few hours. When it is, I’ll add a link to it here. [Here it is.]

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Questions? Comments? More background on what’s been going on at McMaster? I’m at singalminded@gmail.com. Stock image of McMaster University via Getty Images.