The Disaster At McMaster Part 2: My Interview With Gordon Guyatt

“They’re all *terrified*. They’re all *traumatized*.”

Unless you’re already quite familiar with the schism between McMaster University’s Department of Health Research Methods, Evidence, and Impact (HEI) and the Society for Evidence-Based Gender Medicine, this interview might be tough to follow, and you’ll want to read Part 1 first.

I tried to keep the editing as light as possible, other than some minor tweaks for clarity and some jumping-ahead here and there. Otherwise, I’m presenting the transcript more or less as-is. This interview took place on August 24. Some of the footnotes provide useful additional information, so they’re worth reading. All links are added by me, of course, given that this was a verbal interview.

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Jesse Singal: Look, thank you for taking the time. I know there’s a lot of stuff going on over there. Are you okay with sending me the recording of this after, and we’ll say on the record unless—

Gordon Guyatt: Yes.

Singal: Okay. Okay. So, yeah, same rules as last time, like, if you want to go off the record, let me know. But let’s just start with the, sort of the 101 here: patient values and preferences and autonomy and shared decision-making. You know, ever since we first spoke, you’ve been clear with me throughout that, like, evidence-based medicine isn’t just about the evidence per se, there’s the — there are these other pillars of it. So just, just talk me through how that applies here to the question of youth gender medicine, because I know that’s a big part of the controversy at the moment.

Guyatt: Right, okay. So people have legitimate concerns about possible harms, particularly from the hormonal and surgical interventions that are sometimes associated with it, and they also have concerns about the capacity of the adolescents to make decisions for themselves. These are very legitimate concerns. From my point of view, what they dictate is a multidisciplinary approach to the care of these individuals that ensures that they are—

Singal: Oh hey, not to interrupt you. Do you mind if I just ask to record to my computer as a backup and—

Guyatt: No, no problem, you go ahead.

Singal: Okay, “send request.” You should get a request.

Guyatt: “I do.” Okay. So. . .

Singal: Patients’ values and preferences.

Guyatt: So what this situation that I just described mandates is that a multidisciplinary team ensures that patient, and whoever is supporting the patient, understands the situation, understands the limitations in the evidence, has the maturity to make decisions for themselves, but once that is established that the patient’s autonomy should be respected.

Singal: Okay. So I think part of the reason this is so heated in this context is that, you know, I know more about what happens in the U.S. than what happens over there, but in the U.S., like they really do. . . you’re talking about sometimes kids who are as young as 13 or 14. So if you’re talking about a 14-year-old, in most areas of life, we don’t view a 14-year-old as having a tremendous amount of autonomy. I know there’s some exceptions to that. I mean, you could talk about abortion, for example. Most people would accept that a 14-year-old has some autonomy. Patient autonomy, in the context of, say, hormonal treatments, in a situation of a lot of significant medical uncertainty — how do you conceive of how much autonomy to grant a 14-year-old? Like, how does that work? Because it doesn’t seem as straightforward as it is with adults.

Guyatt: Quite right. It’s not. So, however. . . I’m not a pediatrician. I don’t do adolescent medicine. However, it is clear that there are, I believe, physicians who see these young people and who operate in environments of the sort that I have described, with multidisciplinary teams and expertise and so on, who believe that there are these adolescents with the maturity to be able to make difficult decisions that are in their best interest. They may be wrong. Maybe no 14-year-old is ever in that position. I’m not the person who can say. However, it seems plausible to me, from — as I understand the situation, and the folks that I’ve talked to, that there are at least some who do have the maturity, with the support of people around them to make decisions that are very important in their lives.

Singal: So this is different from with adults. As long as they’re of sound mind, we assume they have the capacity—

Guyatt: Well, I suppose. I don’t know. I mean, I’ll tell you, I’ll tell you the situation that I’m in is I have a lot of times, I have people with cognitive impairment who want to go home and some doubt about whether they can go home or not. And presumably there may be — I don’t know what you should do with adults. [chuckles] You should make sure they understand the situation and are of sound mind and have thought about things and so on. There’s still — you don’t just say, Okay [sing-songy], so even in adults one should not be cavalier about it, but it’s obviously—

Singal: But all I was getting at there was like, it’s not — it’s not exactly patient autonomy in the case of a 14-year-old. It sounds like you’re saying you would have to do some level of assessment to make sure they actually understood the risk and benefits.

Guyatt: You always need, in everybody, as a physician, when a patient’s making a difficult decision, to make sure they understand and etc., etc. That’s an obligation in all situations.

Singal: Yeah. Okay, so one of the things I want to get at here, and I don’t yet know, you know, how much of this will go in my book, or some other write-up, or whatever else, but I want to try to understand and like, help readers understand how much of what’s been going on at McMaster was SEGM — like, the argument that SEGM has done something wrong or operated outside of certain boundaries, versus the argument that I’ve heard from some that this is just a very fraught area, and anyone who looks into it is gonna receive some heat.

Guyatt: My opinion is SEGM has no respect for autonomy, that they take the position that we should ban the procedures, that patients should not be able to access them, and I have big problems with that.

Singal: Can you point me to anything SEGM has written or — because they just deny that that is their view.

Guyatt: No. After this, tell me to send you my latest email exchange with an SEGM representative. [laughs]

Singal: Okay, that would be useful. What they’ve told me is that they think a prerequisite for any conversation about what the policy [should be] is the existence of good evidence. And their view is that there just isn’t good evidence, and that’s why they—

Guyatt: What bullshit is that, frankly? If you take that position, we wouldn’t be able to have conversations about two-thirds of our medical therapies.

Singal: Explain that. I want to make sure I’m being—

Guyatt: We have low or very low certainty evidence about most of what we do.

Singal: Sure. Well. Yes, but in terms of introducing something that’s genuinely new, like, putting a 13-year-old on hormones—

Guyatt: There’s lots of things we introduce that are new all the time, where we still only have low or very low certainty evidence.

Singal: But aren’t they usually introduced in the context of some sort of trial?

Guyatt: Not necessarily. Surgical procedures, you don’t have to go through trials. I mean, I think there should be more, but surgical. . . . new devices. New devices are put out all the time with still low certainty evidence.

Singal: Yeah, but that’s not considered good. That’s not the ideal way to do medicine, right?

Guyatt: Well, but come on, the people who are in charge of putting these things [out], making decisions, like drugs that go on the market, think that it’s okay. And the surgeons who give it out and the device people who give it out, it’s an established part of the system.

Singal: But if they’re disseminating the use of a surgical procedure or a medical device before the evidence is in, that can cause problems.

Guyatt: Well, of course it [can]. On the other hand, people will legitimately argue not what the standard should be — people will legitimately argue delaying something that’s of benefit is also problematic. And the point is that you then, ideally — if people say, “Okay, we’ll make it available to people,” then the conversation should go on that includes, “What is the evidence?” when people say yes to doing this. What’s the evidence about it? I am sure in many situations, the appropriate conversation does not go on, but that’s the way it should be handled.

Singal: Um, well, we’ll go back to that.

My experience. . . I’ve been writing about this in one form or another since 2015 and I’m, of course, I’m biased by my experiences, but I have never come across someone who has expressed skepticism of youth gender medicine publicly, who hasn’t been met with, like, a wave of attempts to destroy their reputation and career—

Guyatt: Absolutely. We haven’t even expressed any skepticism ourselves, and have been under attack, okay? So it’s an extremely polarized environment, no question about that. And you know, it’s warfare on both sides, as far as I can see.

Singal: Yeah. Well, because you had said that you had received earlier on in your relationship with SEGM, in one of our previous conversations, you said that you, some of your colleagues at UpToDate ¹ had sort of warned you about an affiliation.

Guyatt: Yeah, they said that by going to a SEGM meeting I’m now being labeled on social media — which I don’t look at, so I don’t know — but they were saying I’m being labeled as an anti-trans activist.

Singal: The reason I’m asking this is, I was at that SEGM meeting [the 2023 conference], and it was not. . . it was a science conference like any other. That was my read. Maybe there were, like, other panels I didn’t go to about them hating trans people—²

Guyatt: Well, did you see my interactions with them?

Singal: Yeah, well you were arguing with them about the patient autonomy thing and about the values and preferences. But that seemed within the bounds of normal scientific dispute, because you’re weighing different values.³

Guyatt: Yeah, yeah, yeah, yeah.

Singal: But SEGM is sort of the only game. . . there’s no one who does what SEGM does. I mean, I’m not saying that because I feel a need to defend them. I’m saying that because, again, I’ve been covering this for 10 years, and other than, like, the federal government, no one is seeking to do the systematic reviews. So when you tell me that UpToDate, which is one of the most serious sort of compendiums of guidance for physicians, years ago, they’re sort of warning you against an affiliation with SEGM — that just — it strikes me as evidence that this group, from very early on, people were saying, “If you touch them, there will be career consequences for you.” Was that the sense you got?

Guyatt: They were telling me that by [having showed] up at an SEGM meeting, that I was being perceived as an anti-trans activist.

Singal: I mean, do you see anything anti-trans in what was going on at the SEGM, or what was said there?

Guyatt: Yes, absolutely I do. Okay? So, for sure I did. So it wasn’t absolutely clear to me that they were saying, “Don’t make these procedures available.” It’s subsequently become evident to me that that’s effectively — whatever the hell they — that is effectively their line. I’ll show you my latest emails with them.⁴

Singal: Okay. If an individual or a group says that “My read of the evidence is such that I don’t think these treatments should be available,” it does sound like you’re saying that’s beyond the pale. That’s the point at which you won’t affiliate with someone. Would you apply that logic to like, a heart valve repair method, to a—

Guyatt: You’d have to tell me the complete context of whatever you say. In this context, that is the case.

Singal: So you thought that even though they were presenting a front as just evidence-minded, they were going—

Guyatt: They, they — sorry, I should let you finish. They’re presenting a front as evidence-minded, yes.

Singal: Well, but then. . . they partnered with McMaster. My understanding of the contracts for these, I think, five systematic reviews is McMaster had full — you agreed on sort of the research questions—

Guyatt: Don’t say I — I didn’t agree to anything. I wasn’t part of that agreement.

Singal: McMaster Uni. . . who agreed? HEI? Who signed the contract?

Guyatt: McMaster somehow or other. I haven’t gone into the inquiry. I did not know about this agreement until the controversy got going. I didn’t know about it.

Singal: But at the time, when we met at the SEGM conference, they were starting to present the results of the systematic reviews. So you knew about it then?

Guyatt: I don’t remember if they presented the results, our results. I did not know about McMaster taking this money till the controversy emerged.

Singal: Which would be when? Like, what year?

Guyatt: Oh, a couple months ago, when it was, maybe three months ago, four months ago. I don’t know, something like this.

Singal: You didn’t know that McMaster had taken money.

Guyatt: [fairly emphatic] No! No!

Singal: Oh. But didn’t SEGM fund the systematic reviews that you’re a co-author on? I could be missing something here.

Guyatt: No, no. So, my colleague tells me, “Gordon, my graduate student is doing a PhD [conducting] these reviews. Would you please be on the PhD committee?” “Sure, Romina, I’ll be on the PhD committee.” So I’m on the PhD committee. I don’t ask questions about whether — didn’t occur to me that the university was taking money for these reviews. So I helped out on these reviews. I did my usual job.

***

I want to break in here to note that I did follow up with Guyatt about this via email after our interview, simply because I was so surprised by it. There’s video of Romina Brignardello-Petersen presenting the methodology and preliminary results of the double mastectomy systematic review at the 2023 SEGM conference. During her presentation, she clearly explains that the study was being conducted in partnership with SEGM.

For what it’s worth, Guyatt maintained in his reply that he had no knowledge of the funding until recently:

Jesse, this highlights my limitations.

When Romina first spoke to me about SEGM I had understood this was personal consulting she was doing for them (I suspect at the time it was). So that’s what got into my head as the arrangement. I’m sure Romina did mention the agreement in her talk, but since I thought I knew what she was going to say I was no doubt on my phone or computer during the talk, and the issue never came up between us (or if it did, it didn’t register). I for sure was never consulted by anyone at McMaster about the agreement between SEGM and the institution. So, I can understand it sounding odd, but I indeed did not have conscious awareness of a formal agreement between McMaster and SEGM until the controversy.

Hope this clarifies the situation.

g

Back to the interview:

***

Singal: Okay, so, um. . . and we’ll get to that, we’ll get to the reviews, but in terms of the broader climate, you were quoted in The New York Times saying that the American Academy of Pediatrics was, quote, “very clearly putting the cart before the horse” because they had effectively put out these guidelines more or less endorsing these treatments. And then they said, now we’ll do a systematic review. In the meantime, we’ll reaffirm the guidelines.

Guyatt: If they’d been smart, they would have said, “There are many systematic reviews out there,” as there were. “The good ones, we’re going to use one of these.” Why go off and do your own? That’s stupid anyway. But if you are, if you are going to claim that perhaps there’s some new information available, maybe that’s why, whatever their rationale for doing another systematic review is, you should do it before you make recommendations, if indeed you believe that a new review is necessary.

Singal: Yeah. Well, I guess what I’m getting at is, like, what you’ve said about the Endocrine Society — I think you’ve been quoted on WPATH, or some aspect of WPATH. . . there seems to be this chronic problem of these important groups not developing guidelines in rigorous ways. And I think that sort of got us to where we are. And arguably SEGM.

Guyatt: That is my impression as well, that people have not developed guidelines in rigorous ways.

Singal: Right. And this was reinforced by — part of the Cass Review was sort of evaluating, in a systematic way, guideline development itself. Now to me, I’ve talked to a lot of parents who are trying to figure out what to do for their kids who are struggling.

Guyatt: Yeah.

Singal: I get a biased sample of parents who have at least some skepticism. But, if you’ll pardon my French, it’s a fucking disaster that you cannot necessarily trust the guidelines put out by the Endocrine Society, the AAP, WPATH. I can’t imagine a worse situation for parents to be in.

So the general arrangement you guys came to with SEGM, where SEGM will give you guys funding and will give you independence to do these systematic reviews, three of which you’ve published, that just strikes me as very important work. I mean, the example that just came out—

Guyatt: Oh, I agree. When I participated in this it was because I thought it was valuable work, for sure.

Singal: Sure. Right. So three of the five reviews have come out. There was just one that was published in Plastic and Reconstructive Surgery. This is a systematic review of double mastectomies performed on individuals under 26 to treat GD.

People debate how often it happens in the States. [But] kids as young as 13, according to published research, get double mastectomies to treat gender dysphoria. I think it’s disastrous that you guys. . . it took us until 2025 for anyone to actually look at the evidence. So, wouldn’t a defender of SEGM say, “This is a very important result for people to have access to”? Like, what’s the problem with you partnering with SEGM on something like this, if you have full independence?

Guyatt: Because we are discredited by our association with SEGM.

Singal: Because if — and SEGM denies this — but you’re saying if SEGM is against these treatments. . .

Guyatt: No, irrespective of anything else, we are discredited by the. . . I don’t know how much, by some, some people in the. . . our audience is the trans community!

Singal: Your audience is the trans community?

Guyatt: Sorry?

Singal: What do you mean by that? Isn’t your audience just anyone. . .

Guyatt: Who’s making the decisions? Our reviews are to inform shared decision-making.

Singal: Okay. Isn’t your audience anyone — I mean, the public, but also — sorry, go ahead.

Guyatt: I agree, we have multiple audiences. One of our key audiences is the individuals facing this decision who should know about the evidence. And to be discredited, to have our work potentially discredited by an association with SEGM in [the eyes of] the people who are faced with this decision is very problematic.

Singal: But what if you’re being discredited for inaccurate or unfair reasons?

Guyatt: Well, do they know that?

Singal: Does who know that?

Guyatt: When the people who are upset at us for associating with SEGM write in the newspaper, “These reviews are pseudoscience. . . ”

Singal: Yeah, you’re talking about The Hamilton Spectator.

Guyatt: Yeah, yeah, yeah, it’s only The Hamilton Spectator. Nevertheless, I’m sure they say it elsewhere in social media, etc., etc.

Singal: But doesn’t this. . . I know that I’m idealizing evidence-based medicine, but ideally the research question is the research question. And I think whether or not. . . well, you tell me. If you had published a systematic review that wasn’t partnered with SEGM that found the evidence for youth or adult gender medicine was weak, wouldn’t that have enraged a subset of the trans community no matter what?

Guyatt: No, I don’t think so. I think that their efforts to discredit us would have been much less powerful.

Singal: You think they would have accepted a review showing that—

Guyatt: No, they may not have accepted — hear what I just said: Their efforts to discredit us would have been much less credible and much less powerful.

Singal: Okay. And again, this all just goes back to your argument that SEGM is for bans, which SEGM—

Guyatt: No, no, no. My argument there—

Jesse: Sorry.

Guyatt: —is. . . let’s say SEGM is well-behaved EBM and I’m wrong. We still shouldn’t partner with them, because you get tarred and feathered in the same way by participating with SEGM. In a certain group in the community, who’s an important group, you get discredited.

Singal: But can’t you see how that could lead to a dynamic where. . . [trails off]

Guyatt: We could have done the reviews without the money. No problem. As a matter of fact, we did. [laughs]

Singal: Just from my experience with this, I think — first of all, I think it’s very important to separate activists from, like, the average member of a community. I think the average trans person probably wants good data on this.

Guyatt: Of course they do. Of course they do. Of course they do.

Singal: Undoubtedly. So I guess, speaking from my own experience, and perhaps editorializing at my own peril: If you guys had released the exact same systematic review that didn’t have SEGM’s name on it, I think a subset of activists would have been furious, because their claim is, your data can—

Guyatt: Let me tell you. . . I’m sure there would have been a subset, yeah, there are crazies everywhere. Okay? But when we put out — you’ve seen the HEI post we put out, I presume.

Jesse: Yeah, I’m gonna return to that.

Guyatt: The local trans community is in ecstasy over it.

Jesse: So you feel like you ameliorated [sic] them by putting out that statement?

Guyatt: Oh, it certainly helped with some people, that’s for sure.⁵

Singal: Okay, so that strikes you as. . . because the local trans community now trusts you more, that’s sort of a good outcome.

Guyatt: Yes!

Singal: Now, just in terms of the status of these systematic reviews, because like everyone else who follows this I’ve been keeping an eye on these. So you’ve published, and you’re a co-author [on a systematic review on] double mastectomies, puberty blockers, and hormones, and you’re basically saying that you agreed to help with these, but you didn’t know the source of funding.

Guyatt: That’s correct.

Singal: Okay. And you found out the source of funding like two months ago or so?

Guyatt: Whenever the controversy — whenever the stuff blew up.

Singal: Okay. There’s two other systematic reviews in the works, one on tucking and binding and one on social transition. My understanding is that you and the other methodologists within HEI have taken your names off them, and that they’re somewhat in limbo now. Is that the case?

Guyatt: Yes.

Jesse: Okay, so can you explain what happened?

Guyatt: Yeah. So. . . [laughs] So the university is. . . the university is in. . . feels in a vulnerable position. They’re all upset about the controversy about McMaster being labeled as this big anti-trans. . . I understand it. And they say, “Oh, man, when this other review comes out, it’s a big problem.” So I say, “Okay, we’ll take our names off,” and the review will still be out, as you say, because it’s important it gets out. So then, when we say we’ll take our names off, everybody else [meaning the other co-authors] says, “We’ll take our names off too.” I mean, “We’re getting out.” So no paper.

So at that point I say, “Look, I want the paper out. I’ll put my name back on.” All the junior people say, “No, no, no, no, no.” You know, “We’ve had enough, we’re too traumatized by the whole thing. We’re staying out.” Okay, I don’t see how I can put this out by myself. Then two co-authors say, “Oh, we’ll stay in.” So I say, “Okay, good, but I’m only going to stay in if we have a paragraph that takes the position that’s basically in the post.” And my two buddies who want to be on the paper say — who are ready to carry it forward — say, “No, nope, nope, nope, we’re not going to put in your paragraph.” I say, “Okay, you want to take that attitude, I’m out of here. Go ahead.” It’ll get published, good, it gets published. But if I’m not — now I decide I’m not publishing anything on this stuff unless I get to make it clear what my ethical position is.

Singal: So, a couple things there. It sounds like there was pressure from parts of the university outside of HEI proper to not publish these reviews because they would just bring more negative consequences.

Guyatt: No, no. As I understood it, to have us in particular [be named].

Singal: Like the senior methodologists.

Guyatt: Yeah, yeah. The HEI representatives, if you will.

Singal: And that is who is famous for doing systematic reviews. So like, without your guys’ names, it takes away from some of the papers’ legitimacy.

Guyatt: Takes away from it, yes, I agree.

Jesse: Okay, and was this sort of like the. . . I mean, are we talking like the dean of the whole university or the DEI office? Who is—

Guyatt: Okay, this — anything that I say that could be taken as discreditable to the university, off the record.

Singal: Well, then we can leave it at. . .

Guyatt: You better — you show me. I’m telling you, your judgment, you’re a smart guy. I do not want anything that I say that could be discreditable to the university — that’s off the record.⁶

Singal: I can’t agree to that in advance. If you want to go off the record—

Guyatt: You cannot? Then we stop right here. And you said at the beginning of this conversation, anything off the record, I can say at the end, it’s off the record—

Singal: Oh no, no, no, I’m not saying — sorry. I’m saying if you want to go off the record to talk about this aspect of it [we can]. I can’t say “We’re on the record, but I’ll cut out anything you say that could be discreditable,” because I can’t judge what will be discreditable to the university. We can also skip—

Guyatt: You’re a smart guy. You know perfectly you can judge what might be discreditable. And if you have any doubt, ask me.

Singal: Okay. Why don’t we skip, um. I’m just trying to try to figure out, I just want to sort of be able to accurately explain.

Guyatt: Man, I am not ready to be quoted with anything that could be seen as discreditable for the university.

Singal: Okay, um. . . [very long pause] Let’s move on to something else.

Guyatt: Okay, well, the other thing is just a few more minutes. I’m actually in clinical service. I have to go back to see my patients, and I could — I’ll talk to you again, but I only have another few minutes now.

Singal: Okay, so in the statement you put out, you have a footnote pointing to, like, a short rapid response published in The British Medical Journal, and that rapid response noted that SEGM had been dubbed a hate group by the Southern Poverty Law Center. Could you clarify just this on the record about, like: Have you looked into the accusation SEGM’s a hate group or the SPLC’s reasoning? Like, is that your view?

Guyatt: No. I mean, I’ve been party to a number of conversations about it, but I haven’t gone out of my way, that’s for sure.

Singal: Well, but do you — do you think SEGM is a hate group?

Guyatt: I don’t know what a hate group means. This is out of my territory, completely.

Singal: Okay. Everyone knows that you’ve had a long relationship with Zhenya Abbruzzese. Have you talked to her at all about the accusation that they’re a hate group?

[Excluding confusing crosstalk where, because of my bad pronunciation and audio issues, he doesn’t immediately understand who I’m talking about.]

Guyatt: Around this controversy we’ve had some email exchanges. My latest with Zhenya. . . Zhenya will never talk to me again after the latest, as you’ll see if I send them to you.

Singal: Yeah. So your view is, you think the definition of a hate group is fuzzy, and you wouldn’t go one way or another with SEGM.

Guyatt: This is outside. . . I don’t feel qualified to talk about the matter.

Singal: Yeah. Do you think anyone. . . younger scholars at McMaster have sort of received the message from folks above them that they should not research this subject? Has that happened at all?

Guyatt: The young people and my colleague who got us into this in the first place are now so traumatized by the whole scene that they want nothing to do with it. That is, they all pulled their names off. They’re all terrified. They’re all traumatized.

Singal: And isn’t it unusual — because both the systematic reviews you guys pulled your names off of, you’ve been working on them for years, and they were close to publication.

Guyatt: Well there’s only one that I know that I pulled my name off, but anyway. . .

Singal: I thought it was the. . .

[unintelligible crosstalk]

Guyatt: Anyway, that one is the only one that I consciously pulled my name off. And as I say, I was ready to go back on if my colleagues had cooperated.

[minor snip]

Singal: And what do you think of the argument that a systematic review should just lay out the state of the evidence and a paragraph explicitly saying, “This shouldn’t be used to endorse bans” just goes beyond the normal scope of a systematic review?

Guyatt: Yeah, it goes beyond the normal scope. This is beyond the normal scope. This has changed my opinion. I previously took the position: I do the work, I put it out, I do it in a high scientific quality, I make the appropriate conclusions and I put it out there. Okay, this has made me change my mind on the matter. I now see that I have an additional responsibility about how my work gets used.

Singal: I saw that this Instagram account, segm_x_mcmaster, or whatever it is, they posted some sort of jarring images of you and Romina and videos of them confronting you. Look, I’ve been through a version of that, probably not as intensely as you because I had less to lose reputationally. And you’re. . .

Guyatt: I have nothing to lose reputationally. I feel invulnerable, actually.

Singal: You do?

Guyatt: I feel completely invulnerable.

Singal: So you’re saying your decision that you have, like, a greater responsibility to change the normal scope — slightly change the normal scope — of a systematic review had nothing to do with that campaign and with like, the pressure you felt. . .

Guyatt: The only thing. . . I feel like it woke me up to something that I was foolishly not getting. The whole thing started, and it somehow hit me in a way that it hadn’t before — and it’s my limitation that it hadn’t — that my work was being terribly misused for nefarious, unconscionable purposes. It somehow shook me to realize that. And when I realized that, I said, “Man, I have a responsibility beyond just putting this stuff out.”

Singal: Couldn’t any systematic review that came to negative conclusions about the state of evidence be used by a malevolent actor?

Guyatt: Yeah, yeah, yeah, on all sorts of things. Everything you do can be. Right? So I don’t know if I’ll ever. . . I can’t think of before where there was a problem where somehow my work was misused in a nefarious and unconscionable way. Nor do perhaps I expect it to ever happen again. But — so it’s a rare situation. I’ve had my work misinterpreted and so on, so forth, a million times. But this is something different.

Singal: I guess the reason I’m interested in that question is because my work on this has largely focused on, like, the major problems with the evidence and what I see as irresponsible science in some cases. And I’ve been accused, you know — a conservative, someone making a legal argument, will cite my work, will cite an article I wrote saying that the evidence is uncertain. And my reaction has been different from yours, because I think as a journalist, I need to be able to follow the evidence where it takes me. And if I put myself in a state where, Well, what if someone misuses this, I genuinely don’t know what else to do, but to. . .

Guyatt: Your position is quite reasonable. I just told you the position that I now feel. I mean, you can argue that I’m wrong. [laughs] That’s fine. No problem.

Singal: I’m not trying to make McMaster look bad, but I do think it’s important from the point of view of the independence of your department. It sounds like you’re saying, without going into any further details, that there was pressure from elsewhere in the university to not have these systematic reviews published with your and your department’s names on them.

Guyatt: Well, the latest one, they didn’t want another one. Yes.

Singal: Okay. Okay, is there anything else you’d add about this? Because I think the tricky part is, I sort of. . . I think people need to be allowed to be skeptical of this evidence base. And my experience has been that you face really severe consequences, just for sort of accurately describing the state of the evidence. And I think some people are worried. . .

Guyatt: I personally, at least, have no — since I’m not getting intimidated, I’ve had no consequences whatsoever, as far as I’m concerned.

Singal: But you said your younger colleagues were traumatized.

Guyatt: My younger colleagues have been traumatized, absolutely.

Singal: Yeah, and I take it you don’t think they were traumatized because they did anything wrong. They were traumatized because there was a. . .

Guyatt: They were traumatized because they were put in the middle of this horrible, irrational business with crazies on both sides and powerful people doing terrible. . . legislators making terrible decisions. The incredible passion by perhaps people who are more reasonable, but particularly the crazy. . . anyway. For anybody who feels vulnerable, it’s a terrible situation.

Singal: I mean, if I was a 25-year-old at McMaster, I feel like I would stay far away from this issue.

Guyatt: That’s right. And even if you’re — as my colleague who started his office. [unintelligible] “Never again. Nothing near this. I’m not going anywhere near to this again.”

Singal: But there’s got to be a part of you — because one thing I liked about you in my initial conversations with you is you don’t. . . your whole thing was opposition to GOBSAT, like good old boys sitting around a table doing things [a certain way], and saying — again, pardon my French — sometimes saying fuck you when you need to say fuck you. It does seem like McMaster has now been bullied out of publishing its work on this subject to a certain extent.

Guyatt: That’s probably true. I’m balancing. I’m a good corporate citizen in terms of the university, right? I’m balancing things that way, if you’re asking my personal stuff with it.

Singal: But, look, three of the five reviews are already out, but my job is, in the book I’m working on, to write a history of how this controversy went down in the States. And this was an important effort that, now about halfway through, has been torpedoed and engulfed in controversy. And it just. . . I don’t know. There’s something here that I find a little bit tragic.

Guyatt: Yeah, I agree with you, and you got a good point. You make me rethink my, umm. . . you make me rethink that I may have put my loyalty to McMaster and my wanting to be in a, you know, you can imagine all the conversations that went on and so forth. And you make me think now that what I should have done is to say, “Okay, no, sorry, I’m going to. . . ” — which I, which I ultimately did [laughing], which I ultimately did when I saw the consequences — to say right from the beginning, “No, I think we should stay on this paper, and too bad if you get more flack from it. But I’m going to change the discussion. And if they won’t accept my change in discussion, then it’s not on anymore.” That’s what I should have done. That’s what I ultimately did to my. . . [laughs] But it should have been the line I took from the beginning. You’re right.

[snipping a bit]

Singal: I guess it just gets back to that question of what a systematic review is and how much sort of editorializing should be within it, and the norm is very little.

Guyatt: And I told you my position is I’m not ready. . . I need to safeguard so nothing I do beyond. . . to do what I can. It’ll be misused anyway. Of course, I know it’ll be misused anyway. However, I need to do everything I can to prevent that.

Singal: I’m trying to think, if there’s anything else I can ask you without. . . I don’t want to put you in a difficult position.

Guyatt: Well, you can put me in as many difficult positions as you want, as long as you don’t get me in trouble with other people.

Singal: Well, you just said you’re invulnerable, and I think you should be able to say out loud, if there were other. . . what’s the point of having your degree of eminence and job security. . . if I were in your position. . . let me put it this way. I co-host a middling podcast that makes a good living for me, but it’s by no means a huge deal. If anyone ever tried to tell me what I could or couldn’t talk about on the podcast, I would be very angry at them. In your situation—

Guyatt: What if your friends, to whom you owe considerable loyalty, are saying, “Oh, man, you know, if you do that, it’s going to put us in a terrible position.” And there are people you rub shoulders with and you care about and it’s not much skin off your back to accommodate them.

Singal: Gotcha. Yeah, you’re right. I would rethink that. So you’re saying it’s a situation where it’s, what happened at McMaster with these reviews is not ideal, but you just have to make certain compromises or concessions when things get hot, basically.

Guyatt: I’d put it another way. I have to make compromises and concessions, when what might be the right way [is] to operate in some independent [manner] of that . . . when it’s going to upset people I care about and with whom I work closely.

Singal: Was there any concern in terms of this donation you guys made to the group Egale Canada. . . I was just poking around on their website. I mean, they say things like puberty blockers offer quote, unquote “tremendous mental health benefits.” That blockers and hormones are “generally understood to be safe.” You’ve looked, your name is on. . .⁷

Guyatt: Okay, all right, okay, so here once again, okay? My time is limited. I have to get back to see my patients, for one thing. My time is limited. Again, I don’t have time to go and look at their website.

Singal: You just made a donation because, like, that’s the. . .

Guyatt: So I’m told by my colleagues, “Oh, it’d be nice to make a donation.” And I say, “Okay, if you guys think it’d be nice to make a donation, and since I’m basically trans-sympathetic, sure, I’ll make a donation. [laughing]

Singal: Okay, fair enough. I will. Yeah, let’s talk more in the future, maybe I’ll just run this as like, provide background and run this as a Q and A, yeah. . .

Guyatt: I enjoy talking to you.

Singal: Thank you, Gordon. I appreciate it. Good luck with your patients.

1. This is considered one of the leading resources in the world for clinical guidance, and Guyatt is an editor there.

2. Just to be clear, I was being a bit flippant here.

3. During the conference there was a fairly spirited exchange between Guyatt and Abbruzzese on — you guessed it — patient autonomy and shared decision-making. A handful of SEGM attendees asked Guyatt if he’d be willing to discuss the matter further after the conference, which apparently led to some further, also-spirited discussion involving a number of the attendees.

4. As I mentioned in Part 1, I just didn’t see anything to support this in the email. But do see my discussion of the Skrmetti amicus brief as well.

5. It could be that this is true for some trans people who were upset at HEI, but the aforementioned Instagram account was not mollified. Instead, it put out a furious statement that read in part: “Pseudo-concern statement, now published on McMaster website. The scale of their harms is global in scope; in response to demands for justice, they offer convoluted denials, lies, and anti-trans claims of commitment to ‘Inclusive Excellence’ in this *literally half*-assed charade to avoid accountability.”

6. Reminder that in addition to Guyatt, I spoke with two individuals affiliated with McMaster who said they were aware of pressure from the university, including within and outside of HEI, to persuade scholars not to work with SEGM.

7. What I was trying to get at here was that Guyatt had donated to a group disseminating claims that his own research had effectively debunked.