Federal Judge DESTROYS “Low Quality” Evidence Claims
When the evidence favoring a treatment is weakly positive and the evidence against the treatment is nonexistent, an evidence-based approach will favor the treatment.
Opinion, by Evan Urquhart
Bad news to Dr. Hilary Cass, SEGM, and just about every sealion who has interacted with the Assigned Media social accounts in the last 9 months or more: A Federal judge saw through your GRADE system/low quality evidence baloney. In his decision ruling that Florida’s ban on gender-affirming care for youth (and many of the restrictions on such care for adults) was unconstitutional, Judge Robert Hinkle of the Northern District of Florida addressed a talking point that has become omnipresent in discussions of gender-affirming care for minors, the idea that the evidence base for such treatment is “low quality” based on rankings in something called the GRADE system.
The GRADE system (an acronym for Grading of Recommendations, Assessment, Development, and Evaluation) is one common method of systematically evaluating research as to the efficacy and safety of a given treatment. GRADE ranks the methodology of relevant studies, with double-blind, randomly controlled trials at the top and case reports at the bottom. This can be very useful for evaluating competing treatments, as a treatment with a lot of highly ranked evidence could be said to have more support in the research than one that has a small amount of lower ranked evidence.
A number of systematic reviews have been undertaken that have scored the evidence for gender-affirming care for youth as “low quality” according to the GRADE system. Opponents of gender-affirming care made the argument that, because these reviews found the evidence to be low quality, Florida was right to ban it.
Judge Hinkle, ruling on a challenge to Florida’s anti-trans laws and regulations in Doe et al. vs Ladapo et al., wasn’t having it. He pointed out that, while the evidence favorable to gender affirming care is considered by some to be low quality, the evidence against this care is nonexistent.
This is, of course, just common sense, and can be demonstrated any number of ways. For example, while two is a low number, it is much higher than zero. Or, while ten percent could be considered a relatively low chance of success, if offered a ten percent chance at $1000 or one in a million chance at $1000, a person would have to actively hate money to prefer the smaller chance of success over the greater one.
And so it is with gender-affirming care. Experts disagree on whether the evidence for treatments such as puberty blockers and hormone therapy really are “low quality.” Many people have suggested that the systematic reviews that found this were politically biased, and there are other reviews in the works that may well come to a different finding. But, you don’t have to know whether the charges of bias are right or wrong, whether the systematic reviews that concluded the evidence quality was low were shady or completely legitimate. All you have to do is ask yourself: If you were struck by a condition and your only options were a treatment with low quality evidence or nothing, would you choose to remain ill rather than taking your chances with the treatment that had some evidence?
The obvious answer, the rational answer, and the only evidence-based answer is to go for something rather than nothing. Judge Hinkle saw that, as can anyone. The only thing that remains is to ponder why, precisely, has this talking point about low quality evidence been dominating the conversation?
Evan Urquhart is the founder of Assigned Media and an incoming member of the 2024-2025 Knight Science Journalism fellowship class at MIT.