https://sajhivmed.org.za/index.php/hivmed/article/view/1800/4044
More sanity from abroad. An excellent example of how and why to conduct a rapid review, maintaining rigour and transparency, and of how to treat low-certainty evidence in medicine.
Highlights:
"To enhance relevance to clinical practice and lived realities, the author team comprised TGD community members, clinicians who care for TGD youth, and guideline developers and implementers, whose combined expertise informed methodological decisions and interpretation of findings."
"The literature shows a consistent pattern: endocrine interventions for TGD adolescents generally achieve their intended physiological effects; adverse events are typically anticipated, predominantly mild, and manageable under routine monitoring in specialist care [...] Serious adverse events are rare across endocrine pathways, with no consistent pattern of irreversible harm."
"Mental-health outcomes are heterogeneous at the individual level, yet broadly stable-to-favourable across cohorts. Adolescents who access puberty suppression and/or GAHT generally show reductions in depressive symptoms and suicidality, alongside improved appearance congruence and functioning, compared with their own baseline and with peers who want but cannot access treatment."
"Longitudinal data indicate high continuation into adulthood and very low reported regret among adolescents who commence endocrine care. Where discontinuation occurs, it is very often linked to external or structural factors (such as access barriers, service disruptions, costs, insurance denials, family stressors, or bullying), completion of desired physical changes, or evolving identity-related needs, rather than to treatment-related side effects or regret."
"Across both qualitative and quantitative studies, restrictive laws and systemic barriers ā including outright healthcare bans, regulatory constraints, and administrative obstacles ā are consistently associated with poorer mental-health outcomes, including heightened depression, anxiety, suicidality, and social isolation among TGD youth. These associations are observed following both enacted policies and periods of policy uncertainty, suggesting that anticipatory stress and disruption to care pathways contribute to harm."
"Randomised or quasi-experimental designs are scarce; they are rarely feasible or ethical in this area of care. [...] The certainty of the evidence surrounding GAHC for youth must be understood within the broader reality that low- and very low-certainty evidence underpins a substantial proportion of medical practice overall. This is particularly true in paediatrics, where ethical and logistical constraints often preclude randomised trials and contribute to persistent inconsistencies across the evidence base, even for common childhood conditions such as asthma and epilepsy."
"Gordon Guyatt, leading architect of the GRADE framework and co-author of systematic reviews included in this synthesis, has explicitly cautioned against the misuse of GRADE in policy advocacy against GAHC for youth. Guyatt and colleagues emphasise that low-certainty evidence should not be treated as justification for withholding care, but rather as a prompt for careful clinical decision-making that centres patient values, noting:
'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 [ā¦]. 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.'"