Clinical guidelines for children and adolescents experiencing gender dysphoria or incongruence: a systematic review of recommendations (part 2)

Abstract

BackgroundIncreasing numbers of children and adolescents experiencing gender dysphoria/incongruence are being referred to specialist gender services and there are various published guidelines outlining approaches to clinical care.AimTo examine the recommendations about the management of children and/or adolescents (age 0-18) experiencing gender dysphoria/incongruence in published guidelines or clinical guidance. A separate paper examines the quality and development of guidelines.MethodsA systematic review and narrative synthesis. Databases (Medline, Embase, CINAHL, PsycINFO, Web of Science) were searched to April 2022 and web-based searches and contact with international experts continued to December 2022, with results assessed independently by two reviewers. The Appraisal of Guidelines for Research and Evaluation tool was used to examine guideline quality.Results23 guidelines/clinical guidance publications (1998–2022) were identified (4 international, 3 regional, 16 national). Guidelines describe a similar care pathway starting with psychosocial care for prepubertal children, puberty suppressants followed by hormones for eligible adolescents and surgical interventions as these adolescents enter adulthood. In general, there is consensus that adolescents should receive a multidisciplinary assessment, although clear guidance about the purpose or approach is lacking. There are differing recommendations about when and on what basis psychological and medical interventions should be offered. There is limited guidance about what psychological care should be provided, about the management of prepubertal children or those with a non-binary gender identity, nor about pathways between specialist gender services and other providers.ConclusionsPublished guidance describes a similar care pathway; however, there is no current consensus about the purpose and process of assessment for children or adolescents with gender dysphoria/incongruence, or about when psychological or hormonal interventions should be offered and on what basis.PROSPERO registration numberCRD42021289659.

Critically Appraising the Cass Report: Methodological Flaws and Unsupported Claims

“…However, its reliability in this context may be questionable since several other systematic reviews have applied this tool to some of the same studies and arrived at quite different conclusions, with some also criticising the usefulness of AGREE-II for GAC guidelines. [22][23][24] Notably, the most restrictive guidelines were rated highest in this systematic review, without a clear justification related to how these guidelines were developed, 6,25 while guidelines for more affirmative models of care were judged to be of higher quality in other reviews than by Taylor and colleagues. [22][23][24] An adapted version of the Newcastle-Ottawa Quality Assessment Scale 26 (NOS) was used in three of the systematics instead of the MMAT 2,3,7 -a deviation from the protocol that was not explained or clearly reported.…”

“…Seven systematic reviews were commissioned by the Cass Report and published in the BMJ Archives of Disease in Childhood [2][3][4][5][6][7][8] with a single systematic review protocol registered in PROSPERO for all seven reviews 9 . To evaluate their risk of bias we applied the ROBIS tool 10 as recommended by Cochrane 11,12 .…”

Guidelines on gender related treatment flouted standards and overlooked poor evidence, finds Cass review

“…The research carried out by York University, published in the Archives of Disease in Childhood , found that the evidence on the use of puberty blockers and hormones in young people with gender related distress was wholly inadequate, making it impossible to gauge their effectiveness or their effects on mental and physical health 4567. “No conclusions can be drawn about the impact on gender dysphoria, mental and psychosocial health, or cognitive development,” the research concluded.…”

The Cass review: an opportunity to unite behind evidence informed care in gender medicine

“…That verdict is supported by a series of review papers published in Archives of Disease in Childhood , a journal published by BMJ and the Royal College of Paediatrics and Child Health (doi:10.1136/archdischild-2023-326669 doi:10.1136/archdischild-2023-326670 doi:10.1136/archdischild-2023-326499 doi:10.1136/archdischild-2023-326500). 3456 The evidence base for interventions in gender medicine is threadbare, whichever research question you wish to consider—from social transition to hormone treatment.…”