Kevin M. Korous: A ‘systematic review’ has nothing to do with transgender youth in Utah

Study ordered by SB 16 won’t answer the Legislature’s questions.

(Trent Nelson | The Salt Lake Tribune) People gather at a rally in support of transgender youth at the Capitol building in Salt Lake City on Tuesday, Jan. 24, 2023.

SB16 has passed the Utah Legislature and been signed into law by Gov. Spencer Cox. It places a moratorium, or pause, on surgical procedures related to sex characteristics and hormonal transgender treatment for Utah youth under the age of 18.

The purpose of this moratorium is to conduct a systematic review of the medical evidence to inform the Legislature of the short- and long-term benefits and risks of hormonal transgender treatments for minors. A systematic review is a structured, comprehensive search and summary of the existing evidence. While a systematic review of medical research can be a powerful tool, it will — by itself — fall short of adequately addressing the concerns of the Legislature.

A systematic review cannot objectively conclude if the risks associated with hormonal transgender treatment among minors outweigh the benefits compared to being denied these medical services.

Systematic reviews often rely on qualitative summaries of the evidence. As a result, conclusions can be subjective, and they frequently rely on tallying the number of findings that are deemed statistically significant. Inevitably, a question will be raised as to how many studies are needed to conclusively support either benefits or risks of receiving hormonal transgender during adolescence relative to the other.

Instead, I encourage Utah legislators to strongly consider the individual differences between transgender youth.

One purpose of the proposed systematic review is to specify under which conditions hormonal transgender treatments should be permitted. Systematic reviews can approach this by identifying factors that account for the variability within outcomes (e.g., differences by age of initiation, differences by country). However, a systematic review is limited in its methodological scope for explaining variability in short- and long-term outcomes.

Even quantitative summaries fall short of fully unpacking these individual differences. Despite the advantage of systematic reviews in synthesizing evidence, the validity and reliability of the conclusions are dependent on the quality of the studies. It is concerning that Utah representatives will refer to this single systematic review for answers to make significant policy decisions for Utah youth.

Although study quality was not overlooked in the proposed systematic review, determining study quality is problematic because there are many tools to examine the methodological quality of a study, which often depend on the research design.

Currently, research synthesis experts debate how to best determine quality, such as whether some parts of the design or statistical analysis are more meaningful than others. There is also a lack of expert consensus on whether systematic reviews should include all the evidence to date or only evidence from high quality studies as this decision can make the review more reliable or more biased.

Overall, a single systematic review based on high quality studies may misrepresent the body of evidence to date.

Given these pitfalls, the request for one systematic review does not justify withholding access to medical treatments with potential life-changing implications for Utah youth. Therefore, what does one systematic review of medical evidence have to do with transgender youth in Utah?

Instead, the Legislature should consider working with medical providers to ensure that the long-term commitment and potential risks associated gender affirming care are clearly communicated to youth and their parents, just like any other medical procedure or medicine used by minors.

I applaud the senators and representatives of Utah for their concern of Utah youth, but the need for a systematic review is not sufficient for the state’s involvement in restricting access to youth’s health care. As it is, SB 16 is part study proposal, thus, the moratorium for the systematic review should have been removed because the Utah Legislature is not a consortium of research administrators.

Kevin Korous

Kevin M. Korous, raised in the Salt Lake Valley, is an alumnus of the University of Utah, has a Ph.D. in family and human development from Arizona State University and currently works as an applied statistician. He has expertise in research synthesis methodology, including systematic reviews, and has published several systematic reviews in empirical, peer-reviewed journals.