The Schwartz and colleagues review, recently published in Discover Mental Health, purports to offer an update on concerns regarding the safety of estrogen therapy for gender dysphoria.  This “review” consistently misrepresents and selectively cites the literature and, as such, does not merit publication. 

This paper presents long-known risks associated with specific formulations of estrogen as “emerging” to generate fear and uncertainty about a medication that has been prescribed for decades. This “review” is riddled with factual errors, shows a lack of even a cursory understanding of the literature with which it engages, and, when it supports the authors’ beliefs, prioritizes literature that is not experimental or peer-reviewed over rigorous, peer-reviewed experimental studies. The authors repeatedly misreport or misrepresent the stated conclusions of multiple research studies. The authors of this review demonstrate only a lay understanding of the methods employed in much of the literature they review, simply summarizing findings, often incorrectly, and failing to engage critically with the strengths and limitations of the methods employed. The authors selectively cite partial quotations from the literature, giving the impression that experts in the field are unwilling to consider the risks associated with estrogen use. These risks are discussed when the quotes are read in context and are well-documented in the World Professional Association for Transgender Healthcare Standards of Care 8. 

A detailed, line-by-line critique of this paper can be found here. The major scientific flaws with this paper can readily be attributed to the biases of its authors. None of the authors appear to have expertise in transgender healthcare, endocrinology, or relevant research methodology. The last author appears to be a journalist with no medical training. None of the authors of this paper list academic or institutional affiliations, and four of five list affiliations with organizations designated as anti-transgender hate groups by the Southern Poverty Law Center. Two authors also do not list their full names. Each of these confounds would be problematic in an ordinary review, but together, in a review that only selectively cites articles clearly pushing a narrative, would raise serious concerns in any scientific journal. This “review” equates to politically motivated misinformation generated by political extremists whose explicitly stated affiliations are anti-transgender hate groups. 

To understand the potential benefits and harms associated with any medical intervention, we need to examine the literature critically and rely on the experience and expertise of clinicians, researchers, and patients. In drawing our conclusions, we must evaluate the scientific rigor of each study – its strengths and limitations – to determine what can and cannot be concluded from the literature overall. In a context as complex as providing clinical guidelines and/or evaluating the safety of a medical intervention, we must consider multiple research approaches to generate a cohesive understanding. This scientific approach means we integrate findings from qualitative, animal, cohort, and observational studies, as well as randomized control trials, where applicable. This process is necessarily iterative and requires continual updating as new evidence emerges from the peer-reviewed literature and from clinical experience.

Misinformation is harmful. The authors of this “review” have stated publicly that advocates for gender affirming healthcare access for those who require it are “anti-science” and unwilling to consider other perspectives. We are eager to consider all perspectives that derive from expertise and rigorous engagement with the scientific literature. Unfortunately, this profoundly unserious paper lacks the scientific rigor expected of a peer-reviewed publication. We cannot be complicit in the spread of misinformation. Furthermore, by platforming individuals with hate group affiliations, the editors of Discover Mental Health have lent legitimacy to beliefs that are biased and bigoted and have no place in the legitimate peer-reviewed literature. It is understood and has been made clear to the editor in chief that such a ‘review’ is primarily used to provide unscientific arguments in legal cases, not for the welfare of people requiring such treatments. To protect the integrity of the scientific record and uphold the standards of peer-reviewed publishing, we demand the immediate retraction of this paper