Gender Medicine’s Citation Cartel

Through circular referencing, authoritative medical bodies misled the public by manufacturing a consensus on ‘gender-affirming care.’

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A Note from the Editor

Citation cartels represent a growing concern in academic circles, where the integrity of scholarship is compromised by networks of researchers artificially inflating citation counts. These networks, also known as “citation rings,” strategically boost the visibility and perceived impact of specific research domains, as well as the reputations and academic metrics of those involved.

Domingo Docampo, a mathematician at the University of Vigo, has recently revealed how certain institutions, notably from regions with little historical prominence in mathematics like China and Saudi Arabia, have surged ahead in terms of producing highly cited papers. This stark rise is attributed to internal citations among papers from a small number of institutions in these countries, suggesting a concerted effort to manipulate citation counts.

The problem of citation cartels extends beyond individual disciplines and affects global academic rankings and the distribution of research funds. Universities and researchers driven by the pressure to climb international rankings or secure funding are tempted to engage in these unethical practices. The consequences are profound, misleading stakeholders about the true quality and impact of research and diverting resources from deserving scholars to those engaged in manipulative practices.

Recently, though perhaps unsurprisingly, citation manipulation has been discovered within the field of gender medicine. This was revealed in a systematic review investigating the emergence of guidelines for pediatric sex trait modification procedures, euphemistically known as “gender-affirming care.” In fields like medicine, where the stakes are high, the presence of citation cartels is particularly alarming, because boosting flawed research on the supposed benefits of body modifying and often sterilizing hormones and surgeries produces real-world harm.

Below, journalist Christina Buttons (who, for full disclosure, I am in a relationship with) dives deeper into the newly discovered citation cartel in gender medicine, providing her own analysis.

Sincerely,

Colin Wright
Founding Editor, Reality’s Last Stand

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About the Author

Christina Buttons is an independent journalist with a forthcoming report on the connection between autism and gender dysphoria, as well as a detransition survey awaiting publication. She is developing a website that will feature the latest data, studies, and fact-checks that will debunk activist arguments related to gender medicine. If you would like to support her work, please consider a paid subscription to her Substack or making a donation.

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A new systematic review of international clinical guidelines for children and adolescents with gender dysphoria has exposed deceptive practices by respected medical authorities who recommend medical transitions for minors. These guidelines are often cited as uncontroversial and scientifically robust. However, the review reveals that these organizations have misled the public by basing their recommendations on insufficient evidence and inaccurately labeling their approach as “evidence-based.” Furthermore, they have engaged in a corrupt practice known as “circular referencing.” Instead of conducting independent evaluations, they have relied on endorsements of sex-trait modification for minors from other medical bodies, artificially creating a consensus on the issue.

Commissioned by NHS England and chaired by Dr. Hilary Cass, the University of York’s research team evaluated 23 international guidelines using the Appraisal of Guidelines for Research and Evaluation tool to assess their quality. The study specifically examined how evidence informed recommendations, the development and agreement processes for these recommendations, the stakeholders involved, and how the guidelines referenced each other during their development.

Insufficient Evidence

The findings of the review were deeply concerning. It concluded that clinical guidelines globally used to treat gender-questioning children and adolescents were crafted in violation of international standards for guideline development. These guidelines recommended medical interventions for minors despite insufficient evidence, particularly regarding long-term treatment outcomes in adolescents. Additionally, they relied on other guidelines that recommended medical treatments as the basis for making similar recommendations.

Circular Referencing

The Endocrine Society (ES) and the World Professional Association for Transgender Health (WPATH) published initial guidelines recommending youth medical transition in 2009 and 2012, respectively. These guidelines became foundational for many subsequent guidelines, shaping their content and recommendations despite the lack of evidence and rigor. In the Cass Review, Dr. Hilary Cass highlighted the ways in which WPATH and ES were closely interlinked, noting their mutual co-sponsorship and input into each other’s drafts. This coordinated effort suggests that WPATH and ES were colluding to grant undue credibility to their guidelines.

The corruption persisted in the formulation of national and regional guidelines by prominent organizations such as the American Psychological Association, the American Academy of Child and Adolescent Psychiatry, the American Academy of Pediatrics, and the Society for Adolescent Health and Medicine. It also extended to international guidelines from countries like Australia, Spain, Italy, and regions including Asia and the Pacific. Rather than grounding their recommendations in robust evidence, these guidelines deferred to the endorsements from the initial guidelines of WPATH and ES.

Years later, when WPATH and ES updated their guidelines, they referenced the same national and regional guidelines that had initially drawn from their recommendations. This perpetuated a cycle in which each iteration reinforced the others, each time without sufficient evidence to support the recommendations. Dr. Cass highlighted the problematic nature of this circular referencing, stating, “The circularity of this approach may explain why there has been an apparent consensus on key areas of practice despite the evidence being poor.”

Figure 3 from Taylor J, Hall R, Heathcote C, et al. (2024)

Part 1 of the systematic review includes Figure 3, pictured above, which illustrates the various ways in which guidelines reference or influence each other. It shows how guidelines draw on the initial Endocrine Society (2009) and WPATH (2012) guidelines, which have influenced nearly all the national and regional guidelines identified. Additionally, it demonstrates how these subsequent guidelines cite and rely on each other, and how the latest Endocrine Society (2017) and WPATH (2022) guidelines have cited and drawn on the national and regional guidelines.

The systematic review highlights an example of this circular referencing: WPATH Version 8, published in 2022, identifies numerous national and regional guidelines published as early as 2012 as potentially valuable resources. It cites guidelines from the APA (2015), Australia (2018), New Zealand (2018), and University California, San Francisco (2016) multiple times to support their recommendations. Importantly, all of these guidelines were themselves significantly influenced by WPATH Version 7 (2012).

Broader Context

In the research world, such circular referencing is sometimes referred to as a citation cartel. This occurs when a group of academic authors collude to excessively cite each other's publications to artificially inflate their citation counts. However, what has occurred here differs slightly; their aim wasn’t to boost citation counts, but rather to enhance their own credibility through mutual referencing in the eyes of the public and other medical professionals. Nonetheless, this practice is highly unethical. By engaging in circular referencing, these medical bodies have actively deceived healthcare professionals and the public, leading them to believe in the validity and reliability of recommendations founded on weak evidence. 

Unfortunately, much of the transgender rights movement has advanced through an approach that heavily relies on appeals to authority. Organizations that once focused on Gay and Civil Rights, now pivoting to champion transgender rights, are deferred to as authoritative bodies by news outlets, schools, teachers' unions, and even the Biden administration, which seeks their guidance on transgender issues. Within academia, idea laundering has bestowed Queer Theory and Gender Theory, foundational to modern gender ideology, with the illusion of legitimacy.

Moreover, significant changes in federal regulations under Title IX, granting biological males (who identify as women) access to female-only spaces and sport categories, have occurred through a process known as institutional leapfrogging. In this process, judges and administrators take incremental steps, each citing the authority of the other, ultimately leading to the expansion of federal mandates.

Not Evidence-Based

WPATH, whose stated mission is to “promote evidence-based care,” and ES, who refers to their approach as “evidence-based transgender medicine,” along with any organization advocating for medical transition for minors, are misleading the public by portraying themselves as being “evidence-based.”

In an investigative report for the British Medical Journal (BMJ), Dr. Gordon Guyatt, a highly respected figure in the field of medical research methods and evidence evaluation, and who pioneered the evidence-based medicine (EBM) movement, stated that the current guidelines in the United States for managing gender dysphoria in adolescents should not be considered evidence-based. He emphasized that these guidelines fail to offer cautious and conditional recommendations appropriate for such low-quality evidence. Guyatt further underscored his concerns in a social media post, labeling these guidelines as "untrustworthy."

Similarly, the systematic review team arrived at the same conclusion: 

Most clinical guidance lacks an evidence-based approach and provides limited information about how recommendations were developed. The WPATH and Endocrine Society international guidelines, which like other guidance lack developmental rigour and transparency have, until recently, dominated the development of other guidelines. Healthcare professionals should consider the lack of quality and independence of available guidance when utilising this for practice.

In the end, the team was only able to recommend two guidelines for practice: the Finnish guideline published in 2020, and the Swedish guideline published in 2022. Both guidelines conducted their own systematic evidence reviews, concluding that the risks of medical transition outweigh any purported benefits. As a result, they do not recommend medical transition treatments for minors but instead prioritize mental health support.

WPATH, ES, and any medical authority that misrepresents guidelines recommending medical transition for minors as “evidence-based” betray public trust and fail those seeking reliable guidance. Healthcare professionals and regulatory bodies must hold guideline developers accountable for these deceptive practices and ensure transparency in the basis of future recommendations.

The National Health Service England issued a statement in response to the Cass Report and new systematic reviews, asserting that their findings "will not only shape the future of healthcare in this country for children and young people experiencing gender distress but will also be of major international importance and significance."

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Christina Buttons is an independent journalist with a forthcoming report on the connection between autism and gender dysphoria, as well as a detransition survey awaiting publication. She is developing a website that will feature the latest data, studies, and fact-checks that will debunk activist arguments related to gender medicine. If you would like to support her work, please consider a paid subscription to her Substack or making a donation.

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