随着时间的推移,制定医学临床实践指南的过程发生了巨大变化。以前,一小组临床医生根据他们的专业知识制定了临床实践指南,但是指南制定者必须越来越多地考虑患者的专业知识,全球专业知识,和循证医学的原则。本文分析了世界跨性别健康专业协会在创建其“跨性别和性别人群健康护理标准”的过程中如何与各种形式的专业知识和循证医学进行斗争,版本8“(此后,SOC-8),一套著名的跨性别医学临床实践指南。分析基于对临床医生的83次访谈,病人,和2019年至2021年期间美国和泰国的活动人士,以及对跨性别健康会议的观察和书面材料的内容分析。我发现,尽管在这个版本的指南中加入更多不同的专业知识是表面上的目标,SOC-8最终再现了科学和医学领域的传统知识层级,在这些层级中,跨性别者和性别不符合患者的非专业知识以及来自全球南方的专业知识仍然被边缘化.我将这种重新边缘化归因于SOC-8修订过程中制定的监管客观性,将专业知识重新合法化,没有建立确保全球南方利益攸关方平等参与的正式基础设施,并允许有限地纳入具有相对较高特权水平的跨性别者和性别不符合者的外行专业知识(根据种族,教育,和其他社会地位)。这些发现对未来科学和医学知识层次的研究以及临床实践指南的制定具有重要意义。
The process for developing clinical practice
guidelines in medicine has changed dramatically over time. Previously, small groups of clinicians crafted clinical practice
guidelines based on their professional expertise, but
guideline developers must increasingly consider patients\' lay expertise,
global expertise, and principles of evidence-based medicine. This article analyzes how the World Professional Association for Transgender Health grappled with diverse forms of expertise and evidence-based medicine in the process of creating its \"Standards of Care for the Health of Transgender and Gender Diverse People, Version 8\" (hereafter, SOC-8), a prominent set of clinical practice guidelines in transgender medicine. Analysis is based on 83 interviews with clinicians, patients, and activists in the U.S. and Thailand between 2019 and 2021, as well as observation of transgender health conferences and content analysis of written materials. I find that despite the ostensible goal of incorporating more diverse expertise in this version of the guidelines, the SOC-8 ultimately reproduced traditional knowledge hierarchies in science and medicine in which the lay expertise of transgender and gender non-conforming patients and expertise from the
Global South remain marginalized. I attribute this re-marginalization to the regulatory objectivity enacted in the SOC-8 revision process, which re-legitimized professional expertise, established no formal infrastructure for ensuring the equal participation of
Global South stakeholders, and permitted limited inclusion of lay expertise from transgender and gender non-conforming people with relatively high levels of privilege (according to race, education, and other social statuses). These findings have implications for future research on knowledge hierarchies in science and medicine and the creation of clinical practice guidelines.