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Cass Report

d4m10n

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d4m10n
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Much sturm, drang, & buzz around the final Cass report these days, but I'd like to focus solely on the scientifically answerable questions raised therein or thereby, since the answers to those questions ought to inform medical best practices outside of the UK.

Here is a brief summary of what the report is about:
The report describes what is known about the young people who are seeking NHS support around their gender identity and sets out the recommended clinical approach to care and support they should expect, the interventions that should be available, and how services should be organised across the country.

It also makes recommendations on the quality improvement and research infrastructure required to ensure that the evidence base underpinning care is strengthened.

In making her recommendations, Dr Cass has had to rely on the currently available evidence and think about how the NHS can respond safely, effectively, and compassionately, leaving some issues for wider societal debate.​

There is a reasonably detailed summary at SEGM and a breakdown of common myths at Quack-o-Meter.

In skeptic circles, there has been some discussion over the inclusion criteria for the systematic review:

https://twitter.com/OffTaupe/status/1779878838140383539

Still looking for a detailed critique which focuses on the science and does not repeat the lie about rejecting double-blind studies (none were rejected, none were considered, none were performed).
 
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And just to get a couple of other lies out of the way early (because I know a lot of people will not look at the links).

The systematic reviews did not reject 98% or 90+% of studies for being low quality. For puberty blockers, 26 out of 50 studies were retained for the systematic review of puberty blockers and for cross-sex hormones, 34 out of 53 were retained.

The quality ratings for quantitative studies were done using a scale that awards points for different features of the study design. On each criterion a study can be awarded 0, .5 or 1 point. The points are then totalled and standard, pre-determined numerical cut-off points used to determined the quality rating.

The quality ratings were done by researchers at the University of York and the systematic reviews published in the British Medical Journal. The appendices provide full details of the studies and the points awarded for each one. They can be accessed on this here: Gender Identity Service Series

Cass did not 'retain studies because she liked the conclusions'. The quality ratings were done as above and studies receiving a low quality rating were rejected. The single study on puberty blockers that received a high rating was one where the authors supported the availability of puberty blockers.

Given the difficulties evaluating research in this area, I am also interested in hearing any criticisms of the report that are evidence-based.
 
I have not read it but I've heard some reporting on it. I understand that the real take away is that the research on youth transition is generally pretty poor and inconclusive?

The thing about supposedly rejecting double blind studies, how exactly do you do a legit double-blind study? From what I gather, the effects of puberty blockers and hormones are pretty obvious pretty quickly.
 
ahhell said:
I have not read it but I've heard some reporting on it. I understand that the real take away is that the research on youth transition is generally pretty poor and inconclusive?

The thing about supposedly rejecting double blind studies, how exactly do you do a legit double-blind study? From what I gather, the effects of puberty blockers and hormones are pretty obvious pretty quickly.
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They did not reject any studies for not being double-blinded. That is a lie being circulated by people attempting to discredit the report.

Here is a copy of the scale used to rate the studies from the supplementary materials in the appendix.

My summary above was slightly oversimplified as only cohort studies could get a total score of 8. The other two types of research design could get a maximum score of 7 since one of the eight criteria did not apply in each case.


Cohort studies – total score = 8
Pre-post single group studies – total score = 7 (Q2 not relevant)
Cross-sectional studies with comparators – total score = 7 (Q7 not relevant)

The cut-off points were less than or equal to 50% for low quality, 50% to 75% for moderate quality and > 75% for high quality. The highest rated study was a cross-sectional one with a rating of 5.5 out of 7. Studies with a low quality rating were discarded from the final report.
 
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Reading through more of the background literature for the Cass Review, I noticed this includes a systematic literature review of current guidelines for treatment of children and adolescence with gender dysphoria/incongruence.

This reviewed 23 clinical guidelines published between 1998 and 2022. The report concluded that few guidelines were based on systematic reviews of evidence and most lacked transparency in how evidence was linked to recommendations. In addition, although many reviews were published recently, most linked back to two sets of guidelines published by the World Professional Association for Transgender Health and Endocrine Society, meaning they were not based on independent assessment of evidence. WPATH ignored some findings of their own systematic review in developing clinical guidelines. The review found "Most clinical guidance for managing children/adolescents experiencing gender dysphoria/incongruence lacks an independent and evidence-based approach and information about how recommendations were developed."

The tendency of guidelines to cross-reference each other was suggested as a reason for why "there has until recently been an apparent consensus on key areas of practice for which evidence remains lacking" (p7). This is an important point because the illusion of consensus has been and is still used as a reason to dismiss criticisms of the gender-affirmation approach. Currently the Cass review is being criticised for not agreeing with internationally established guidelines, ignoring the fact that the review found these guidelines not to be evidence based.

The review ranked all guidelines for quality on several criteria and concluded that only two scored sufficiently to be recommended for clinical practice. These were recent Swedish and Finnish guidelines both of which recommend scaling back on medical transition for minors due to lack of evidence.

Guidelines which received very low quality ratings include the 2018 AAP guideline. This is no surprise to some of us as it has previously been discussed in more than one thread and it was noted that none of its citations actually support the claims.
 
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In the early years of The Lancet there was no evidence based medicine, no controlled experiments, no statistically significant results, only doctors talking to each other about what they tried in individual cases. These guidelines feel something like a throwback to that era.
 
d4m10n said:
In the early years of The Lancet there was no evidence based medicine, no controlled experiments, no statistically significant results, only doctors talking to each other about what they tried in individual cases. These guidelines feel something like a throwback to that era.
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I think it's a little different because organisations have claimed that there is evidence, and there is indeed a body of peer-reviewed evidence but it is mostly of low quality, not allowing any strong conclusions, and is misrepresented in clinical guidelines and by clinicians (not to mention activists and media).
 
I wonder if it wouldn't have been better, if they'd just said up front that there wasn't yet a lot of good research data, and that they were working from case studies.
 
BBC: More or Less has a short episode (12 minutes) looking at the 98% claim. They speak to Cass.

They also have an interesting definition of trans identity (or "gender incongruence") that I have not heard: someone whose "experienced gender" differs from their "registered sex".

Cass review found that children and young people had been let down by "remarkably poor evidence".

It sounds like many (about 40%) of the studies were garbage, that only 2% were of "high quality" and the rest were of "medium quality".

https://podcasts.apple.com/gb/podca...ad-about-a-review/id267300884?i=1000652995863
 
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theprestige said:
I wonder if it wouldn't have been better, if they'd just said up front that there wasn't yet a lot of good research data, and that they were working from case studies.
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I don't think it's entirely accurate to say that they were working on case studies either, because the main take home message is lack of any attempt to collect systematic long-term follow-up data either for benefits or side-effects.
 
angrysoba said:
It seems like a good subject for an episode of The Studies Show, and indeed, they have just brought one out on the Cass Report.
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I went ahead and donated for a month, it's a good listen. Nothing new to those of us who've been following along since the interim report but still a pretty good summary of the dismal state of the evidence base undergirding paediatric gender medicine.
 
Darat said:
They do offer a 7 day free trial.
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Thanks. I was thinking of doing the trial when I get time and then maybe binging what other paywalled content they have which is not much at the moment, but….

d4m10n said:
I went ahead and donated for a month, it's a good listen. Nothing new to those of us who've been following along since the interim report but still a pretty good summary of the dismal state of the evidence base undergirding paediatric gender medicine.
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… this is probably the nicer option. I like both of the hosts and wouldn’t mind paying them for a bit, and might even be able to get my university to pay on my research budget given that their whole show is about what constitutes good and bad studies and an entertaining discussion about that would be useful for my own research, so it’s a legitimate expense.
 
d4m10n said:
I went ahead and donated for a month, it's a good listen. Nothing new to those of us who've been following along since the interim report but still a pretty good summary of the dismal state of the evidence base undergirding paediatric gender medicine.
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This is why I'm a transphobe, the evidence is bad. It may well be a good idea to transition kids early, even with hormones, surgeries, etc but we really don't have the evidence yet and until we do, we are experimenting on children, we should be careful about that. As far as I can tell, the science isn't settled, and I have more choices than a living daughter/son and a dead
son/daughter.

Elaedith said:
They did not reject any studies for not being double-blinded. That is a lie being circulated by people attempting to discredit the report.

Here is a copy of the scale used to rate the studies from the supplementary materials in the appendix.

My summary above was slightly oversimplified as only cohort studies could get a total score of 8. The other two types of research design could get a maximum score of 7 since one of the eight criteria did not apply in each case.


Cohort studies – total score = 8
Pre-post single group studies – total score = 7 (Q2 not relevant)
Cross-sectional studies with comparators – total score = 7 (Q7 not relevant)

The cut-off points were less than or equal to 50% for low quality, 50% to 75% for moderate quality and > 75% for high quality. The highest rated study was a cross-sectional one with a rating of 5.5 out of 7. Studies with a low quality rating were discarded from the final report.
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Just to circle back here. The point I was trying to make is, I don't see how it's even possible to do a double-blind trial in youth transitions, so I think the claim that they were thrown out is BS on its face. Fairly surprising to me that anyone believes it and a lot of folks spreading that rumor are knowingly lying about it.
 
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ahhell said:
Just to circle back here. The point I was trying to make is, I don't see how it's even possible to do a double-blind trial in youth transitions, so I think the claim that they were thrown out is BS on its face. Fairly surprising to me that anyone believes it and a lot of folks spreading that rumor are knowingly lying about it.
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I agree they are either knowingly lying or indifferent to the truth of the claim.

As discussed in the podcast, there is an open letter from academics condemning the Cass Review. It contains the statement "It does not include a proper systematic literature review since it disregards most research evidence because it fails to reach the impossibly high bar of a double-blind trial. " This is demonstrably false, and unless these letter writers are living in a bubble totally insulated from all contrary opinion and evidence (which I suppose is possible), they cannot still believe this is true.

The statement 'It disregards the wealth of expertise at national and international levels on best practice guidelines to support young trans people.' is also stupid, because these clinical guidelines were systematically analysed as part of the review and almost all were found to be in violation of agreed standards, not evidence based, and to create an illusion of false consensus by cross-referencing each other. So to say these guidelines should be favoured is to say these practices are acceptable and should be preferred over evidence-based guidelines.
 
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