Cass Report

[Elaedith]

Puberty blockers a 'safe, effective and reversible' form of gender-affirming care, finds review triggered by Westmead Hospital investigation



https://www.abc.net.au/news/2024-09...afe-effective-and-reversible-review/104322428

I saw something about this yesterday and had a quick look at the actual report, although I haven't had time to read it in depth yet. From what I have seen I don't think it is based on any independent peer-reviewed evidence reviews as the Cass report was (although I need to check this), but is an evidence update (summarising research findings published since the last evidence check). I could find very little about the methodology used (unlike the systematic reviews conducted for Cass which published full details of how studies were graded for quality) but I might find some more information when I get time to look more closely. Just from what I have seen, it acknowledges similar problems with evidence quality, but stays with the conclusions of the previous evidence check because it claims that nothing published since then changes these conclusions.

I want to check if the Cass review was published in between this evidence check and the previous one they refer to, and if so whether the systematic reviews conducted for this were included. I saw somebody tweet that the Cass research was not included, but that this doesn't matter because it was a review of primary evidence only. I am not sure this is correct though, because I remember seeing that they did include systematic reviews in their evidence search.

 

[Planigale]

I saw something about this yesterday and had a quick look at the actual report, although I haven't had time to read it in depth yet. From what I have seen I don't think it is based on any independent peer-reviewed evidence reviews as the Cass report was (although I need to check this), but is an evidence update (summarising research findings published since the last evidence check). I could find very little about the methodology used (unlike the systematic reviews conducted for Cass which published full details of how studies were graded for quality) but I might find some more information when I get time to look more closely. Just from what I have seen, it acknowledges similar problems with evidence quality, but stays with the conclusions of the previous evidence check because it claims that nothing published since then changes these conclusions.

I want to check if the Cass review was published in between this evidence check and the previous one they refer to, and if so whether the systematic reviews conducted for this were included. I saw somebody tweet that the Cass research was not included, but that this doesn't matter because it was a review of primary evidence only. I am not sure this is correct though, because I remember seeing that they did include systematic reviews in their evidence search.

They do not mention or reference Cass.

 

[lionking]

They do not mention or reference Cass.

You can bet on the funding organisation (or the NSW Health Department) prohibiting this so as not be branded transphobe.

 

[cookpassbabtridge]

Puberty blockers a 'safe, effective and reversible' form of gender-affirming care, finds review triggered by Westmead Hospital investigation

That report was actually published in February and the evidence cuts off in September 2023, so didn't account for Cass.

 

[d4m10n]

That report was actually published in February and the evidence cuts off in September 2023, so didn't account for Cass.

Fair enough, but I'd argue that both reports are trying to evaluate some of the same questions and (AFIACT) coming to rather different conclusions. My impression is that both reports acknowledge shortcomings in the evidence base but where the NHS report urges increased caution the NSW report favors the status quo, that is, continued care under a gender affirmative model.

 

[theprestige]

Whistleblowers say Cass Report omitted spike in trans youth suicides.

https://www.erininthemorning.com/p/trans-youth-suicides-covered-up-by

This is a lie and Erin in the Morning is a liar.

Cass reported on reviews of published science.

These alleged whistleblowers allege that the NHS is blocking research and publication of suicide rates correlated with lack of trans-affirming treatment.

Cass obviously cannot report on science that hasn't been reviewed. The reviewers at University of York obviously cannot review science that hasn't been published.

EITM is very obviously trying to spin this alleged shortcoming of the NHS into a false impression that Cass omitted important research from her report. And you're either falling for her scam, or else you're complicit in that scam.

 

[Elaedith]

This is a lie and Erin in the Morning is a liar.

Cass reported on reviews of published science.

These alleged whistleblowers allege that the NHS is blocking research and publication of suicide rates correlated with lack of trans-affirming treatment.

Cass obviously cannot report on science that hasn't been reviewed. The reviewers at University of York obviously cannot review science that hasn't been published.

EITM is very obviously trying to spin this alleged shortcoming of the NHS into a false impression that Cass omitted important research from her report. And you're either falling for her scam, or else you're complicit in that scam.

There was no spike in suicides anyway.

 

[Elaedith]

That report was actually published in February and the evidence cuts off in September 2023, so didn't account for Cass.

Thanks for that, I was having trouble finding the full report again but have located it now.
Since this was published in February, I'm not clear why this is suddenly in the media now, leading to people claiming that it 'refutes Cass'. More misinformation?

Here is the link to the full report.

 

[Elaedith]

Fair enough, but I'd argue that both reports are trying to evaluate some of the same questions and (AFIACT) coming to rather different conclusions. My impression is that both reports acknowledge shortcomings in the evidence base but where the NHS report urges increased caution the NSW report favors the status quo, that is, continued care under a gender affirmative model.

This is largely my impression, and this is also the case even with WPATH where their review (the one that was not suppressed) found weak evidence but they concluded in favour of the treatment anyway.
This is also an update to an evidence check using a different approach from the Cass review which was a four-year study underpinned by independent peer-reviewed systematic evidence reviews.

I can see some spin when interpreting evidence within the Sax report. On page they state next to the 'puberty suppression' section 'The review undertaken by the National Institute for Health and Care Excellence (NICE) (2020)24 reported that GnRHa had positive effects on psychosocial functioning and may reduce depression' (p9).

What NICE actually said in relation to puberty suppression was "A key limitation to identifying the effectiveness and safety of GnRH analogues for children and adolescents with gender dysphoria is the lack of reliable comparative studies." (p12)
"The studies included in this evidence review are all small, uncontrolled observational studies, which are subject to bias and confounding, and all the results are of very low certainty using modified GRADE. They all reported physical and mental health comorbidities and concomitant treatments very poorly......Many of the studies did not report statistical significance or confidence intervals. .....The results of the studies that reported impact on the critical outcomes of gender dysphoria and mental health (depression, anger and anxiety), and the important outcomes of body image and psychosocial impact (global and psychosocial functioning), in children and adolescents with gender dysphoria are of very low certainty using modified GRADE. They suggest little change with GnRH analogues from baseline to follow-up. Studies that found differences in outcomes could represent changes that are either of questionable clinical value, or the studies themselves are not reliable and changes could be due to confounding, bias or chance " (p13)

Summarising that as finding positive effects sounds like a somewhat creative spin.

 

[Orphia Nay]

This is a lie and Erin in the Morning is a liar.

Cass reported on reviews of published science.

These alleged whistleblowers allege that the NHS is blocking research and publication of suicide rates correlated with lack of trans-affirming treatment.

Cass obviously cannot report on science that hasn't been reviewed. The reviewers at University of York obviously cannot review science that hasn't been published.

EITM is very obviously trying to spin this alleged shortcoming of the NHS into a false impression that Cass omitted important research from her report. And you're either falling for her scam, or else you're complicit in that scam.

Neither, I was posting something that had been getting noticed in the hopes of seeing some comments to help me make up my mind. Thanks for your comments.

 

[Samson]

Matt Doocey hides this and continues to sterilize NZchildren.

 

[angrysoba]

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.

Unfortunately all but the first 10 minutes is behind a paywall which they do for their more controversial hot button episodes.

https://www.thestudiesshowpod.com/p/paid-only-episode-7-youth-gender

They do offer a 7 day free trial.

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.

So I have listened to all but the last five minutes of the podcast, finally.

They essentially talk about two main points:

1.) Do puberty blockers reduce gender dysphoria?

Answer: The report says no.

2.) Do puberty blockers reduce psychological problems, including, but not restricted to suicidality?

Answer: probably not.

They then go into what the evidence was for using puberty blockers was to begin with, and they find that the evidence was pretty weak, which suprised them. It is not unusual to have small studies with big effects that then get smaller when the studies get larger.

They point out how the report assessed the quality of studies and even that the studies were somewhat leniently judged. One of the hosts, Tom, says he looked at the studies which the Cass report considered to be among the best and found the studies to be pretty bad.

From memory, they were saying something along the lines of "if we were looking at the evidential basis for, say, Ozempic, and the best we had was a study of fewer than 100 participants and they didn't even lose weight, we wouldn't consider the evidence for Ozempic to be very good" and yet that is effectively what the studies for puberty blockers reducing gender dysphoria found.

They also point out that 6 out of 7 clinics that were asked to provide data on the effectiveness of their treatments refused to share. Tom says he is astounded that there seems to be an active attempt to refuse to show the effectiveness of puberty blockers. Why would anyone not want to know how effective their treatments are?

There is talk about what would and would not be good evidence, and how it is difficult to have RCTs and how even Cass accepts the difficulty (Stuart actually disagrees somewhat and thinks that RCTs could be conducted). They also both agree that just because evidence is hard to get does not mean that treatments can or should be given without it.

Stuart does then have some minor criticisms of the report such as the rather speculative musings about the effects of pornography, etc... on gender dysphoria. He thinks that if there is no support for the musings, don't put them in the discussion as it undermines the point of a review which is to base arguments on strong evidence.

However, on the whole, they both argue that the Cass Review is a good piece of science writing.

 

[Orphia Nay]

Thanks for the summary, angrysoba!

 

[angrysoba]

Thanks for the summary, angrysoba!

You're welcome. There is quite a bit more that I may have missed, though, so I encourage anyone to give the episode a listen.

 

[Elaedith]

They point out how the report assessed the quality of studies and even that the studies were somewhat leniently judged. One of the hosts, Tom, says he looked at the studies which the Cass report considered to be among the best and found the studies to be pretty bad.

Yes, the rating method used was extremely lenient, so that even fairly weak research could meet the high or moderate quality threshold. Of course, that needs to be taken into account when assessing the overall findings from the body of evidence that met the threshold to be considered. If even fairly weak designs that have poor control for confounds/placebo effects fail to find large and consistent effects, the overall evidence is weak.

I think a lot of people fail to understand this, perhaps willfully. I have seen people imply that if overall many studies seem to find associations (ie. correlations) between affirmative treatment and positive outcomes, this is strong evidence for the treatment. But one would expect such correlations from confounds, placebo effects and publication bias alone. In some cases, the results are often less than one might expect from placebo effects. If study A measures outcomes X Y and Z and reports no effects for X and Y but a positive association for Z, and study B measures the same outcomes and finds a positive association for X but no effect for Y and Z, that is not a replication because both found one positive outcome, it is a failure to replicate, and probably less than one might expect from placebo effects.

There is talk about what would and would not be good evidence, and how it is difficult to have RCTs and how even Cass accepts the difficulty (Stuart actually disagrees somewhat and thinks that RCTs could be conducted). They also both agree that just because evidence is hard to get does not mean that treatments can or should be given without it.

I listened to this some time ago and my memory is a bit foggy, but I seem to recall thinking there was some lack of clarity between RCTs and blinded RCTs. Cass accepted the inability to blind treatments but I don't think she has stated that RCTs without blinding are impossible. One of the podcasters said he disagreed with Cass but he seemed to be saying that RCTs are possible rather than blinding, but I found it somewhat unclear.

In theory, it is certainly possible to do unblinded RCTs. In practice, it might not work because the idea that this is essential, safe and life-saving treatment has been so strongly promoted now that people would likely withdraw from the study if finding they had been randomised to the control. If they don't withdraw, they would likely feel aggrieved and have a strong motivation to suspect and report that they are being harmed by being denied treatment. It's hard to see how this would not affect any subjective outcomes.

 

[angrysoba]

I think a lot of people fail to understand this, perhaps willfully. I have seen people imply that if overall many studies seem to find associations (ie. correlations) between affirmative treatment and positive outcomes, this is strong evidence for the treatment. But one would expect such correlations from confounds, placebo effects and publication bias alone. In some cases, the results are often less than one might expect from placebo effects. If study A measures outcomes X Y and Z and reports no effects for X and Y but a positive association for Z, and study B measures the same outcomes and finds a positive association for X but no effect for Y and Z, that is not a replication because both found one positive outcome, it is a failure to replicate, and probably less than one might expect from placebo effects.

Yes, on this one if I remember correctly they pointed out that one study reported that people on puberty blockers felt better but no less gender dysphoric. This is the study where they negatively compared to Ozempic saying that it makes little sense to claim it does what it is supposed to do. People on Ozempic could presumably say they felt better on it while not losing weight but then it would hardly be doing what it is supposed to do. Maybe we should look at the specific study to see it in more detail.

 

[d4m10n]

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...

Probably "therein or thereby" should include all subsequent efforts at comprehensive systematic reviews of gender medicine, especially youth gender medicine. With that interpretive gloss on the OP, consider this:

New Zealand finally publishes its evidence brief showing 'a lack of good quality evidence to back the effectiveness and safety of puberty blockers' for treating gender dysphoria.

You can skip directly to the report findings on mental health using this link.

 

[Elaedith]

Another recent update is this peer-reviewed analysis of the errors in the Yale Integrity Project's critique of the Cass Review, a paper which activists like to claim has 'debunked' the Cass review. The authors point out that the YIP piece was primarily written for litigation rather than academic purposes and list numerous factual and interpretation errors. This also mentions the paper by Noone et al. which was linked to earlier in this thread.

"McNamara et al’s arguments and language are tailored for the courtroom. Viewed through this lens, the way in which the authors highlight their perceived authority, with an emphasis on their ‘86 years collectively caring for 4800 transgender youth’—which would be an unusual addition in a purely academic context—makes more sense. Similarly, a ‘shotgun’ argumentation approach, where an argument is made to seem more persuasive not by the quality but volume of arguments (fallacious or otherwise), is an approach which is well suited to litigious, adversarial settings."

 

[Planigale]

CRITICALLY APPRAISING THE CASS REPORT: METHODOLOGICAL FLAWS AND UNSUPPORTED CLAIMS

Preprint: https://osf.io/preprints/osf/uhndk

Summary;

We don't like the conclusions so we will nitpick the methodology but don't have any new facts.

 

[Elaedith]

Probably "therein or thereby" should include all subsequent efforts at comprehensive systematic reviews of gender medicine, especially youth gender medicine. With that interpretive gloss on the OP, consider this:

You can skip directly to the report findings on mental health using this link.

They used GRADE and ROBINS-1 for rating quality of outcome studies of puberty blockers (Appendix 4). It appears that every study without exception has been rated as having serious risk or bias or critical risk of bias with ROBINS. Almost all studies were rated low or very low quality on GRADE, except for handful that were moderate. Harsher than Cass. The funny thing is, the Yale Integrity Project critique of Cass was complaining about Cass not using GRADE (although it isn't clear exactly what they were complaining about since the whole paper is incoherent). The NICE review prior to Cass 2024 used GRADE and downgraded nearly all studies as being low quality, consistent with this latest review, and with the Swedish review prior to Cass. So Cass is the outlier in being overly generous to weak evidence (accepting many more studies as being at least moderate quality) What are they going to come up with to 'debunk' this one?