Cass Report

[ahhell]

I wonder which trans rights activists are going to say “I was worried about Guyatt’s association with SEGM for a second, but I’m glad he cleared up what he thinks in an interview with…. *checks notes* … Jesse Singal.”

It might be greater than zero but I doubt it. He was taking a chance even talking to Singal.

 

[d4m10n]

Guyatt admits to living without paying any attention to social media, so he'd be uniquely unaware of the hate radiating in from cyberspace.

Jesse does fine in legacy media, such as The Atlantic and the NYT.

 

[angrysoba]

It might be greater than zero but I doubt it. He was taking a chance even talking to Singal.

I was joking. I would have thought Singal is even more toxic in those quarters.

 

[angrysoba]

Guyatt admits to living without paying any attention to social media, so he'd be uniquely unaware of the hate radiating in from cyberspace.
Jesse does fine in legacy media, such as The Atlantic and the NYT.

Wait a minute, what's this?

Gordon Guyatt has a Twitter account and it looks reasonably active. He's even tweeting about the controversy in question.



How is it that he doesn't know of Jesse Singal's reputation? I mean, sure, maybe he might not know that Singal is Bluesky's Most Hated, but.... no wait... he has a Bluesky account as well!!!


Link

 

[d4m10n]

How is it that he doesn't know of Jesse Singal's reputation?

Wow, yeah, that's crazy.

I've got terrible service right now but need to look up when he joined and got active.

 

[angrysoba]

Because it is always worth looking at the other side of this, I just read Gideon M-K (AKA: The Health Nerd) responding to the McMaster controversy.

He agrees that gender-affirming care has a low evidentiary basis. But he says that that is true of pretty much all the alternatives (AS - Is this the case?).

The point here is that we already knew that the evidence wasn’t very strong. That’s not news. What the new statement from Prof Guyatt and team points out is what weak evidence means for the medical treatment of gender dysphoria.

It’s important to consider the context here. There are really only three proposed ways to treat a teenager or young adult who says that their gender feels wrong. There’s the 60s/70s/80s approach which we mostly describe as conversion therapy these days - manipulate and emotionally/physically abuse the kids until they stop saying things about their gender.

Then there’s the model proposed by SEGM and similar organisations, which argues that young people’s brains are not developed enough to decide on lifelong interventions like hormones or puberty blockers. They say that most gender dysphoria goes away by the time kids turn 20 anyway, so just give them therapy and psychiatric medications until they stop feeling trans.

Finally, there’s gender-affirming care. This modality is supported by the lead professional organisation for the treatment of transgender people - the World Professional Association for Transgender Health - and promotes the idea that young people should be supported in any way possible. If they want to transition genders, they can, and medical providers are simply there to help them understand the risks and benefits and support their mental health through the process.

Of these three methods of treating children with gender dysphoria, none have strong evidence. There are few studies on gender-affirming care and many of them are weak. There are even fewer studies on conversion therapy, and also many of the methods are repugnant and awful. There are quite literally no studies at all looking at whether therapy has benefits for kids with gender dysphoria, nor whether forcing them to experience “natural” puberty is better than using medications to delay or prevent this.

The statement by the McMaster team is, therefore, precisely what you’d expect an unbiased expert in evidence-based medicine to say. If a dysphoric teen turns up at a doctor’s clinic, we don’t know what the best treatment is. I personally think that the current evidence is in favour of gender-affirming care, but the data isn’t very good. I can see why an expert in evidence appraisal would argue that there are no proven options at all.

 

[theprestige]

Because it is always worth looking at the other side of this, I just read Gideon M-K (AKA: The Health Nerd) responding to the McMaster controversy.

He agrees that gender-affirming care has a low evidentiary basis. But he says that that is true of pretty much all the alternatives (AS - Is this the case?).

He goes on to say:

We have low certainty that gender-affirming care is the best option for transgender youth. The only way to fix that is with high-quality research, ideally either some really strong observational studies or randomized trials.

But we have even less data on the vague idea of therapy that is the main proposed alternative. We don’t even know if forcing children to undergo psychological assessment makes them less likely to go on to puberty blockers or hormones at a later date, never mind how this therapy impacts their long-term mental health.

In this context, calls for bans on gender-affirming care are simply not scientific.

The thing he's ignoring is that puberty blocking and trans-affirming surgery are irreversible procedures with *lots* of evidence about their downsides.

He's basically arguing that even though we have no idea if this is more good than bad, we should do it anyway because we haven't thought of anything better yet. At least therapy doesn't do lasting harm to the body.

 

[Elaedith]

Because it is always worth looking at the other side of this, I just read Gideon M-K (AKA: The Health Nerd) responding to the McMaster controversy.

He agrees that gender-affirming care has a low evidentiary basis. But he says that that is true of pretty much all the alternatives (AS - Is this the case?).

Prior to the adoption of affirmation-only approaches under activist pressure, the favoured approach for prepubescent children was watchful waiting. The main rationale for watchful waiting was that gender dysphoria resolved in the majority of children at puberty and that only a minority continued to want to transition in adolescence and young adulthood. Watchful waiting was branded 'outdated' and abandoned in the 2018 AAP clinical guidelines without citing any rationale (in fact the citations given actually supported watchful waiting). AAP guidelines were not based on any systematic evidence reviews and were rated low quality in the University of York reviews conducted for Cass.

Activists have attacked these desistance studies and declared them discredited, but although the studies certainly have flaws (such as small samples) many of the attacks are dubious as we have discussed elsewhere. Just for one example, the study by Steensma et al. (2013) is often rejected on the grounds that it classified non-responders to follow-up surveys as having desisted (not transitioned), as though this was done to artificially inflate the desistance rate. But the non-responders were classified that way because there was only one clinic offering medical transition in the Netherlands at the time, and they were able to check the records to show that none of the non-responders had attended. Activists also exaggerate the differences between DSM5 and earlier versions to claim that no evidence based on diagnoses prior to DSM5 is reliable.

'Health Nerd' doesn't address the rationale for watching waiting at all. The idea of providing support to manage distress while taking a neutral approach towards identity before puberty is to maximise the chance for gender dysphoria to resolve naturally and avoid consolidating a cross-sex identity that may not have persisted otherwise.

 

[ahhell]

He goes on to say:


The thing he's ignoring is that puberty blocking and trans-affirming surgery are irreversible procedures with *lots* of evidence about their downsides.

He's basically arguing that even though we have no idea if this is more good than bad, we should do it anyway because we haven't thought of anything better yet. At least therapy doesn't do lasting harm to the body.

That's the obvious rebuttal. We don't have good evidence for any treatment of... pick any ailment so we should go ahead with the most invasive and irreversible option.

There is the problem with all of this. To figure what the best choice is, we need to experiment on children.

 

[jt512]

That's the obvious rebuttal. We don't have good evidence for any treatment of... pick any ailment so we should go ahead with the most invasive and irreversible option.

There is the problem with all of this. To figure what the best choice is, we need to experiment on children.

This is one area where decisions will have to be made on the basis of observational studies. That's not unprecedented. We figured out that cigarette smoking was harmful without conducting randomized clinical trials.

 

[lionking]

He goes on to say:


The thing he's ignoring is that puberty blocking and trans-affirming surgery are irreversible procedures with *lots* of evidence about their downsides.

He's basically arguing that even though we have no idea if this is more good than bad, we should do it anyway because we haven't thought of anything better yet. At least therapy doesn't do lasting harm to the body.

Exactly. Critics of Cass (including Steve Novella who should know better) keep repeating that puberty blockers are reversible. They are not.

 

[Gulliver Foyle]

I think its more like "the Cass report didn't follow the gold standard for the type of review they were performing", while ignoring that there are reasons in the underlying studies that made it impossible to do that.

Its the repositioning from a mental health condition to one of bodily autonomy that is interesting, as I think this is an attempt to tie it into abortion rights arguments ie align you argument to a more popular position.

Yes, there is a reason why Cass threw out all the good scientific papers on the matter and only included two by quacks paid to provide adverse reports.

But it wasn't because of science, bub. It was simply because the whole Cass report had a predetermined conclusion and had to engage in policy based evidence making to uphold said conclusion.

 

[lionking]

Yes, there is a reason why Cass threw out all the good scientific papers on the matter and only included two by quacks paid to provide adverse reports.

But it wasn't because of science, bub. It was simply because the whole Cass report had a predetermined conclusion and had to engage in policy based evidence making to uphold said conclusion.

Utter ◊◊◊◊◊◊◊◊. Not unexpected.

 

[zooterkin]

Yes, there is a reason why Cass threw out all the good scientific papers on the matter and only included two by quacks paid to provide adverse reports.

But it wasn't because of science, bub. It was simply because the whole Cass report had a predetermined conclusion and had to engage in policy based evidence making to uphold said conclusion.

Nonsense.

 

[Pixel42]

Sounds like someone needs to take the time to actually read the Cass report.

 

[Elaedith]

Yes, there is a reason why Cass threw out all the good scientific papers on the matter and only included two by quacks paid to provide adverse reports.

But it wasn't because of science, bub. It was simply because the whole Cass report had a predetermined conclusion and had to engage in policy based evidence making to uphold said conclusion.

Is there a reason why you keep repeating the lie that Cass included only two papers, even though everyone here already knows this is false?

 

[Darat]

Yes, there is a reason why Cass threw out all the good scientific papers on the matter and only included two by quacks paid to provide adverse reports.

But it wasn't because of science, bub. It was simply because the whole Cass report had a predetermined conclusion and had to engage in policy based evidence making to uphold said conclusion.

Which good papers? Did any of them deal with the reversibility of "puberty blockers"?

 

[angrysoba]

Yes, there is a reason why Cass threw out all the good scientific papers on the matter and only included two by quacks paid to provide adverse reports.

But it wasn't because of science, bub. It was simply because the whole Cass report had a predetermined conclusion and had to engage in policy based evidence making to uphold said conclusion.

This is not what happened.

Why do you speak with such supreme confidence about the "reason why Cass" did this or that by bare assertion?

Would you even be able to explain what the Cass report actually is?

 

[d4m10n]

There are really only three proposed ways to treat a teenager or young adult who says that their gender feels wrong.

Sorry for putting Gideon's words inside your quote box here @angrysoba; I just wanted to reply to this bit.

I don't buy the idea that the original approach was to "manipulate and emotionally/physically abuse the kids until they stop saying things about their gender" because kids did not yet have the words and concepts to talk about their "gender identity," and they definitely didn't have anyone giving them hope that they could physically transition from living as one sex to another. The fact that almost everyone accepted their birth sex was largely the result of them understanding that there wasn't really any viable alternative. This approach cannot be resuscitated without heavy-handed political intervention, and even then it might just be adding an onerous commute in order to obtain treatments in a nearby jurisdiction.

As to the competing medical models (therapy first with medical pathways heavily gatekept vs. patient-led gender affirmation) I'd say Gideon is substantially correct about those two competing models. Advocates of each have been saying that they have good evidence for their preferred approach, but probably Guyatt is correct that they are both incorrect about this. So far as I've seen, we've yet to witness a substantially-sized well-designed study which directly pits the older approach against the newer one, randomly assigning patients to each treatment group.

 

[ahhell]

Sorry for putting Gideon's words inside your quote box here @angrysoba; I just wanted to reply to this bit.

I don't buy the idea that the original approach was to "manipulate and emotionally/physically abuse the kids until they stop saying things about their gender" because kids did not yet have the words and concepts to talk about their "gender identity," and they definitely didn't have anyone giving them hope that they could physically transition from living as one sex to another. The fact that almost everyone accepted their birth sex was largely the result of them understanding that there wasn't really any viable alternative. This approach cannot be resuscitated without heavy-handed political intervention, and even then it might just be adding an onerous commute in order to obtain treatments in a nearby jurisdiction.

As to the competing medical models (therapy first with medical pathways heavily gatekept vs. patient-led gender affirmation) I'd say Gideon is substantially correct about those two competing models.
Advocates of each have been saying that they have good evidence for their preferred approach, but probably Guyatt is correct that they are both incorrect about this. So far as I've seen, we've yet to witness a substantially-sized well-designed study which directly pits the older approach against the newer one, randomly assigning patients to each treatment group.

The highlighted bit I think should be emphasized. All though some of the folks on therapy first side are saying we don't have good evidence either way so maybe we should err on the side of caution and the least...permanent intervention to start with.