The Cass Review

[The Cinnabon]

Alright, time to bite. For those familiar, what are your thoughts on the Cass Review from the NHS?

Final Report – Cass Review

cass.independent-review.uk

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[WisNeuro]

This should be good. I can't wait for the raft of opinions, most of which have read none of the 388 pages of the report.

 

[The Cinnabon]

This should be good. I can't wait for the raft of opinions, most of which have read none of the 388 pages of the report.

Going to a cafe today where I usually watch videos about aviation disasters and have some Cafe De Olla. Instead I'll crank this puppy out or try and get a decent bit.

I'm curious to read what she means by "weak evidence base." Those are bold claims given similar reports from Germany, American Academy of Pediatrics, etc.

 

[WisNeuro]

Going to a cafe today where I usually watch videos about aviation disasters and have some Cafe De Olla. Instead I'll crank this puppy out or try and get a decent bit.

I'm curious to read what she means by "weak evidence base." Those are bold claims given similar reports from Germany, American Academy of Pediatrics, etc.

I'd have to imagine it relates to qualitative evidence, small n's, self-selected populations, lack of long follow-up. Not that this is all necessarily avoidable, this isn't exactly an issue that can be easily studied with RCTs and such. I think one can be supportive of the treatments in general, but acknowledge that there is a lot we do not know, and potential harms with certain treatments. And, as we gather more data, that is fine, many of our treatments have adverse side effects, and we as patients and doctors hopefully know these and make informed decisions about the cost/benefit of treatments.

 

[psych.meout]

This should be good. I can't wait for the raft of opinions, most of which have read none of the 388 pages of the report.

The Editor in Chief maligning anyone who has any methodological critiques of the articles used by the report and turning off replies doesn't seem like the practice of good faith scientific inquiry.

 

[The Cinnabon]

The Editor in Chief maligning anyone who has any methodological critiques of the articles used by the report and turning off replies doesn't seem like the practice of good faith scientific inquiry.

View attachment 385410

I decided, perhaps naively, that I would give this report as "objective a chance as possible."

Then I read that they ended up excluding 98% of articles they used on the basis of the studies "not being blinded." These are puberty blocker studies ... I immediately discounted this "review" after reading that, to be blunt.

 

[psych.meout]

I decided, perhaps naively, that I would give this report as "objective a chance as possible."

Then I read that they ended up excluding 98% of articles they used on the basis of the studies "not being blinded." These are puberty blocker studies ... I immediately discounted this "review" after reading that, to be blunt.

Uh oh, you just demonstrated a limited understanding of research methods and evidence based medicine.

 

[clausewitz2]

I decided, perhaps naively, that I would give this report as "objective a chance as possible."

Then I read that they ended up excluding 98% of articles they used on the basis of the studies "not being blinded." These are puberty blocker studies ... I immediately discounted this "review" after reading that, to be blunt.

Where did you read this in the report? The relevant section under puberty blockers identifies 50 relevant studies and says 24 of them were excluded for being low quality evidence. How are you calculating the 98% number?

EDIT: They also explicitly talk at the top of the report about the fact that they made use of qualitative research and epidemiological data, so I'm not sure where the idea comes from that only blinded studies were examined.

Reasonable people can disagree about the conclusions or interpretation but this does not appear to have been a hack job.

 

[WisNeuro]

Where did you read this in the report? The relevant section under puberty blockers identifies 50 relevant studies and says 24 of them were excluded for being low quality evidence. How are you calculating the 98% number?

EDIT: They also explicitly talk at the top of the report about the fact that they made use of qualitative research and epidemiological data, so I'm not sure where the idea comes from that only blinded studies were examined.

Reasonable people can disagree about the conclusions or interpretation but this does not appear to have been a hack job.

In a short time, I've seen a number of critiques of the review, of which I can find no evidence of such critique within the review thus far. There are definitely some issues here and there, as there are with any systematic review, but some people are simply making things up, it seems.

 

[WisNeuro]

The Editor in Chief maligning anyone who has any methodological critiques of the articles used by the report and turning off replies doesn't seem like the practice of good faith scientific inquiry.

View attachment 385410

I mean, some of the critiques I have seen definitely have no actual basis, which seems to be what he is referring to. And, the turning off of replies seems to be for his personal account from this screenshot. Given the nature and past experience with this area, hardly blame him. I wouldn't call someone's personal twitter account replies the bastion of scientific inquiry.

 

[psych.meout]

I mean, some of the critiques I have seen definitely have no actual basis, which seems to be what he is referring to. And, the turning off of replies seems to be for his personal account from this screenshot. Given the nature and past experience with this area, hardly blame him. I wouldn't call someone's personal twitter account replies the bastion of scientific inquiry.

Except he's not referring to specific criticisms that have been flawed, he's casting aspersions at any criticism of the methodology.

Where did you read this in the report? The relevant section under puberty blockers identifies 50 relevant studies and says 24 of them were excluded for being low quality evidence. How are you calculating the 98% number?

EDIT: They also explicitly talk at the top of the report about the fact that they made use of qualitative research and epidemiological data, so I'm not sure where the idea comes from that only blinded studies were examined.

Reasonable people can disagree about the conclusions or interpretation but this does not appear to have been a hack job.

Citing a Mormon YouTube channel as the source for this study seems pretty hack.

 

[clausewitz2]

Except he's not referring to specific criticisms that have been flawed, he's casting aspersions at any criticism of the methodology.


View attachment 385441
Citing a Mormon YouTube channel as the source for this study seems pretty hack.

I mean, if that is the best source they could find for the study in question and the data was never really published anywhere, that speaks to the underlying study being of poor quality, doesn't it? Regardless, a single dodgy reference in a 398 page report doesn't move my priors much in any direction.

EDIT: yeah, it looks like no results from the study were published until 4 years later and were deeply underwhelming. Seems like the point they were trying to document was that the data was being discussed in 2016 even if it didn't see the light of day until 2020.

 

[WisNeuro]

Except he's not referring to specific criticisms that have been flawed, he's casting aspersions at any criticism of the methodology.

Not how I saw the comment, but the ambiguity will definitely lead to different interpretations.

 

[cara susanna]

Okay, i fully admit that I may be missing something, but the recommendations don't seem too extreme in one side or the other to me. What is the controversy here? Or is it just because it's a controversial topic in general?

 

[WisNeuro]

Okay, i fully admit that I may be missing something, but the recommendations don't seem too extreme in one side or the other to me. What is the controversy here? Or is it just because it's a controversial topic in general?

That's my take. Also, this is one of those areas that seems to want to be resistant to any criticism, warranted or not.

 

[Ollie123]

Okay, i fully admit that I may be missing something, but the recommendations don't seem too extreme in one side or the other to me. What is the controversy here? Or is it just because it's a controversial topic in general?

Didn't read the full report but just read the overview and recommendations.

I'm going to (perhaps incorrectly) assume that because it was relatively equivocal we are now in a situation where everyone is reading what they want into it and everyone is pissed. I suspect Fox News will seize on the "hormones before 18 should be used with extreme caution" aspect and advocates will be upset, advocates will seize on the "care should be individualized, parents should support their children in a non-judgmental way" and Fox News will be upset, etc.

So basically what WisNeuro said. A report stating that water is wet is destined to generate controversy in our present political climate, let alone something like this...

 

[MCParent]

So basically what WisNeuro said. A report stating that water is wet is destined to generate controversy in our present political climate, let alone something like this...

Your ignorance and erasure of other liquids is problematic.

 

[Shiori]

Okay, i fully admit that I may be missing something, but the recommendations don't seem too extreme in one side or the other to me. What is the controversy here? Or is it just because it's a controversial topic in general?

I didn't see as much pushback on the recommendations. The interpretation of some of the literature was...off to me. I didn't do a deep dive because I only work with adults, and I figured I would end up annoyed. I have enough to keep me busy in my state.

ETA: I took a deeper dive. As expected, the review was used as a hammer and essentially ended this as a treatment option.

 

[cara susanna]

I didn't see as much pushback on the recommendations. The interpretation of some of the literature was...off to me. I didn't do a deep dive because I only work with adults, and I figured I would end up annoyed. I have enough to keep me busy in my state.

ETA: I took a deeper dive. As expected, the review was used as a hammer and essentially ended this as a treatment option.

Can you explain the last part more?

 

[Shiori]

Can you explain the last part more?

This review has been a few years in the making. This is just the final version.

This is from last year:
The National Health Service said Friday that “outside of a research setting, puberty-suppressing hormones should not be routinely commissioned for children and adolescents.”

England's health service says it won't give puberty blockers to children at gender clinics

England's publicly funded health service says it will not routinely offer puberty-blocking drugs to children at gender identity clinics. It says more evidence is needed about their potential benefits and harms. The National Health Service said Friday that “outside of a research setting...

apnews.com

Now fewer than 100 are receiving puberty blockers:

NHS says children to no longer receive puberty blockers at gender identity clinics

Puberty blockers, which pause the physical changes of puberty such as breast development or facial hair, will now only be available to children as part of clinical research trials

www.independent.co.uk

 

[WisNeuro]

This review has been a few years in the making. This is just the final version.

This is from last year:
The National Health Service said Friday that “outside of a research setting, puberty-suppressing hormones should not be routinely commissioned for children and adolescents.”

England's health service says it won't give puberty blockers to children at gender clinics

England's publicly funded health service says it will not routinely offer puberty-blocking drugs to children at gender identity clinics. It says more evidence is needed about their potential benefits and harms. The National Health Service said Friday that “outside of a research setting...

apnews.com

Now fewer than 100 are receiving puberty blockers:

NHS says children to no longer receive puberty blockers at gender identity clinics

Puberty blockers, which pause the physical changes of puberty such as breast development or facial hair, will now only be available to children as part of clinical research trials

www.independent.co.uk

In the puberty blocking section of the report, which specific parts are problematic?

 

[Shiori]

In the puberty blocking section of the report, which specific parts are problematic?

No part of the report has to be problematic for the outcome to be unfortunate. Science is nuanced. Policy is not.

 

[borne_before]

This Review is not about defining what it means to be trans, nor is it about undermining the validity of trans identities, challenging the right of people to express themselves, or rolling back on people’s rights to healthcare. It is about what the healthcare approach should be, and how best to help the growing number of children and young people who are looking for support from the NHS in relation to their gender identity.

 

[borne_before]

Despite the best intentions of everyone with a stake in this complex issue, the toxicity of the debate is exceptional. I have faced criticism for engaging with groups and individuals who take a social justice approach and advocate for gender affirmation, and have equally been criticised for involving groups and individuals who urge more caution.

 

[WisNeuro]

No part of the report has to be problematic for the outcome to be unfortunate. Science is nuanced. Policy is not.

Then people should be attempting to sway their elected representatives, not critiquing the report?

 

[Shiori]

Then people should be attempting to sway their elected representatives, not critiquing the report?

They're doing both. The critiques are available for people to evaluate for themselves.

 

[WisNeuro]

They're doing both. The critiques are available for people to evaluate for themselves.

I get that, I was genuinely asking what that section was missing or misrepresented that made it problematic, as that portion was specifically brought up.

 

[Shiori]

I get that, I was genuinely asking what that section was missing or misrepresented that made it problematic, as that portion was specifically brought up.

I was answering in earnest that it doesn't matter what the review says. The Cass Review assessed 50 articles and felt the literature was weak for puberty blockers. The recommendation was that we take a holistic approach. I agree that we should take a holistic approach. Then puberty blockers were essentially banned in all but the most "exceptional" of cases. I don't agree that it should be banned. My specific thoughts on aspects of the review are irrelevant.

 

[WisNeuro]

I was answering in earnest that it doesn't matter what the review says. The Cass Review assessed 50 articles and felt the literature was weak for puberty blockers. The recommendation was that we take a holistic approach. I agree that we should take a holistic approach. Then puberty blockers were essentially banned in all but the most "exceptional" of cases. I don't agree that it should be banned. My specific thoughts on aspects of the review are irrelevant.

That's fair, then the review was not the problem. I wouldn't say the review or critical thoughts on it are irrelevant, we should always look at such things with a critical eye. Some reviews are deeply flawed, like the Cochrane reviews on donepezil, and that's how we get prescribers selling billions of a drug that largely does nothing. Some are merely reviews of a body of literature in it's infancy in which there are many unanswered questions.

 

[Shiori]

That's fair, then the review was not the problem. I wouldn't say the review or critical thoughts on it are irrelevant, we should always look at such things with a critical eye. Some reviews are deeply flawed, like the Cochrane reviews on donepezil, and that's how we get prescribers selling billions of a drug that largely does nothing. Some are merely reviews of a body of literature in it's infancy in which there are many unanswered questions.

Sort of. The review happened for a myriad of reasons including political pressure from groups with differing motives. The UK has fewer than 2,000 people this information even applies to. The science, like most science about human nature and biology, is messy. That's all that was needed to all but end access to a tool that was used by teams of likely competent people to basically tell them to do what they were already doing. That was all that was needed to close the door completely. It will likely be very challenging to change things in the future.

There is a nuanced, thoughtful conversation about abortion care. For example, some people regret their decision later. The vast majority don't regret it, but some do. Very similar to gender affirming care. This real occurrence was used as part of the justification for why, in many states, women are required to wait at least 24 hours before getting an abortion. They also tied it to informed consent, which opened the door to transvaginal ultrasounds. They keep adding additional layers and hoops to make accessing care challenging. For a while the only major changes to abortion care came from people arguing about health and safety. This was motivated by clinicians who were trying to be helpful, but it was also strongly encouraged by people against abortion period. They were playing the long game. Gender affirming care feels like it's in a very similar position.

I don't have a solution. I think we should be able to do good, thorough science to maximize outcomes for everyone involved. In theory, the results could have looked like what the VA puts out for best practices. That would have been really helpful. The use of the review seems to be signaling something much different. Many of the articles hailing this review are anti-trans period. They never cared about safety. They just want it stopped. The review could be flawless, humane, and beyond reproach, and it was still going to be used to dismantle access because people have strong reactions to trans folks.

 

[Ollie123]

I recall some really interesting discussions in ethics classes around "Science doesn't occur in a vacuum". There are definitely somewhat competing camps in thinking on these issues. On the one hand, by definition we are supposed to be seeking truth and relatively agnostic about the ultimate answer. Many argue our job is simply to get the best answers we can and put them out there for the world to see. On the other hand, particularly in fields like ours, we are generally doing this because we ultimately want to help people. So others argue that we have to take responsibility for the truth we're putting out there and consider how people are going to use/abuse our findings.

I don't fall squarely in either camp. I lean a bit towards the former, but that is also much easier to do in my area of study. While not entirely devoid of politics in light of national drug policy and tobacco regulation, the impact of nicotine on striatal-prefrontal connectivity is not exactly likely to create political shockwaves any time soon. Work like this report is very much the opposite. Every party is going to read it and skew it to their advantage. I'd like to say thoughtful wording could resolve the issue, but frankly...people are dumb, our national discourse is exceptionally dumb and whether a scientist says "There is no evidence to support using x" or "We currently lack sufficient evidence to support the use of x and thus recommend caution until more rigorous studies can be completed" isn't likely to make a bit of difference in how that information gets used/abused by those with a vested interest in doing so.

At the same time, synthesis is needed at varying stages of work. We can't just NOT summarize findings. If we don't, someone less qualified to do so will take that on. We can't keep things a secret. Lack of transparency undermines our fundamental mission. More practically, the body of scientists/providers with a readily justifiable need to have that information is immensely too large to think secrets could be effectively kept. I haven't read the report in detail, but just based on the scientific summary I'd be shocked if the scientists actually did anything fundamentally wrong. Even as an outsider, I'd have bet the farm on "insufficient evidence" as the foregone conclusion going into this because small Ns, relatively new area, difficult to run controlled studies, etc. What we do with that information is going to differ from what random state senator does though.

I don't know the right answer here, but I am very much reminded of those debates in ethics class. Much more interesting fodder for discussion than the usual fare...

 

[Shiori]

I think I'm just tired and cranky. Keeping up with the deluge of meddling politicians eager to score political points is wearing me out. I just want to show up and do my job. I'm just glad I don't do peds.