Cass review - out on Wednesday

Ha ha! Yes, I've already started doing just that on X.

That's a really helpful explanation Bread. Hopefully others can use it when challenging the fuckwits flailing around trying to discredit Cass.

Couldn't see this posted yet. Great article in the BMJ:

t.co/tSJVPtFKjE

"One emerging criticism of the Cass review is that it set the methodological bar too high for research to be included in its analysis and discarded too many studies on the basis of quality. In fact, the reality is different: studies in gender medicine fall woefully short in terms of methodological rigour; the methodological bar for gender medicine studies was set too low, generating research findings that are therefore hard to interpret. The methodological quality of research matters because a drug efficacy study in humans with an inappropriate or no control group is a potential breach of research ethics. Offering treatments without an adequate understanding of benefits and harms is unethical. All of this matters even more when the treatments are not trivial; puberty blockers and hormone therapies are major, life altering interventions. Yet this inconclusive and unacceptable evidence base was used to inform influential clinical guidelines, such as those of the World Professional Association for Transgender Health (WPATH), which themselves were cascaded into the development of subsequent guidelines internationally (doi:10.1136/bmj.q794).7"

In my experience you have to know how to use the diagnosis to get help. The diagnosis doesn't automatically bring help but it's an esssential building block.

hopefully avoiding the child seeking out gender care as an explanation for feeling “other”.

It hasn't necessarily worked out that way in practice. Autism charities that used to avoid whacky ideas are very gender-id positive. (They probably claim to be LGBT-etc inclusive but they don't really talk about sexual orientation because that's, well, sex) And the end result of charities normalising gender confusion to autistic people is - well, imagine if the chelation nutters had taken over the NAS.

Though to be fair - I did complain at one point to the NAS a couple of years ago about them having some unsuitable material on their website. The site's been reorganised and it's not there now, so maybe these whacky ideas are already falling out of favour at last.

The Cass report will help some more.

I’ve seen objections about Cass citing toy preferences not just being gendered stereotypes but partially biologically driven.

I won’t derail this thread but I’ve seen many teachers and many schools miss the signs of an autistic child - and I include autism-specialist units and schools in that. Girls especially tend to be missed.

I may have misunderstood but you seem to be suggesting that diagnosis doesn’t help because there’s so little practical help available. Although it can be difficult to come to terms with, it’s invaluable for an individual- particularly a vulnerable teen - to understand why they struggle with the things they do. I can’t overstate the importance of truly understanding yourself and eventually realising that you’re not just rubbish at life - there’s a reason why things are hard.

There’s a chance that a diagnosis will provide a sense of identity- and sometimes even community - hopefully avoiding the child seeking out gender care as an explanation for feeling “other”.

Quite.

As soon as a bunch of quality level evidence is built up, I'm curious as to where exactly it's going to lead us and whether it will find any clinical benefits.

If it doesn't... Well...

YetAnotherSpartacus · Today 11:59

Has anyone objecting to Cass actually based their objections in a critique of the methods/methodology used or an evidenced case that she didn't find or use the best quality evidence?

Or do they just not like it?

They just don't like it, because it shows the practitioners to be a gang of unethical shits, who were winging it all the way.

That would be great!

Definitely not holding my breath tho!

The number of people commenting, they could all take one of these studies apiece and

• evaluate it using the standard tools
• make an argument as to why [X study] should have been included
• explain that it doesn't fit within the agreed methods and processes of a systematic review (see link to Cochrane Handbook above) but
• they'd include it in a narrative view because…
• integrate all of these into a rapid evidence synthesis and pop it onto a pre-publication server for review by others.

They could do this with a team of 20 in a 10-20 days because they obviously have a list of studies that they think should have been included (although that would have breached the protocol that stated the cut-off date). A team of 50, could do this earlier if they had a decent formatter. They'd just have to publish the PICO (population, intervention, comparator, outcomes), extracted data, and their arguments, I'm not asking for a full blow evidence synthesis but they could still pop it onto a pre-publication server.

Has anyone objecting to Cass actually based their objections in a critique of the methods/methodology used or an evidenced case that she didn't find or use the best quality evidence?

Or do they just not like it?

I strongly suspect that the people who are having their voices and assertions about the Cass Review amplified to such great effect by the media have been far too busy appearing on media spots or posting their reckons on TwiX to have actually read the report.

They've been successfully brief with Lifton's thought terminating clichés to articulate and they've rarely been challenged to move beyond that.

Gosh, that point re: unknown risk factors of the cohort who were referred via non-clinical routes is really quite upsetting. Thanks for flagging it up @SinnerBoy.

19.4 When the Review commenced, access to the specialist GIDS service was unusual in that the service accepted referrals directly from primary care (a GP) and from non-healthcare professionals including teachers and youth workers.

19.5 The audit of GIDS discharge notes, undertaken by Arden & Gem CSU in spring 2023 (Appendix 6), found that 48.6% of patients referred to GIDS were referred by CAMHS/ child and young people mental health services and 40.68% were referred by their GP. Of the remaining, referrals were made by other healthcare providers (2.6%), local authorities (3.3%), the voluntary sector (3.1%) and schools (1.8%).

19.6 This created a number of problems:

The information recorded on the referral was highly variable and often lacked even the basic information that the specialist team would need to screen and triage the patient.

Patients who would not usually meet the threshold for a specialist service were being referred, meaning waiting times increased for everyone without a way to discern those who genuinely required specialist input from those who could be managed in secondary care or even primary or community care.

Once referred, it was unclear who held clinical responsibility for the care of the young person.

Usual assessments that would be undertaken by a secondary care practitioner (for example, safeguarding assessment, mental health assessment) were not being completed for these young people, particularly those referred through a non-healthcare route. This means that there is an unknown level of risk inherent in the legacy waiting list, that is, it is not known which young people may be at risk of self-harm or suicide, and which may be at risk due to family breakdown or other safeguarding issues.

borntobequiet · Today 07:33

I understood that the “weak evidence” was a more or less total lack of evidence on account of not bothering to collect any reliable data on outcomes (probably in the knowledge that they would be unlikely to support the case for the use of the medication anyway).

I've been delving into parts of Cass. Appendix 4 is quite interesting:

/https://cass.independent-review.uk/wp-content/uploads/2024/04/CassReview_Final.pdf

There is a lack of high-quality evidence to support recommendations for puberty suppression or hormones for masculinisation or feminisation in children/adolescents experiencing gender dysphoria or incongruence. There is a lack of evidence comparing outcomes of adolescents who receive puberty suppression followed by hormones for masculinisation or feminisation to those who receive hormones only. Future guidelines should report the methods of development in full, with greater transparency about the links between evidence and recommendations and how recommendations are made in the absence of evidence.

Robust research is needed to address the significant gaps in our understanding of the potential short- and long-term outcomes of social transition, the risks, and benefits of puberty suppression and hormone interventions, and the appropriateness and effectiveness of different psychosocial interventions. Identification and agreement of core outcomes would help to ensure that what is important to relevant stakeholders is being collected and this would support future aggregation of evidence. High-quality studies using an appropriate study design are needed as is robust reporting. High quality standardised data collection should be routinely undertaken in gender clinics to enable comparison in outcomes for children and adolescents accessing different services.

I downloaded a copy of the Cass review last night and looked through it. Haven't read it all through (it's too long and detailed to read in a sitting!) but read the intro and contents and looked over the references and dipped in to a couple of sections (can you tell I'm an academic by trade? 😀) And I am deeply impressed. This review is comprehensive, thorough, rigorous, and readable. It even includes a summary of what kinds of studies could realistically be done. No wonder it took so long to produce.

And I don't expect to like everything the report says, though I'm in agreement what most of what I have read so far. But the idea that anyone could "debunk" this whole work within 24 hours is ludicrous and reflects badly on whoever made such claims.

Well done Dr Cass.

Not appropriate to a) discuss someone else's child's trauma in detail in this way to illustrate an unrelated point, b) bracket autism diagnosis, with this discussion, as though it was similarly medically contested, and c) use the rhetoric of 'dishing out' autism diagnoses. As PP has said, it is phenomenally hard to get an assessment. Families wait years.

Indeed.

That's where the belief vs fact threshold becomes critical.

If everyone who is doing their best is doing so through a lens of gender identity belief, their "best" will always include a bias towards an affirmation model. Particularly if they are on the psychology/psychiatry end of things.

KJK is right to hold people to account on this issue. My preference would still be that she doesn't call doctors morons. I don't think it helps to do so.

Whilst I'm very disappointed to see Dr Cass validating the existence of gender identity as a truth in her report, I don't think she's a moron. It just highlights the power of belief when it comes to explaining complex issues about the human psyche. It also highlights the difficulty of the journey ahead in getting queer theory out of public institutions.

Thankfully, there seems to be enough in the Cass Review to stop the conveyor belt to medical intervention from happening, and also to stop social transition automatically being part of that. But through a lens of gender identity belief, the route for the children and young people who are caught up in this is paved with risk and potential loopholes. Loopholes that will be exploited by activist groups and individuals.

'TLDR of the Cass Review: "we disregarded nearly all studies because they weren't double blinded controlled studies. We also stopped reviewing newer studies released in the last two years. As a result, we were left with very little evidence." This is an impossible standard.'

My overview of Testing Treatments and Cochrane Handbook was in response to Callebrano's unfounded claims. (I see Callebrano's speciality is Cyberlaw although AC also claims to have a clinical speciality which seems to manifest in claims that laws regulating "gender-affirming care" amount to "genocide.")

I despair of academics who are playing into the hands of those who want all of higher education deconstructed.

Testing Treatments and the Cochrane Handbook are linked above. They

• explain trials, variations on randomised controlled trials (no blinding, single to triple blinded, cluster etc.)
• explain placebo (and there is a tool to describe the varieties of these, the TiDiER)
• explain all of the methods, processes and tools use to assess studies for risk of bias (RoB), quality (GRADE) etc.
• explain literally how you perform a systematic review -
• you publish what you'll do
• you'll give the terms for your literature search
• you describe the studies you'll looking at and their design
• you state the outcomes you'll look at
• you explain the analyses you will perform
• you summarise the trials, you exclude and include
• you state the cut-off data beyond which you don't include publications (yes, reviews take so long to conduct in such grinding detail that, by the time they're published (its own additional delay), they may be out of date but not always because not all areas of research are fast-moving.

There is literally nothing to stop a group of people, getting together, and adopting the methods of the evidence review, and performing the same on the studies that have been published since the cut-off point of the review.

If they don't want to perform something to that standard, they need to pre-publish their protocol, roll up their sleeves, and do the work. Given the importance of this evidence (given the wretched state of the literature), I'd advise them to follow the well established protocol or those that govern rapid evidence syntheses.

They could then rework any analyses that were done with Cass and publish a rapid update to the review's findings.

They could crowdfund the employment of an Evidence Advisory/Assessment Group who carry out rapid evidence syntheses all the time. There's a fair number in the UK and Europe.

People who want to critique Cass have many options that would advance the field of knowledge and add to the evidence base. It will be interesting to see what they actually do.

@SpidersAreShitheads id only say it with confidence in this situation. I teach children with autism.

@CasadeCoca id never make an arm chair diagnosis. I witnessed the psychological abuse of her and her mother for years. Her anxiety reduced hugely when he recently was given a restraining order. I've known her since she was born. And I've taught in a specialist school for autism for nearly two decades.

My main point is that it's all very well dishing out autistic diagnoses but there's often no real practical help for these children when they get them. The difficulties they're dealing with should be being targeted, not least as no one experiences autism in the same way.

And if they're not autistic, what then? They're still struggling. What provision will be put in place?

(Cahms have abandoned the idea of autism in her and that's the only instance I've ever felt it was right to not follow it up. Her trauma was caused by her father.)

CAHMS have been at breaking point for years. Whilst I think it's worth assessing any child for these specific diagnosis, just incase it opens doors to supportive approaches (though the resources have shrunk enormously) at the same time I'm seeing less evidence that it's helpful in real terms. Which is exactly what happened to the children shunted off to gids.

I have seen it being useful if the child is already in specialist send setting, without a specific autistic diagnosis, as it ensures they remain there rather than being sent to a pupil referral unit.

The supportive approaches should be there for all children who are struggling.

Which is the issue with the "trans diagnosis." It led to magic pills, or the potential for them. Operations that would "fix it all." Except it didn't.

Agreed.

Evidently some people are unaware of just how bloody hard it is to get an actual diagnosis and how many specialists need to agree.

Sigh.

I honestly think some people believe we just toddle along to the paediatrician where a diagnosis is handed out just for attending.

The number of children I know who have been referred for assessment but not received a diagnosis as the paediatrician wanted to see how certain things developed first…it really can take a while before a diagnosis is confirmed. It can also be a fight to get a diagnosis if there’s any hint of disagreement from one of the professionals - plus lots of children are still missed and not even referred. Usually girls.

I really really hate this rhetoric that’s prevalent in some quarters on MN that implies autism and ADHD aren’t real.

Thank you for your armchair diagnosis. I am sure we all feel you are eminently qualified to make this sort of determination of your friend's child. Especially as one of the takeways is the harm caused by key board warriors.

@BonfireLady I have some issues with the whole thing and also her interview on the today programme yesterday.

There was a huge gaping hole 🕳️ where she was asked about the outside influences and she wrote it off as "everyone was doing their best."

No.

On what planet do you stop following normal paediatric procedures for mental health issues? Who were they listening to instead?

Don't forget how much the whistleblowers were silenced.