Breakdown of the Yale Law School Cass Criticism

[Ingenieur]

It looks like we now have a long-awaited breakdown of the Yale Law School "debunking" of the Cass report by Jesse Singal, who has been a good source of sanity regarding the medical side of the trans debate thus far.

jessesingal.substack.com/p/yales-integrity-project-is-spreading

I particularly enjoyed this juicy paragraph

McNamara et al. is an exceptionally misleading, confused, and fundamentally unprofessional document. The authors make objectively false claims about the content of the Cass Review, badly misrepresent the present state of the evidence for youth gender medicine, and, just as alarmingly, exhibit a complete lack of familiarity with the basic precepts and purposes of evidence-based medicine. In some cases, the errors are so strange and disconnected from the Cass Review that they can only, realistically speaking, be attributed to malice, a severe lack of curiosity and reading comprehension, or both. This might sound harsh, but you’ll see what I mean shortly. It is genuinely surprising that any of the co-authors would agree to put their names on a document like this.

As we all suspected, the Yale "Integrity Project" is a load of hot air.

Sadly, in my experience as a reviewer, it's not unusual for Advisory Boards, Trustees etc. to lend their names to something that they've not read.

I couldn't tell you the number of times that I've challenged a finding in a report/testimony from an organisation | charity | thinktank, had unsatisfactory answers from the authors, escalated it to the (Scientific) Advisory Board who are listed in the report, and they've all responded that they've not read it.

Critique of bona fide medical expert by law school (sic) in total bollocks shocker. Well, Duh!

I think I need to read that. I suspect it will be entertaining.

Why would you risk your reputation on a report that you don't bother to read?

Singal quotes Leor Sapir’s article regarding Meridithe McNamara and her dubious presentation of herself as an expert in this area of medicine but I think it’s worth having a separate link for Sapir’s article because it’s detailed and very informative:

https://www.city-journal.org/article/the-deposition-of-meredithe-mcnamara

Hm. Can those lawyers ask for the money back for expert testimony (apparently $400 per hour) given than Meredithe MacNamara is not actually an expert in what she is testifying about? Such a distinctive name is both a blessing and a curse if you are an academic.

lonelywater · Today 12:04

Critique of bona fide medical expert by law school (sic) in total bollocks shocker.

Well, quite.

UtopiaPlanitia · Today 13:41

"Singal quotes Leor Sapir’s article regarding Meridithe McNamara and her dubious presentation of herself as an expert in this area of medicine..."

I wonder how medical experts, Yale Law School, managed to miss this?

Serving as expert witness can be financially lucrative, but it also has a potential downside: experts must testify under oath. On April 4, as part of her role as expert witness in Boe v. Marshall, a lawsuit challenging Alabama’s age-restriction law, McNamara submitted to an eight-hour deposition. The transcript of that deposition reveals that McNamara’s many public and under-oath statements about her clinical experience are fundamentally misleading, if not outright false—and even perjurious.

As it turns out, McNamara admits that she does not perform or provide any of the “gender-affirming care” that is implicated in these state laws. She admitted that she “generally” does not perform diagnoses or assessments for gender dysphoria in minors and has never prescribed puberty blockers for this purpose (though she has prescribed them for other conditions). She has never been appointed as a member of any gender clinic. Since arriving at Yale School of Medicine in 2021, McNamara referred a total of two minors to its pediatric gender clinic. Neither of these patients had undergone medical “transition” as of the time of her deposition; one had not even been seen.^

This little gem is near the end of the report:

On July 11, almost two weeks after the paper came out, a disclaimer appeared in it notifying readers that the views expressed were the authors’ own and did not reflect the official views of Yale. McNamara conveniently forgot to add the disclaimer when the paper first appeared and when she submitted it into evidence in Boe. Despite the added disclaimer (mandatory in such circumstances), advocates of “gender-affirming care” in the U.S. and abroad continue to refer to the critique of the Cass Review by “the world-class Yale School of Medicine,” though Yale’s Integrity Project is actually housed at the law school.

That is a humiliating discovery isn't it? Totally undermines any credibility McNamara had attempted to establish.

There's no official way to collate the individuals who do this so it's the usual ability to operate within a culture of impunity and immunity.

It's typically high profile or senior people, so there's relatively little that can be done about it. Unless and until there's an open scandal because individuals have what are known as gossip biographies where some people know about them.

I have to admit that it's increasingly frustrating. Understandably, funders want reviewers to be positive and polite. I'm always polite but it's difficult to describe flaws and incompetence in a way that wouldn't attract criticism of not being positive.

The day is probably not far off when I give up the unequal struggle because it's not worth the aggravation.

Part 2 is now available for all those who are interested, looking at the principles of evidence-based medicine and critiquing the Yale document's approach.

https://jessesingal.substack.com/p/yales-integrity-project-is-spreading-ba7

It looks like there will also be a Part 3 given the expanse of the problems with the Yale team and their work.

Ta very much @Ingenieur for keeping us updated on the new info 👍

I found this section of Singal’s article interesting and a little concerning with regards to the methodology of the Cass Review:

'The University of York systematic reviews didn’t use GRADE. Instead, they used significantly more lenient evidence grading systems that did not hold the studies under examination to the high standard of an RCT. In the Cass Review and the SRs, “high-quality” is genuinely used either colloquially or in reference to these gentler grading systems.

In fact, Gordon Guyatt flagged this as a possible problem with the Cass Review. “There are, as I understand it, appreciable risk of bias problems in the observational studies that are in the literature,” he explained. “But let’s say those observational studies were done well. You could say, oh, observational studies done well. Now we have ‘high quality evidence,’ we have high certainty evidence — well, except the fact that they’re observational studies means you don’t have high certainty evidence. That’s where it could play out as very problematic.”

In other words, even well-done observational studies simply can’t tell us as much as experimental ones, so if you’re using a grading system that is gentler on observational studies, you could end up with an inflated assessment of the body of research. Most of the studies examined by the York University SR team were rated “moderate” or “low” quality, but because under GRADE a study starts at “low” certainty if it is observational, explained Guyatt in a follow-up email, “all this evidence would be low or very low certainty (likely very low)” under GRADE.

So for all McNamara and her colleagues’ concerns that Cass and her SR authors were unduly harsh on the evidence base, the use of a non-GRADE instrument is much more likely to have had the opposite effect, casting the evidence in a rosier light than is warranted by normal medical-evidence standards.'

Since the Cass Report was released, I’ve been puzzled by Cass making statements that show she accepts gender identity as existing medically rather than being a culture-bound psychiatric syndrome and also I was very unhappy that she recommends clinical trials of puberty blockers. Having read the above section of Singal’s article has given me some insight into why Cass may be making these statements based on the assessment criteria used for the available evidence.

Yes this is a curious section. It is interesting that the evidence might be overstated even within the Cass report, which is damning.

I'll need to digest it in a bit more detail before I can speculate on motive, but I'd initially assumed Cass's working assumptions about the existence and nature of gender identity were made to avoid accusations of bias, while simultaneously introducing a new bias in the TRA's favour...

There's increasing pressure on NICE and other guideline making bodies to accept Real World Evidence and observational studies in areas where there is a paucity of randomised controlled trials. The paucity of adequate research in this area makes it a prime target for that and that's before considering the potent admixture of ideology having been permitted to drive clinical practice and to trump EBM.

There is a STROBE checklist for assisting with the reporting of observational studies but there's an annoying tendency to conflate these with validation of the studies or a quality assessment of them.

Among 19 systematic reviews, 10 (53%) used STROBE inappropriately as a tool to assess study quality. Conclusions: The STROBE reporting recommendations are frequently used inappropriately in systematic reviews and meta-analyses as an instrument to assess the methodological quality of observational studies

da Costa BR, Cevallos M, Altman DG, et al. Uses and misuses of the STROBE statement: bibliographic study. BMJ Open 2011;1:e000048. doi:10.1136/bmjopen-2010- 000048

https://bmjopen.bmj.com/content/bmjopen/1/1/e000048.full.pdf

Cuschieri S. The STROBE guidelines. Saudi J Anaesth. 2019 Apr;13(Suppl 1):S31-S34. doi: 10.4103/sja.SJA_543_18. PMID: 30930717; PMCID: PMC6398292.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6398292/

I'm pleased to see Singal make such a transparent correction about Langton.

I wonder if the contriversy and manufactroversy around the Cass Review will lead to a consensus exercise about whether or not there need to be guidelines about reporting contentious practices driven by ideology.

Well-respected Hilda Bastian was brought in by Cochrane to resolve some matters around the contested reviews for ME/CFS although that does have a major RCT (contested as it is). Gender identity is plainly an area shaped and driven by ideology.

If EBM tolerates ideology-driven interventions without attempting guidance around assessing ideology, the EBM movement is in for a very rough ride with profound consequences for the soundness of clinical guidelines and decision-making, never mind informed consent and shared-decision making.

Thank you Rethinking for that additional information; it’s both fascinating and worrying.

If Evidence Based Medicine is an attempt to get away from medical decisions made as a result of patient feelings, personal clinician experience, and anecdata then an increasing push to include less stringent methods of data collection seems likely to dilute the effectiveness of evidence gathering and analysis. And, as you say, is very likely to be more susceptible to influence by patient lobby groups or to ideological capture.

So what I don’t understand is why researchers would go along with it. Is it because of the pressure to publish? Is it because some clinics/clinicians want to prescribe certain treatments and this is a way of getting permission to do so?

As a follow-up, Part 3 is now available

https://jessesingal.substack.com/p/yales-integrity-project-is-spreading-dbb

In summary:

“An Evidence-Based Critique of ‘The Cass Review’ on Gender-affirming Care for Adolescent Gender Dysphoria” is a calumnious 30-car pileup of scientific misinformation. It offers an ugly, remarkably messy case study on what happens when highly credentialed, trusted experts simply stop caring about the truth, when they let the pull of political righteousness guide them instead. Legitimate disagreement is one thing, but a paper this flawed and this dishonest should leave a mark on any institution or scientist who promotes it. It’s really that bad. Yale Law School should be exceptionally careful about promoting the work of “The Integrity Project” going forward."

Ouch.
That is an undeniably eloquent statement of fact.
Shame on Yale, and all those who did (and still do) use their nonsense to argue for GI and transitioning children.
Contemptible, unscientific and dangerous - the authors of the critique need to be disciplined and retract the paper.

@SeethingHarpie yes definitely.

It's instructive that Singal also attempted to contact the authors to clarify a number of points, including a few examples of definitively incorrect statements, and the authors refused to respond.

I wasn't expecting Part 3 to be quite as damning as it was, but it just keeps on giving!