BMJ, Cass review - why the law and medicine make bad bedfellows

[ArabellaScott]

https://adc.bmj.com/content/early/2024/10/13/archdischild-2024-327994.info

Article examining the BMA/Cass debacle and urging acceptance of Cass' advice.

'The original [BMA] motion was based on two non-peer-reviewed online papers, prominently the work of McNamara et al—a paper which was written for a primarily litigious, rather than academic, purpose. We critically examine these sources and analyse the wider legal context in which they have been applied. We conclude that these sources misrepresent the Cass Review’s role and process (specifically, by mistakenly comparing the Review to clinical practice guideline development), while many of the methodological criticisms directed at the Cass Review, including its use of evidence appraisal and systematic reviews conducted by York University, are unfounded.

These misunderstandings, based on flawed and non-peer-reviewed analyses intended for legal (rather than clinical) purposes, jeopardise the implementation of crucial reforms in the care of gender dysphoric youth. The UK clinical community should move beyond these critiques and focus on the Cass Review’s recommendations to establish a safer, more holistic and evidence-based service model for children and young people experiencing gender identity issues.'

Oof, well written, particularly trenchant about McNamara's offering "which continues to undergo multiple silence changes".

In an action at odds with this widespread support, however, the British Medical Association (BMA) Council, without consultation with its wider membership, passed a motion in July to ‘publicly critique’ the Review and called for its implementation to be paused pending this critique.5 This unexpected announcement was founded on ‘concern about weaknesses in methodologies’, referencing two papers: one, a preprint of a paper by Noone et al yet to undergo peer review,6 and another, a non-peer-reviewed online-only paper by McNamara et al, which continues to undergo multiple silent changes.7 Of the two online papers, the paper by McNamara et al, titled ‘An Evidence-Based Critique of ‘The Cass Review’’ and hosted on the Yale Law School’s web page named The Integrity Project,8 is the more extensive, as it incorporates the arguments by Noone et al while adding additional claims of its own. The apparent imprimatur of Yale University on one of the sources may perhaps have imbued it with a status not normally attributed to a web-based publication that had not been peer reviewed. It should be noted, though, that a disclaimer clarifying it had no official endorsement from Yale University was eventually added.
The BMA Council did not specify the basis of its concerns beyond these online sources, nor identify which of the Review’s 32 recommendations it objected to, nor how the impact of a potential pause in the implementation might be mitigated for patients. Following some negative reaction from its membership and the wider clinical community, the BMA subsequently announced that it has changed its position from ‘public critique’ to a ‘position of neutrality’ while it conducts its own review.9

Thank you for sharing. I haven't finished reading the article yet but wow, it's scathing.

A few initial takeaways:

1. it's got several people named as authors. Perhaps it's getting easier to speak up within the medical profession?

2. it makes it very clear that the two papers that the BMJ motion were based on are not recognised as good research: one is from a non-peer reviewed paper which self-IDed as being written by Yale (until Yale said it wasn't) and the other is one "which continues to undergo multiple silent changes" (i.e. one that began and still continues reverse-ferreting)

3. it reminds us that Cass spoke to over 1000 stakeholders, including people who identify as transgender and doctors who support "gender affirming care"

Even though I haven't finished yet, and I'm no medic or medical researcher, it seems blindingly obvious that it's utterly pointless for a geriatrician to spend a year speaking to stakeholders and reviewing evidence for the best care approach for children when a paediatrician has already spent four years doing that. Plus his "neutral" position is that he's reviewing care for "trans children".... which is quite the oxymoron when it comes to the definition of neutrality and David Bell's explanation as to why the phrase "trans children" is unhelpful - it forecloses on the outcome of any exploration of the root cause of someone's distress by examining everything through the lens that the child is trans.

Thanks for sharing this Arabella, it's reassuring to see that the members of the BMA are so keen to distance themselves from the actions of a handful of ideologues at the union.

All of it is very enlightening, but this bit stood out as being particularly scathing: "The apparent imprimatur of Yale University on one of the sources may perhaps have imbued it with a status not normally attributed to a web-based publication that had not been peer reviewed. It should be noted, though, that a disclaimer clarifying it had no official endorsement from Yale University was eventually added."