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Well, the final report of the Cass Review just dropped. It's getting coverage in mainstream publications like the BBC. Surprising no one who paid attention to the interim report, it concludes that there is insufficient evidence in the realm of trans healthcare for children:
Critics are already jumping on the fact that the report used the GRADE approach to categorize evidence, which only allows randomized control studies to be classified as "high quality of evidence" and which can drop non-blinded studies one level in assessed quality, thus preventing many non-blinded studies from qualifying as high quality evidence. (Bold is edit added later. See ArjinFerman's response below, and my response - original GRADE standards can be found here.) The critics point out that double-blinded randomized control studies just aren't possible in some areas of medicine. For a simple example, if the intervention is something like "cosmetic breast augmentation", then there's logically no sensible control group - since there's no placebo that can make people believe they got bigger breasts when they didn't. (It's worth pointing out that this criticism of GRADE isn't unique to trans activists. The Wikipedia page for GRADE mentions it is criticized in general when it comes to slowly progressing diseases like atherosclerosis, where observational studies are easier to perform than RCTs.)
As a result of the GRADE approach, we read things like this in the report:
My own opinion is that I can partially agree with Cass that I want to see higher quality studies around trans healthcare for children in general, but I think that her methodology (using GRADE) is of the sort that will always say we "don't have enough high quality studies", and so her arguments don't have legs to stand on. A problem I see a lot in studies is using some "industry standard" for investigating a topic, and coming to a result of some kind, but failing to justify why the "industry standard" was the best thing to use here. In a better version of the Cass Review, I would have liked to see a few paragraphs justifying the use of GRADE, and explaining why they used this standard and not some other standard.
I mean, isn't that a thing good scientific reports in general do at all steps of the process? Think of what a critic would claim about your model and methodology, and then explain why your model or methodology is the best one to use in this particular instance. Show that your findings are robust even if you used some slightly different model or methodology, and explain what conditions are necessary for your model or methodology to fail. A quick search through the Cass Review shows that it doesn't seem to have done this. It just used GRADE, didn't really justify the decision, and didn't discuss alternatives or why its arguments are robust under alternative assumptions about the data.
It's a bit circular to arbitrarily use a standard that will say, "there are basically no high quality studies in this medical field" no matter what, and then to conclude in your recommendations to the government, "We need more high quality studies before we do anything more in this medical field!"
And the critics are wrong. If you give a treatment to one group, and not give it to another to another, that's still an RCT. Or you can offer an alternative treatment to the control group. It's a plus when you can blind a patient to what they're getting, but it's not a strict necessity. In this case it's probably just as important to blind the researchers when they're assessing results as to blind the patients themselves.
That demand seems arbitrary to me, and "that's what we use for everything" is a perfectly fine justification.
Where did you get the idea that the decision was arbitrary? That studies with a control group are better than studies without one, or that random samples are better than self-selected surveys, isn't something that Cass ceme up with on the spot. The critics are more than happy to use the same strict standards when dismissing studies they don't like (see: ROGD).
This is all without going into the juicy details about some of these studies, some of which are hilariously bad. The "Dutch study" that kicked off the whole puberty blockers thing would most likely get the same result, even if you replaced blockers with farting in the patient's face, for example.
My opinion is that trans activists and researchers wildly oversold the scientific basis for the interventions they were promoting, and sometimes they were outright lying ("puberty blockers are reversible"). They could have just not done that, and tried to gradually accumulate stronger evidence. But the way things are, gender medicine should have never seen such widespread adoption, and people who allowed it should probably be punished.
Addressing the other parts of your post:
I agree it's "fine" from a CYOA point of view, as in, no one will be able to blame you for using a standard tool used across the industry. But from the perspective of trying to perform a Bayesian update based on the final report, I'm not sure I agree.
A lot of the scientific method in general is a heuristic crystallization of Bayesian approaches, and so I have no doubt that a lot of what is present in GRADE is justifiable across a wide swath of evidence, and comes to largely the same answer as a Bayesian approach would. But I think that if GRADE systematically downgrades some kinds of evidence from being "high quality", which in a proper Bayesian approach wouldn't require any serious adjustment, that can lead to certain evidence being ignored or de-emphasized compared to where it should.
I think absent any other evidence, just the existence of the Replication Crisis is enough to call a lot of medicine into doubt, and I see no reason why this wouldn't apply to trans healthcare. That the evidence is weaker than often claimed, is almost certainly true. (I'm not sure that that isn't the case for a wide variety of healthcare fields as well though - is trans healthcare uniquely bad, or is it just as bad as medicine as a whole, and do we need to adopt a whole swath of reforms to deal with things like p-hacking, the file drawer effect, small sample sizes, etc.)
I agree with Cass' conclusion, even if I question her methodologies, because I want to see higher quality medical evidence around trans issues, and especially trans kids. I want the medical research to be beyond reproach, whatever conclusions it comes to.
The basic problem with medicine, across the board, is that we're routinely doing barbaric things to be people, and the only justification we can have is that the evidence shows it will have a better outcome for the patient. Chemotherapy involves poisoning a patient with the hope that the poison will kill the cancer faster than it kills the patient. Amputating a limb might be a tough decision sometimes, but it is most justified if a patient would likely die if you didn't do it.
I want the evidence we use in all instances, especially trans healthcare to be airtight so that no one can say we're poisoning people or removing functional limbs or organs for no reason. It'll still be "barbaric", but if it can be justified as much as chemotherapy, then I think trans healthcare will be in a good place.
Well then I have 4 words for you: isolated demand for rigor. If you want to throw out all the published studies, and force the authors to do them right, I'm game. If we're supposed to apply the highest standards to Cass, and ignore the gaping holes in the literature published to date, I don't think you'll get a lot of people signing up for that.
As per my other comment, I've seen no indication that it does. The whole argument smells like a scramble to get some talking points out ASAP so the report doesn't get to circulate uncontested, even for just a few days.
There's a few major differences between cancer/chemotherapy and dyshporia/GAC. For one, the risks of cancer are pretty well measured. A doctor can tell you "you have an X% chance of living Y months/years" and be mostly right. By contrast a GAC doctor saying "would you rather have a happy daughter or dead son" is stoking fears that aren't justified by data at all. We are also open about the mechanism and effects of chemotherapy, every doctor will tell you it's basically poison, but the hope is it will kill your cancer before it kills you. By contrast puberty blockers are declared to be a magical pause button, safe, and fully reversible. That's just an outright lie. We also have good data about the chances of chemotherapy working, but not for puberty blockers improving outcomes for dysphoria. Finally, even if the decision to undergo treatment is the right one based on available data, we only do it with informed consent, which we tend to not have in case of GAC, by gender clinicians' own admission (see: WPATH Files).
You're right that there are issues in all of medicine, but we ensured there are some guardrails around it to minimize the barbarity. The guardrails were happily abolished for GAC at the insistence of trans activists, and the result is that "gender affirming care" is a lot more barbaric than other forms of medicine practiced today.
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