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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!"
Not all randomized control trials are blinded randomized control trials. All you need for a randomized control trial is to randomly assign a group of patients that gets the treatment and a group that doesn't. As far as I know, no long-term randomized control study of gender transition has ever been conducted, in either children or adults.
Non-RCT's are if anything even worse than euphemisms like "moderate-quality" make them seem, reading something like Scott's ivermectin post might help give a sense for it. That's why fields like nutrition, where long-term randomized control trials are impractical, are so terrible despite far more quantity and quality of research than a small field like gender dysphoria.
No, it's way worse than that, the high/moderate/low quality ratings were based on the cited meta-study and seem if anything too lenient. Reading the meta-study, many of the studies only looked at physical outcomes like "is puberty suppressed", they made no attempt to measure psychological outcomes to determine whether suppressing puberty actually provided any benefit. This is the supposed single "high-quality" study. It isn't a randomized control study, it compares patients who have been given puberty blockers to ones who just started the assessment process. (It also compares to a "cisgender comparison group", such comparisons tend to be even more worthless.) Among other potential problems, this means the results are very plausibly just regression to the mean or benefits from the other mental-health care provided. If you think the parents of children with worse self-reported "internalizing, suicidality, and peer relations" are more likely to seek treatment than the parents of children who are currently doing fine, which the study itself shows, then improvement over time is the expected result even if you don't do anything. And then here are the detailed explanations of why they considered the other studies to be even worse.
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