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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!"
Were there even any randomized, non-blinded studies cited? I skimmed the references and didn't see anything. And it'd make sense that there aren't any randomized trials of puberty blockers or hormones given the emotional weight everyone puts on the issue. I'm not sure how this is relevant unless there are specific 'non-blinded studies' that aren't classified as 'high quality'.
Or maybe you're referring to a more sophisticated criticism, that these "critics" are making. What critics? Where? May we have a link?
Why make this particular criticism? How does it tie into the main claims the report makes? Can you at least outline the core of the report, what it wants to tell us and how it attempts to support those claims, before you attempt to undermine it? This is like a twitter swipe - take a thing, point out a "flaw", write like this flaw is a critical flaw, and watch as everyone's satisfied that the bad guys were wrong again, without anyone involved understanding what the thing even is.
It'd be more interesting to explain the context behind the report - the politics and medical practice in youth transgender medicine in the UK for the past few years - and then explain what the report claims, and then go into the reactions it's gotten.
If you want a criticism, I think the best one is just: There are ethical (it's conversion therapy for the control group) and methodological reasons to not do RCTs in trans youth. Given that, we need to use the evidence we have, and a standard requiring RCTs is bad.
(edited because I used the wrong link)
I'd dispute that - there's a reason high quality evidence requires RCTs, it's because history has shown that observational studies are just not reliable. If you disagree, I'd suggest picking a specific study (not review) that this review considered low-quality but you think is good enough to form part of the foundation for a medical guideline, and we can critically examine it and see if it is. I don't think there are ethical reasons to not do RCTs for trans youth that wouldn't also apply to RCTs for treatments for deadly diseases, which we do all the time when it isn't clear if the treatment is beneficial or not. I think the methodological reasons are ... significant, but (guessing) not in fact worse than the problems with observational studies.
Not only were they cited, the study that got graded "high quality" wasn't even really randomized, let alone blinded. Here's a list of all the papers the systematic review of puberty blockers looked at, and a breakdown of their grades.
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