Brilliant work here! As a fellow scientist, I appreciate this hard look at how data is chosen and framed for a review. And clearly this is a case where the conclusion was written and pre-determined, and then they went out looking for articles to support that conclusion.
Excellent as ever, Gideon. I just had two points that I think might need some clarification. I would kind of agree with Cass that the treatment of mental health conditions in the UK is extremely inadequate, but that is not the same as saying that the GiDs team did not do a thorough (6+ session) assessment which will have some therapeutic elements, or that their approach ignored these aspects. The other point is that I think Cass quite subtly and sneakily does put social transition within the realm of the medical. By doing a systematic review on it and consistently emphasising that social transition is an intervention, with downsides as well as potential upsides, she has effectively terrified anyone who is not a specialist into 'watchful waiting' as regards social transition (meaning by default no transition), and opened the door to the government's extremely draconian guidance on transition within schools.
“At best, we could say that psychological and psychosocial interventions could theoretically have benefits for trans teens, but that they seem less effective than medical assistance.”
I don’t see where you got that psychological and psychosocial interventions are less effective for children with gender dysphoria than medical interventions. Yes, the studies looking at psychological interventions are low quality but so are the studies looking at medical interventions. And that single study that found more improvement in the children who also received puberty blockers was also of poor quality. Given all this, we can’t say that medical interventions are more effective than psychological ones.
It’s also important to note that decisions about medical treatment involve not just comparisons about the effectiveness of each treatment but also a consideration of the trade-offs of each approach. Medical interventions for gender dysphoria have not shown to be superior, have significant side-effects, and can lead to permanent changes that are unwanted in children who might eventually overcome their gender-related dysphoria. Given current state of the research, it makes sense to take a wait-and-see approach, or to first try psychotherapy to see if that helps resolve the gender-related distress.
As I acknowledge, the evidence is sufficiently low-quality that we cannot necessarily draw causal conclusions in either direction. But to the extent that we have data, it seems to support the belief that psychological therapies are less effective than medical management for the treatment of gender dysphoria.
Of course, treatment decisions are complex, which is why it's important to be honest about the data that we have. For example, there is consistent data supporting the use of cross-gender hormones that was considered of moderate or high quality by the University of York reviewers, while there is no such data supporting the use of psychotherapy at all. There is also no data on the potential long-term harms of psychotherapy, but there are studies looking at 3+ years of data for hormones. Those are, I think, interesting facts to consider.
The key thing the review fails to consider is that we have been doing medical interventions for transgender youth for decades now.
We know the outcomes, we know the regret rates.
From that, we know that gender-affirming care works and is well-tolerated.
Whether it is the best tool possible is an interesting point of study, but you don't throw out the chemotherapy until you have sufficient data to show that talk therapy isn't more effective for cancer.
Forcing young people to go through the wrong puberty is hugely damaging to their mental and physical health. The review completely fails to weigh that harm against the potential harm of intervention.
The only possible conclusion that can be drawn from the data is to maintain medical options - which we know work - until we have proof that a different approach offers better outcomes.
“improving gender dysphoria - the entire point of the document” This doesn’t seem like an accurate statement of the entire point of the Cass Review, which seems to be focused on overall mental and physical health rather than relieving gender dysphoria specifically with no consideration of the bigger picture.
Boy, we’re really in an age of pseudoscience and weird political campaigns to hype the public up to be suspicious of medicine in ways essential to human lives. You got your antivaxxers, you got your antiabortion crowd, you got your antitrans people. Now we have new attacks on IVF and birth control in the USA.
I will always wonder what the ultimate causes are. The effects, I suspect, are going to be destruction of the value of the individual, and the right of individuals to freedom and quality of life. I suppose it is all just authoritarianism under a camouflaged umbrella.
"thinking that there is not treatment that the authors of the Cass review believe should be given to children specifically for gender dysphoria" -> "no treatment"
Brilliant work here! As a fellow scientist, I appreciate this hard look at how data is chosen and framed for a review. And clearly this is a case where the conclusion was written and pre-determined, and then they went out looking for articles to support that conclusion.
Excellent as ever, Gideon. I just had two points that I think might need some clarification. I would kind of agree with Cass that the treatment of mental health conditions in the UK is extremely inadequate, but that is not the same as saying that the GiDs team did not do a thorough (6+ session) assessment which will have some therapeutic elements, or that their approach ignored these aspects. The other point is that I think Cass quite subtly and sneakily does put social transition within the realm of the medical. By doing a systematic review on it and consistently emphasising that social transition is an intervention, with downsides as well as potential upsides, she has effectively terrified anyone who is not a specialist into 'watchful waiting' as regards social transition (meaning by default no transition), and opened the door to the government's extremely draconian guidance on transition within schools.
Thank you for your work here. We need to use this to get the incoming government to halt this dangerous path they are on.
“At best, we could say that psychological and psychosocial interventions could theoretically have benefits for trans teens, but that they seem less effective than medical assistance.”
I don’t see where you got that psychological and psychosocial interventions are less effective for children with gender dysphoria than medical interventions. Yes, the studies looking at psychological interventions are low quality but so are the studies looking at medical interventions. And that single study that found more improvement in the children who also received puberty blockers was also of poor quality. Given all this, we can’t say that medical interventions are more effective than psychological ones.
It’s also important to note that decisions about medical treatment involve not just comparisons about the effectiveness of each treatment but also a consideration of the trade-offs of each approach. Medical interventions for gender dysphoria have not shown to be superior, have significant side-effects, and can lead to permanent changes that are unwanted in children who might eventually overcome their gender-related dysphoria. Given current state of the research, it makes sense to take a wait-and-see approach, or to first try psychotherapy to see if that helps resolve the gender-related distress.
As I acknowledge, the evidence is sufficiently low-quality that we cannot necessarily draw causal conclusions in either direction. But to the extent that we have data, it seems to support the belief that psychological therapies are less effective than medical management for the treatment of gender dysphoria.
Of course, treatment decisions are complex, which is why it's important to be honest about the data that we have. For example, there is consistent data supporting the use of cross-gender hormones that was considered of moderate or high quality by the University of York reviewers, while there is no such data supporting the use of psychotherapy at all. There is also no data on the potential long-term harms of psychotherapy, but there are studies looking at 3+ years of data for hormones. Those are, I think, interesting facts to consider.
The only thing to conclude would then be to have no treatment available at all.
The key thing the review fails to consider is that we have been doing medical interventions for transgender youth for decades now.
We know the outcomes, we know the regret rates.
From that, we know that gender-affirming care works and is well-tolerated.
Whether it is the best tool possible is an interesting point of study, but you don't throw out the chemotherapy until you have sufficient data to show that talk therapy isn't more effective for cancer.
Forcing young people to go through the wrong puberty is hugely damaging to their mental and physical health. The review completely fails to weigh that harm against the potential harm of intervention.
The only possible conclusion that can be drawn from the data is to maintain medical options - which we know work - until we have proof that a different approach offers better outcomes.
Well said
“improving gender dysphoria - the entire point of the document” This doesn’t seem like an accurate statement of the entire point of the Cass Review, which seems to be focused on overall mental and physical health rather than relieving gender dysphoria specifically with no consideration of the bigger picture.
Boy, we’re really in an age of pseudoscience and weird political campaigns to hype the public up to be suspicious of medicine in ways essential to human lives. You got your antivaxxers, you got your antiabortion crowd, you got your antitrans people. Now we have new attacks on IVF and birth control in the USA.
I will always wonder what the ultimate causes are. The effects, I suspect, are going to be destruction of the value of the individual, and the right of individuals to freedom and quality of life. I suppose it is all just authoritarianism under a camouflaged umbrella.
"thinking that there is not treatment that the authors of the Cass review believe should be given to children specifically for gender dysphoria" -> "no treatment"
"should receive one for of care" -> form of care