Last week's SGU podcast episode 995 featured a segment on the Cass review of treatment for children and adolescents with gender dysphoria. The recent review represents four years of research including multiple systematic evidence reviews from the University of York. Following the review, there was a surge of misinformation, including false claims that the review rejected 98% of studies, that the review rejected studies of treatments for not being double-blind placebo-controlled trials, among other claims including conspiracy theories from people being upset with the findings that challenged the quality of research and evidence basis for current practice. The Cass team was forced to issue a FAQ to counter some blatant misinformation.
In the SGU podcast, Steven Novella repeats misinformation so egregious it appears he has not read the review (although he claims to have done so) and is basing his view on misinformation which he has accepted uncritically. This is assuming, of course, that he is not simply lying. I will list the misrepresentations and falsehoods. This is not the place to argue about the review itself, but to discuss the inaccuracy of the claims made.
1) Novella starts with the false statement that the review '.... included cross-sex hormones and gender affirming surgeries, you know, either breast reduction surgery, mastectomy, or vaginoplasty, or whatever, right? So, you know, basically genital surgery.'
Fact: The review dealt only with paediatric patients (under 18) and gender-affirming surgeries are not used in the UK on minors, so were not included. Although it is not an example of online misinformation, it suggests Novella did not read the review as he claimed.
2) Novella claims that the review is ' largely in line with the existing standards of care of the Endocrine Society clinical practice guidelines and the WPATH guidelines. This is sort of the major international group looking at gender affirming care, right? So it actually isn't that out of line with the published standards of care that already exist.'
Fact: The University of York conducted systematic reviews of international clinical practice guidelines (evaluating quality of evidence and recommendations) using Appraisal of Guidelines for Research & Evaluation (AGREE) II. The review of guideline quality found most international guidelines, including WPATH and Endocrine Society guidelines, lacked rigour and transparency, and had no clear links between evidence and recommendations. They also reported that the guidelines created an illusion of consensus by cross-referencing each other, and that ‘this may explain why there has until recently been an apparent consensus on key areas of practice for which evidence remains lacking’. The review team recommended only the Swedish and Finnish guidelines for practice (which both recommend rolling back medical transition of minors). In view of this, Novella’s statement that the Cass recommendations are consistent with WPATH/ES practice again suggests he has not examined the review and is repeating misinformation designed to deflect criticism.
3) Most seriously, Novella repeats misinformation that the Cass review disregarded studies of hormone treatments for not being double-blind placebo-controlled trials. This false statement was already debunked on the FAQ to the review and on various interviews given by Cass. Novella first asserts without providing any evidence that the review did not follow any established standard for evaluating evidence quality but ‘made it up as they went along’. This appears to be accusing the University of York team of fraud or incompetence. He then falsely claims that studies of hormone treatments were rejected because they were not DBPCT, and that this means the review ‘rigged the game’ by rejecting good evidence for not meeting an impossible standard.
Fact: The UoY reviewers used a modified version of the Newcastle-Ottawa scale for evaluating non-randomised studies to evaluate studies of hormone treatments. This scale does not downgrade studies for not being double-blinded. The version used for Cass did not downgrade for not being single-blinded either. The cut-off for rejecting a study of low quality was a rating of <50%, which his lower than often used. Even by this lenient system, nearly half the research was low quality and almost all the remaining studies only moderate. No studies were rejected or downgraded for not being DBPCT, all studies could have scored 100% on the scale if they were well designed and conducted. This lenient rating method was used because a previous NICE review employed GRADE and rejected nearly all studies for not being blinded RCTs (as did other reviews from Germany and Sweden). If Cass had wanted an excuse to reject evidence, she could have simply accepted the NICE reviews and not bothered to commission a new research programme.
This is particularly egregious given that he claims these false statements about methodology are the main reasons for US organisations not accepting the review. There is now a new surge in people repeating this misinformation online and I have not seen any attempt by SGU to issue a correction. This suggests that they do not actually care about promoting misinformation if it protects an approved narrative.
In the SGU podcast, Steven Novella repeats misinformation so egregious it appears he has not read the review (although he claims to have done so) and is basing his view on misinformation which he has accepted uncritically. This is assuming, of course, that he is not simply lying. I will list the misrepresentations and falsehoods. This is not the place to argue about the review itself, but to discuss the inaccuracy of the claims made.
1) Novella starts with the false statement that the review '.... included cross-sex hormones and gender affirming surgeries, you know, either breast reduction surgery, mastectomy, or vaginoplasty, or whatever, right? So, you know, basically genital surgery.'
Fact: The review dealt only with paediatric patients (under 18) and gender-affirming surgeries are not used in the UK on minors, so were not included. Although it is not an example of online misinformation, it suggests Novella did not read the review as he claimed.
2) Novella claims that the review is ' largely in line with the existing standards of care of the Endocrine Society clinical practice guidelines and the WPATH guidelines. This is sort of the major international group looking at gender affirming care, right? So it actually isn't that out of line with the published standards of care that already exist.'
Fact: The University of York conducted systematic reviews of international clinical practice guidelines (evaluating quality of evidence and recommendations) using Appraisal of Guidelines for Research & Evaluation (AGREE) II. The review of guideline quality found most international guidelines, including WPATH and Endocrine Society guidelines, lacked rigour and transparency, and had no clear links between evidence and recommendations. They also reported that the guidelines created an illusion of consensus by cross-referencing each other, and that ‘this may explain why there has until recently been an apparent consensus on key areas of practice for which evidence remains lacking’. The review team recommended only the Swedish and Finnish guidelines for practice (which both recommend rolling back medical transition of minors). In view of this, Novella’s statement that the Cass recommendations are consistent with WPATH/ES practice again suggests he has not examined the review and is repeating misinformation designed to deflect criticism.
3) Most seriously, Novella repeats misinformation that the Cass review disregarded studies of hormone treatments for not being double-blind placebo-controlled trials. This false statement was already debunked on the FAQ to the review and on various interviews given by Cass. Novella first asserts without providing any evidence that the review did not follow any established standard for evaluating evidence quality but ‘made it up as they went along’. This appears to be accusing the University of York team of fraud or incompetence. He then falsely claims that studies of hormone treatments were rejected because they were not DBPCT, and that this means the review ‘rigged the game’ by rejecting good evidence for not meeting an impossible standard.
Fact: The UoY reviewers used a modified version of the Newcastle-Ottawa scale for evaluating non-randomised studies to evaluate studies of hormone treatments. This scale does not downgrade studies for not being double-blinded. The version used for Cass did not downgrade for not being single-blinded either. The cut-off for rejecting a study of low quality was a rating of <50%, which his lower than often used. Even by this lenient system, nearly half the research was low quality and almost all the remaining studies only moderate. No studies were rejected or downgraded for not being DBPCT, all studies could have scored 100% on the scale if they were well designed and conducted. This lenient rating method was used because a previous NICE review employed GRADE and rejected nearly all studies for not being blinded RCTs (as did other reviews from Germany and Sweden). If Cass had wanted an excuse to reject evidence, she could have simply accepted the NICE reviews and not bothered to commission a new research programme.
This is particularly egregious given that he claims these false statements about methodology are the main reasons for US organisations not accepting the review. There is now a new surge in people repeating this misinformation online and I have not seen any attempt by SGU to issue a correction. This suggests that they do not actually care about promoting misinformation if it protects an approved narrative.
