Trans people make Glasgow

This isn't shocking to anyone versed in gender studies there's like a dozen academic books offering slightly different versions of this history.

Or should we favour inaction, no matter how much harm it seems certain to cause, until an arbitrary (and possibly unachievable) threshold is passed?

I’m very much of the view that the former is the only morally defensible course of action.

The really important question that data CAN’T answer is ought we draw our conclusions about the right course of action from the best evidence available while ethically pursuing even stronger evidence?

It should also be clarified that the Cass Review didn’t downgrade studies for not being RCTs (the NOS is used to assess non-randomised trials) but did downgrade them for not having a non-treatment control group or if too many members of the control group got fed up and quit.

This is the sense in which the Cass Review absolutely did ignore almost all evidence on the efficacy & safety of PBs and CSH. The majority of moderate certainty studies were included in the results section but then arbitrarily ignored in the conclusion entirely.

What conclusions would you draw from this?

Our intrepid authors draw no conclusions from this whatsoever, instead declaring the evidence for every outcome for which there was no high certainty study “inconclusive.”

Similar is true for other outcomes and for puberty blockers.

The review found 5 studies of moderate certainty relevant to psychological health. All 5 supported the conclusion that treatment of trans teens with CSH improved psychological health. There were no findings of worsening psychological health.

This is what is meant when people like Barnes insist Cass didn’t through out most of the evidence. 34 out of 53 studies made it in. But there’s a twist.

Let’s use psychological/mental health outcomes of CSH as an example.

In the CSH review, out of 53 studies the authors assessed 1 as high certainty, 33 as moderate, and 19 as low. The high certainty trial only dealt with side effects. The 19 low certainty studies were excluded from further analysis and the 1+33 were synthesised in the review.

Certainty is an estimate of how confident the authors are in that the effect reported by the study in question is similar to the true effect (i.e. the effect that would be measured if we had a god’s-eye-view.)

NOS works by assessing studies by a list of criteria and assigning points for each box they tick. Based on it’s total point score, each study is designated either ‘low’, ‘moderate’ or ‘high’ certainty.

The reviews sifted through the available studies and used a variation on the Newcastle-Ottawa Scale (NOS) to grade each study as high, moderate or low certainty (the word used by the authors is “quality”).

Cass commissioned a series of systematic reviews from the University of York, two of these looked at the outcomes of treatment with puberty blockers and with cross sex hormones. We’ll focus on the latter for our example.
adc.bmj.com/content/early/…

Did the Cass Review disregard the evidence of all but 2 of 103 studies on puberty blockers & hormones to reach it’s conclusions? Yes and no.

I’d like to offer a brief breakdown of what they did & didn’t do & clear-up some misunderstandings.
twitter.com/hannahsbee/sta…

pardon my language but this is 'you'll be horny and hench but we dunno if you want that (regardless of what you say) so there's an unknown and it's hard to tell you about the material risk (of you not wanting that)'
it's a distortion of Montgomery.

Montgomery is clear that a doctor's duty of disclosure is sensitive to the facts, the patient's characteristics and values.
conceptualising the effects of T as an 'unknown' because the person hasn't been an adult 'c*s-gender woman' rests on presuming and problematising values.

it argues that a person on T wouldn't have 'experience as an adult c*s-gender woman' and, as such, 'may have no frame of reference to cause them to regret or [but] may have had a different outcome without medical intervention [and] not needed to take life-long hormones.'

there is a strand of logic here, but it takes Montgomery out of its clinical negligence context and into a regulatory realm in which it did not originate.
the report goes on to discuss issues of the unknown in this frame.

how does Cass deploy Montgomery?
in an argument about how the presence of unknowns complicates the ability to give such information and, ultimately, to urge extreme caution and restriction about provision of hormonal treatments.