Talk:Cass Review

Mostly news articles?

This article currently relies way too much on news articles covering it for a medical topic. Is there a reason why this published paper isn't in use in the article? Silverseren^C 20:43, 10 April 2024 (UTC)

No, and I agree - I think the sections should be citing the report directly, following the structure and wording of the review and recommendations, and news articles reserved for commentary/reaction. Void if removed (talk) 20:55, 10 April 2024 (UTC)

I agree: it's a long and detailed report and there needs to be a summary of the different focuses of the report, the recommendations noted and then, in the separate criticism section, commentary and reactions from others. Zeno27 (talk) 22:07, 10 April 2024 (UTC)

I disagree. I think it's probably a good idea to use the report itself and various statements as primary sources sparingly.

If points in the report haven't been covered elsewhere, they aren't notable enough to be included. Points covered in widely recognised reliable sources which have had time to digest, analyse, and summarise the report should be sufficient in detail for this article, which is a summary of the most notable aspects of a ~400-page report.

If a group has put out a statement that hasn't been covered in a reliable news source, it isn't notable enough to warrant its inclusion. Such a statement probably isn't a reliable source in and of itself anyway. 13tez (talk) 17:00, 17 April 2024 (UTC)

I think it is fair for us to summarise the reports main points just as we summarise a book. The published paper the OP mentions has been well discussed and refers to some draft text and out of date as it complains about the NICE reviews from 2020 rather than the BMJ reviews from 2024.

Wrt news articles, this is a report with health service implications and political implications and those are likely to be covered by the news rather than MEDRS sources. Were the article needs to discuss WP:BIOMEDICAL aspects, this report is often itself a first class secondary source (as are the systematic reviews it refers to). -- Colin°^Talk 16:14, 18 April 2024 (UTC)

My main reason for using news articles when writing the sections this morning was that for a 400 page report, I wasn't certain what would qualify as WP:OR, so I wanted to rely on secondary coverage. Snokalok (talk) 22:32, 10 April 2024 (UTC)

The article OP linked should count as a secondary source. Flounder fillet (talk) 03:16, 11 April 2024 (UTC)

I agree Snokalok (talk) 07:09, 11 April 2024 (UTC)

Yes I think that's fair to flesh it out initially, I think we should aim to reference the review and the 9 accompanying MEDRS in the body in preference now: https://adc.bmj.com/pages/gender-identity-service-series Void if removed (talk) 07:52, 11 April 2024 (UTC)

Criticism

The sentence that begins "Academic criticism also fell on the report..." in the Criticism section references a paper (Horton, 14 Mar 2024) that pre-dates the publication of the final report. Is there a better source for this? Zeno27 (talk) 15:49, 11 April 2024 (UTC)

Trying to track the original source for this: "Dr. Natacha Kennedy of the Feminist Gender Equality Network described the Cass review as "attempting to establish an all-enveloping ambient conversion therapy approach to trans children".[21]". This cites PinkNews but the article says, "In an opinion piece on the report, Dr Natacha Kennedy, co-chair of the Feminist Gender Equality, criticised the report’s approach to analysing research." but there's no link to where Kennedy says this and a Google returns nothing. Any idea where this opinion piece is? Zeno27 (talk) 16:42, 11 April 2024 (UTC)

Just answering both comments in 1, I believe the Horton paper is a response to the interim report and this should be noted in that section. And with 2 I don't believe it is the editors job to ask where a source got it's sources. However googling that sentence got a blogspot up authored by a Natacha which checking her twitter she does in fact link to so it does seem she did author that comment. LunaHasArrived (talk) 17:20, 11 April 2024 (UTC)

Yes, it should be noted that the Horton paper was referring to the Interim report. I was unable to find Kennedy's blog post - all I got was this page and PinkNews. I'll take another look. Ta! Zeno27 (talk) 17:34, 11 April 2024 (UTC)

Dropping in the PinkNews quote:

“In an opinion piece on the report, Dr Natacha Kennedy, co-chair of the Feminist Gender Equality, criticised the report’s approach to analysing research.

Kennedy wrote that she believes the Cass Report is “attempting to establish an all-enveloping ambient conversion therapy approach to trans children,” saying that the report, if implemented, would remove “their autonomy, freedom of expression, mental health, helpful support and healthcare.”” Snokalok (talk) 17:21, 11 April 2024 (UTC)

This sentence is wrong: "Criticism was also levied for the exclusion of transgender expertise - wherein the original terms of reference for the Cass Review explicitly stated that it "deliberately does not contain subject matter experts or people with lived experience of gender services".[14]"

The quote comes from that reference (Horton) but the full sentence is, "The original published Terms of Reference (ToR) for the Cass Review’s assurance group explicitly excluded trans expertise, stating that it “deliberately does not contain subject matter experts or people with lived experience of gender services”"

That quote does not come from the ToR and the ToR make no mention of the Assurance Group, but from an early description of the Assurance Group on the Cass website. It is therefore not about the review itself, but about the Assurance Group. The purpose of the Assurance Group is explained clearly:

"Members are independent of NHS England and NHS Improvement and of providers of gender dysphoria services, and of any organisation or association that could reasonably be regarded as having a significant interest in the outcome of the Review.

Because the group is advising on process and not outcomes, it deliberately does not contain subject matter experts or people with lived experience of gender services. Professional and lived experience will be used to determine the outcomes of the Review and will be captured through our participative and consensus development approach.

Members have been appointed by the Chair to provide expert challenge from broad perspectives and have proven expertise relating to the conduct of the Review."

So, the Assurance Group is simply about ensuring the review was conducted to high standards.

Therefore, the reference does not say what that sentence says - and neither does the ToR - and is therefore highly misleading and needs to go. Zeno27 (talk) 18:44, 11 April 2024 (UTC)

Criticism sections are generally discouraged as they wrongly create a binary reaction to the subject, and can clump opinions that are more nuanced or varied into being "critical". I don't think we should do that. Also, way way too much room is being given to this opinion piece by some random academic at Oxford Brookes Business School. Not only is it only based on the interim report, but it is just some guy's opinion. If it has weight to be included at all (which I doubt), it would be something like "Dr Cal Horton criticised the interim review as an example of cis-supremacy" and that frankly is it. And our readers would be going "Who the heck is Dr Cal Horton and why should we care what they think" and rightly so. We do not bang on about "the International Journal of Transgender Health" nor do we confused one guy's opinion with facts we can present in Wikivoice. That entire section should be deleted: we don't contrast major four year healthcare reviews with someone from the business school of a minor university. -- Colin°^Talk 19:21, 11 April 2024 (UTC)

Agreed. Zeno27 (talk) 19:26, 11 April 2024 (UTC)

While I understand the view on criticism sections, it's somewhat difficult to not have one here given, everything. Like I get the criticisms of the Cal Horton paper, but a criticism section is somewhat necessary here given the controversial nature of the review. Snokalok (talk) 19:27, 11 April 2024 (UTC)

Oh and this sentence, also sourced to Horton "Academic criticism fell on the report for centering the concerns of professionals who did not believe in the existence of transgender children, for the demand for what is widely recognized as an "infeasible and unethical" level of evidence from studies for affirming treatments, due to requiring a control group to be subjected to what some consider conversion therapy; while non-affirming treatments were not held to the same standard of evidence" is not something we can say in Wikivoice at all, and is frankly such complete bs we should not be even quoting it. Dr Cal Horton is not "academic criticism" as though he speaks for all of academia who are all critical. It is not in any shape or form a universal (or even widespread) belief that what systematic reviews do (assess evidence) is demanding the infeasible and unethical. We are giving way too much voice to extremist positions critical of evidence based medicine.

Snokalok, once you get a Criticism section, it becomes a dumping ground for everyone who gets their opinion published. Do you think all serious minded analysis of the Cass review will entirely fall into wholesale criticism and . oh, wait, nobody created a Praise section. What a surprise. Life is not so simple. There will be serious sources on this review who take a very nuanced reaction. Right now, you only have a place for the critics. That's not NPOV. And it isn't solved by creating a Praise section, I was only joking about that. We just aren't recommended to do this at all. -- Colin°^Talk 19:40, 11 April 2024 (UTC)

I agree with what Colin says. Especially on "criticism"-sections in general, no matter the intention they invariably turn into flypaper for POV-edits. Draken Bowser (talk) 19:47, 11 April 2024 (UTC)

You say this as though crictism/controversy sections are not, incredibly common across Wikipedia. Calling it not NPOV is somewhat ridiculous. As for "infeasible and unethical", it is an incredibly commonly held position in medicine that there are some treatments for which the requirement of blind or double blind tests, are infeasible and/or unethical. Acting as though that's some unique idea here is, flat out incorrect. There are no double blind tests of "One person receives insulin, the other receives water" - that's ethics. Likewise, for feasibility, there are many treatments that are impossible to do blind because when one group starts growing a beard or tits, suddenly everyone knows which side has received hormones. Snokalok (talk) 19:48, 11 April 2024 (UTC)

Many bad ideas are common across Wikipedia, the compendium is a work in progress. Draken Bowser (talk) 19:56, 11 April 2024 (UTC)

I think at the very least if there is going to be a section it needs to be handled with great care. Just a few days ago when reading stuff related to this I came across Great Ormond Street Hospital#Controversies which IMO shows how absolutely terrible such sections can become when not handled properly. [1]

If you don't want to read it, that section currently includes quite a few stuff in the form of "In X date it was revealed". Worse than that, many of these and others in different form seem to be just random mostly clearly bad stuff that undoubtedly happened that was mentioned in the media that some editor decided to add. Some of them might belong, but many of them don't seem to have long term significance. And at least thing there in the gender identities subsection is just a random thing where the controversy isn't even established or obvious.

I mean this article doesn't quite carry the same risks since there won't be so much new stuff all the time, but still the point remains just because plenty of articles have such sections it doesn't mean they're working properly.

Nil Einne (talk) 07:09, 13 April 2024 (UTC)

I don’t actually mind the combined sections here anymore. It’s less organized, to be certain, but not unworkably so Snokalok (talk) 07:40, 13 April 2024 (UTC)

Snokalok, can I suggest you type "RCT on insulin" into your favourite search engine. So much nonsense gets written about this, please let's not be like Twitter where the ignorant argue with the ignorant. Cass is neither stupid nor evil and I'm sure knows more about evidence based medicine than everyone on this talk page many times over. Do you really think they aren't aware of these tired arguments about EBM?

Complaints about infeasibility or ethics are a deflection from basic statistical facts. Let's imagine I toss a coin three times and get heads each time: a 1/8 chance. It isn't proof the coin has two heads. If I now accidentally drop the coin in a drain, continuing the tossing to get a statistically convincing number is now both infeasible and asking you to retrieve it for me would be unethical, as you'd get stuck and drown. That fact doesn't magically make the coin any more likely to have two head. People playing this card, which demonstrates basic statistical ignorance, are like the folk that tell you bumblebees shouldn't be able to fly according to aerodynamics. They are spinning a story while ignoring the obvious: the bumblebees really can fly and the evidence about e.g. puberty blockers really doesn't make the grade any more than my three coin tosses do. -- Colin°^Talk 20:20, 11 April 2024 (UTC)

"Do you really think they aren't aware of these tired arguments about EBM?"

Somewhere around 90% of modern medical practice doesn't have "high quality" evidence backing it up. I think most medical researchers are aware of these arguments, they just don't care about the need for "high quality" evidence because RCT's are an impossible bar for many treatments. My question is why it suddenly matters so much more for this highly politicized and controversial treatment?

"Complaints about infeasibility or ethics are a deflection from basic statistical fact"

They're not, they're an observation that the overwhelming majority of medical care is without such studies backing it up for exactly this reason, and that it's thus unreasonable to demand that standard of evidence for only this specific treatment and no others. Snokalok (talk) 20:32, 11 April 2024 (UTC)

"Somewhere around 90% of modern medical practice doesn't have "high quality" evidence backing it up." This is an old trope caused by a misunderstanding (promulgated extensively by quacks) and usually originates from the BMJ Clinical Evidence page. I don't think that exists any more but it's explained by Prof Ernst here. It's also a tu quoque fallacy. Zeno27 (talk) 21:26, 11 April 2024 (UTC)

https://www.jclinepi.com/article/S0895-4356(20)30777-0/fulltext

As you can see above, "only a minority of outcomes (9.9%) for healthcare interventions are supported by high quality evidence". I'm not saying that high quality means good evidence, I'm saying that the standard for high quality is unfeasible to meet for a wide array of medical treatments, and that's being used here by others to say that there is no good evidence - because for some reason high quality means good evidence only when it applies to gender transition. Snokalok (talk) 21:48, 11 April 2024 (UTC)

No, but what quality of research does the vast majority of children's healthcare require. And let's not pretend that the research is anything like the coin toss example in terms of actual probability (although I do appreciate the good comparison). Also there is this study which is outside of the time period considered but shows that the research is being done and Is there (although the ethics have been questioned about this study). LunaHasArrived (talk) 20:34, 11 April 2024 (UTC)

Your giving undue weight to the review simply because it is a review, and not considering that there is legitimate criticism about it. In general I agree with the points made above, that RCT's is both unethical and largely impossible to implement in the studies rejected. If your review rejects most of the evidence on criteria that has been judged unreasonable on the basis of ignoring the ethical problems inherent with trying to implement said criteria, it is not something that can be ignored in the article itself. I agree Wikipedia shouldn't attempt to balance both sides of the debate in the case where one is overwhelmingly incorrect, but in this case claiming all the opposition are 'extremist voices critical of evidence based medicine' is completely and utterly ridiculous. Not only is there no consensus apart from the Labour Party and a couple of other organisations whether or not the Cass Review is even correct in its findings, it's completely ignoring the legitimate position taken by some critics. Keep and expand the Criticism section if necessary, because it's a reflection of the actual response to the review: Considering how controversial it is to pretend that the response was unending praise and zero backlash is factually incorrect. Angryman120344 (talk) 08:01, 12 April 2024 (UTC)

RCT's is both unethical and largely impossible to implement in the studies rejected

That's not why studies were rejected, and this article should not be a forum for spreading ill-informed opinion about MEDRS. Include the backlash, sure, but some of these specifics need to be backed up and corroborated with far stronger sources IMO.

And just to add, this is now the fourth systematic review into puberty blockers in as many years finding the exact same thing. Void if removed (talk) 13:33, 12 April 2024 (UTC)

The NOS still requires a blind assessment (impossible to do for this form of medicine), and an external control group (meaning one side gets forced through the wrong puberty, raising tremendous ethical concerns) Snokalok (talk) 14:11, 12 April 2024 (UTC)

You can read it in the review itself, but alongside a large number of incredibly vague assertations such as them being 'low quality', yes that is why they were rejected. It's not spreading an 'ill-informed opinion' the point of a criticism section is to reflect the reality that a large group of people have genuine concerns about the methodology and intentions behind the review. Again ignoring this is fundamentally misunderstanding how Wikipedia works. Also you are now making a personal assertation in the same response criticising me for giving weight to a single viewpoint, by once again arguing there is a consensus that puberty blockers are harmful.Just to add, this is now the fourth systematic review into puberty blockers in as many years finding the exact same thing. - This is not only completely irrelevant to my initial point, but is also not a point in of itself, because 1. there is no large scientific consensus on the efficiacy of puberty blockers and 2. To argue that because a review is 'systematic' automatically makes it correct or more worthwhile than the studies that it rejected and should be linked in the article in the Criticism page, is absolutely absurd. This isn't a debate on puberty blockers, but its generally accepted there is no consensus, so kindly stop trying to pretend there is. Angryman120344 (talk) 14:25, 12 April 2024 (UTC)

genuine concerns about the methodology

I think raising specific methodological concerns about a MEDRS, in wikivoice - particularly one of the highest quality - needs a source stronger than popular press, per WP:MEDPOP. Statements from recognised orgs like AUSPATH are, IMO, fine, but a person making an unverifiable claim in passing to the press is not.

To argue that because a review is 'systematic' automatically makes it correct or more worthwhile than the studies that it rejected and should be linked in the article in the Criticism page, is absolutely absurd

That is why a systematic review sits at the top of the MEDRS pyramid. Void if removed (talk) 15:24, 12 April 2024 (UTC)

agreed. it would be better if the criticism sectionw as retitled either "reactions" or "reception" Bird244 (talk) 15:16, 20 April 2024 (UTC)

Request for review of a sentence

Hi all

I'd like someone with a good understanding of research to check the sentence below, my understanding is that the report was criticised by academics for inconsistent standards of evidence. How the sentence in the Background section gives a different impression.

The final report of the Cass Review was published on 10 April 2024. It included several systematic reviews of scientific literature carried out by University of York, encompassing the patient cohort, service pathways, international guidelines, social transitioning, puberty blockers and hormone treatments.

Thanks

John Cummings (talk) 10:50, 13 April 2024 (UTC) John Cummings (talk) 10:50, 13 April 2024 (UTC)

The sentence quoted here isn't incorrect, but I can understand that to a reader that's not used to critically analyzing every source they read (that is, the majority of readers), it could read as lending a credibility to the report when in reality that credibility is in dispute.

It's like how "Studies say XYZ" is a true statement regardless of how credible the studies in question are. The studies could be utter nonsense, but they're still studies and they're still saying XYZ. And most people aren't going to question it beyond that.

Ultimately, if you feel a change should be made, by all means propose it and let it be discussed. Snokalok (talk) 11:03, 13 April 2024 (UTC)

the report was criticised by academics for inconsistent standards of evidence

That is the understanding you will get from reading some opinions in the popular press.

However, Cass is based on 9 MEDRS of the highest quality, none of which have received criticism of equivalent quality. So balancing unevidenced speculation in the press VS the actual MEDRS upon which Cass is based is difficult.

I think that reporting that takes issue with Cass' findings and recommendations is absolutely fair game - but reporting which actually makes specific unverifiable claims about the evidence base should fall foul of WP:MEDPOP, unless it is in an equivalent MEDRS.

For example, I have added the underlying UoY systematic review into puberty blockers to the relevant article - but absolutely none of the evidentiary criticism being levelled at so far Cass would be WP:DUE for inclusion on that page, even though they are actually talking about the same evidence base.

IMO, this page should not be a free for all to inflate non-MEDRS criticism of a highest quality MEDRS. Void if removed (talk) 11:28, 13 April 2024 (UTC)

Why is the praise/agreement regarding the evidentiary findings from Kamran Abassi and Sallie Baxendale considered acceptable then, if the criticism regarding the evidentiary findings from Ada Cheung (to reiterate, the head of trans health research at U of Melbourne) isn't? Snokalok (talk) 11:39, 13 April 2024 (UTC)

I think it is fine to say notable figures and orgs gave their opinion about the standards of evidence - but incorporating the specifics inflate and repeat what are completely unsubstantiated and unverifiable claims about the actual underlying MEDRS in a manner that is a FALSEBALANCE criticism. It isn't even clear what the allegation is about the "four studies" - have they been excluded wrongly? Have they been published after the cutoff? What's actually being said here? It is garbled. Void if removed (talk) 13:46, 13 April 2024 (UTC)

The issue of "inconsistent standards of evidence" is that the actual Cass Review has an absolutely huge scope and so one can find things to criticise and say that recommendation X is has less evidence than recommendation Y. This is not a secret or a surprise. As a statement itself it is pretty meaningly accusation, as one would expect a report of this size to have varied levels of evidence supporting the recommendations. Indeed, I've read quite a few NICE reports on other healthcare matters, and some recommendations have high levels of evidence and some very low, and NICE are very explicit about which recommendations they make are based on solid ground and which are weaker. So really the "inconsistent standards of evidence" is itself nothing more than a statement of reality even though it sounds like and is used as a criticism. Really, it's the sort of argument that indicates to us the source is bs, and not all "academics" are equal. There will be plenty "academics" who think they have an opinion about this, who are not in any shape or form qualified to assess or recommend healthcare practice, but know how to write an essay. -- Colin°^Talk 12:00, 13 April 2024 (UTC)

I mean that's not really what's being said, it's more than there's little to no evidence for the practices the report is advocating, while there is - even by the review's own standards - some degree of evidence for gender affirming care, and yet the recommendations use this presumed lack of evidence for GAC to castigate it in favor of GET which has far less evidence.

It's a matter of confirmation bias, essentially. GET is treated as the default without any evidentiary scrutiny, while GAC needs to prove itself to such a high level as to not be physically possible with medication that changes your physical appearance. Snokalok (talk) 12:14, 13 April 2024 (UTC)

Is it any surprise to me that the "inconsistent standards of evidence" line in our article comes from Cal Horton, see below. You use the word GET as though that appears in the Cass Review. Indeed Cass themselves comment that "Terms such as ‘affirmative’ and ‘exploratory’ approaches have been weaponised to the extent that it is difficult to find any neutral terminology". I think you are attacking a strawman. Please base your arguments on what actually appears in the report and not what twitter feeds. -- Colin°^Talk 12:41, 13 April 2024 (UTC)

Can you go five replies, perhaps, without dismissing what someone else is saying as just twitter? It's beneath you.

Anyway, regarding GET, how would you characterize the therapy it advocates if not as that? Snokalok (talk) 12:53, 13 April 2024 (UTC)

Read section 11 of the report. The evidence base for psychological and psychosocial interventions is also described as low quality. It goes on to recommend that Standard evidence based psychological and psychopharmacological treatment approaches should be used to support the management of the associated distress and cooccurring conditions., about which it previously said, in section 11.36: Some therapies, which are well proven for associated mental health problems, already have a strong evidence base.

So what the review actually seems to recommend is to treat co-occurring conditions with standard evidence-based practices, where the evidence is strong. There is a separate recommendation (6) that the evidence base for both medical and non-medical interventions must be improved. Cass advocates for a "holistic" approach so as to identify psychiatric comorbidities, and give them appropriate evidence-based treatment - rather than assume that gender is the only thing going on.

So in fact it's quite consistent, and if you spot sources complaining that Cass promotes a particular type of psychiatric intervention based on low-quality evidence, that could be a sign that the source hasn't read the review. Barnards.tar.gz (talk) 13:45, 13 April 2024 (UTC)

Right but the meat of the report's recommendations are still that medical pathways should not be deployed for the majority of cases, in favor of psychiatric treatment as the default. That's very much privileging one form of care over the other. Even if the level of evidence for them is the same (which is an if that I by no means cede), that's still recommending one based on low quality evidence and recommending against another based on the same quality of evidence. Snokalok (talk) 14:09, 13 April 2024 (UTC)

Which source disputes which part of Cass in this manner? Barnards.tar.gz (talk) 15:26, 13 April 2024 (UTC)

I think Horton put it well In several sections the Cass Review emphasizes the risk or significance of any affirmative medical or social interventions, whilst negating or ignoring the potential harms of nonintervention or denial of social or medical transition. Trans healthcare is referred to as comprising “challenging decisions about life-changing interventions” [Report 5, p. 18], whilst the denial of trans healthcare is not weighed as a significant or life-changing intervention. This is another example of the Cass Review centering a cisnormative perspective to evidence or decision-making. A trans person being denied affirmative healthcare and being forced through incongruent puberty is not considered “life-changing.”.

Additionally, Support for affirmation of a trans child’s identity is upheld as a medical “intervention” requiring high quality evidence. Rejection or non-affirmation of a child’s identity is presumed the natural default position, requiring no evidence at all. Arguably, denying and rejecting a child’s self-knowledge is a far greater intervention in that child’s life, requiring a greater burden of clinical proof, than simply letting each child assert and affirm their own identity. Yet the Cass Review considers acceptance of a child’s identity as trans as a significant “intervention.” The Cass Review’s position frames rejection of a trans child’s identity as neutral and benign, requiring no evidence for such a policy proposal. Accepting and embracing a trans child is viewed as more extreme and in need of “high quality” evidence. This position demonstrates extreme cisnormativity, with only cis children viewed as natural or inherently worthy of respect and acceptance. This position is also pathologizing, with acceptance of a trans identity considered a medical intervention.

The paper gives many more examples, but the TLDR is that there is "low-quality" evidence transition helps, but no evidence of any quality that denying it helps (with plenty of evidence denying it causes suffering), so concluding that transition is risky and denying it should be the default based on looking at the former and ignoring the latter is not sound science. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 17:57, 13 April 2024 (UTC)

Just to use one very clear example where I think this sentence is missleading, the report choses to ignore 100 of the 102 studies into puberty blockers and hormones they found (Puberty Blockers, para 14.19, and Masculinising/feminising Hormones, para 15.16). John Cummings (talk) 16:59, 13 April 2024 (UTC)

John, did you read that section, or did someone else tell you "the report choses to ignore 100 of the 102 studies into puberty blockers"? Let me quote them (and add one paragraph for better context):

• 14.19 The systematic review on interventions to suppress puberty (Taylor et al: Puberty suppression) provides an update to the NICE review (2020a). It identified 50 studies looking at different aspects of gender-related, psychosocial, physiological and cognitive outcomes of puberty suppression. Quality was assessed on a standardised scale. There was one high quality study, 25 moderate quality studies and 24 low quality studies. The low quality studies were excluded from the synthesis of results.
• 15.15 In addition to the systematic review on care pathways (Taylor et al: Care pathways) discussed in Chapter 13, the University of York conducted a systematic review of the use of masculinising/feminising hormones in adolescents with gender dysphoria (Taylor et al: Masculinising/feminising hormones). This systematic review aimed to synthesise the evidence for gender-related, psychosocial, physiological or cognitive outcomes for the use of feminising/masculinising hormones in adolescents with gender dysphoria/incongruence.
• 15.16 A total of 53 studies met the inclusion criteria. The most frequently reported outcomes were adverse physical health outcomes and the intended development of puberty in the identified gender. A smaller number of studies looked at side effects in relation to bone health and fertility

The 14.19 paragraph refers to Taylor et al: Puberty suppression. When it says "Due to high risk of bias in low-quality studies, these were excluded from the synthesis" this is exactly normal and what systematic reviews do all the time. The 15.15 and 15.16 paragraphs refer to Taylor et al: Masculinising/feminising hormones. The breakdown of what was high/moderate/low for that one is that there was one high quality, 33 moderate and 19 low. It repeats the same sentence about low quality studies. You'll likely find that sentence in pretty much every systematic review. What is the issue here? Snokalok complains about me assuming this crap comes from twitter. Well, where does it come from? The "inconsistent standards of evidence" line comes from an opinion piece that was written well before the Cass Review was published, before either of the systematic reviews were completed, never mind published. Confusing the various criticisms of the Cass Review with two papers that are very much "Taylor et al" is likely a deliberate ploy by some activists, because there's a lot of recommendations that reasonable people may criticise in Cass's review, but the systematic reviews that underpin it less so. They are solid high quality science in one of the worlds most respected medical journals. We really should not be wasting our time with criticism of them by random people on the internet who can't even add up. -- Colin°^Talk 17:35, 13 April 2024 (UTC)

Here! Here! Well said. I agree with and am impressed with Colin's assessment of the situation. It is good to have knowledgeable people on Wikipedia. ---Steve Quinn (talk) 03:18, 15 April 2024 (UTC)

References

Cal Horton

Why is so much guff from Cal Horton still in this article. The several paragraphs of text beginning "A 2024 article in the International Journal of Transgender Health..." needs entirely removed. It is the opinions of someone who is employed by the business school of Oxford Brooks University (a former polytechnic, not to be confused with Oxford University) who's qualifications wrt criticising the Cass Review appear to be "mother of a trans child" who did a phd on that.[2] Sure, they've done some research on trans issues that may well be valuable and could well be a source of information to the Cass Review itself. But our article is presenting their personal opinions, many of which are false and highly contested, as though we consider them a counterbalance to this review. Dozens of people were interviewed and gave their opinions to the Cass Review, and here we give space to one who feels ignored perhaps?

For a start, I think we need to realise that criticisms about how systematic reviews reject low quality evidence that are based on views about the infeasibility or ethics of RCTs, and guff about blinding, are themselves a striking example of misinformation. And Wikipedia needs to avoid being a source of misinformation. Anyone serious about evidence based medicine rolls their eyes when reading such nonsense. It demonstrates deep ignorance of how evidence based medicine really works, and is what you get when you start quoting people who work in a business school rather who's day job is conducting systematic reviews for NICE or Cochrane or whatever. If you don't believe me, please go read some NICE reviews or Cochrane reports on random other bits of medicine like epilepsy or breast cancer or depression or diabetes, and you will find the systematic reviews commissioned and cited by the Cass review are entirely typical and the ethical issues they face not that unusual.

If the approach of these systematic reviews was as outrageous as some trans activists are suggesting it to be, do you really think the BMJ would have published it, or that Cass and their Clinical Expert Group (who assessed the evidence) would not have gone "Hold on a sec, this is demanding the infeasible and is totally unethical"? These are Trumpian-level arguments that sound great to the activist base but should ring alarm bells. -- Colin°^Talk 12:37, 13 April 2024 (UTC)

Firstly it is important to remember that the Cal Horton part is criticism to the interim report specifically. I agree that I think citing criticism of the solely medical aspects of this is probably undue but Horton has done a PhD on trans kids wellbeing and works advising about that so should be credible for the top 3 points. I also think that crediting criticism of the systematic reviews was by transgender activists and not professional health organisations is intriguing. I would also point that some of the criticisms are saying that members of the clinical expert group was inherintly biased and influenced the decision. This idea that the reviews are infallible when health organisations have criticised them is an idea that should not be entertained. LunaHasArrived (talk) 13:12, 13 April 2024 (UTC)

This review also contained peer-reviewed analysis of those self-same organisations and levelled criticism at the weak evidence base and circularity of their standards of care.

Devoting 5 paragraphs to the opinions of a parent advocate of a trans child is way, way overkill. Void if removed (talk) 13:39, 13 April 2024 (UTC)

I agree that the space taken up was overkill Snokalok (talk) 13:50, 13 April 2024 (UTC)

Please remember this is the interim report. I agree with the change that has been made on the page and that the criticism made from the international orgs is far better. LunaHasArrived (talk) 13:52, 13 April 2024 (UTC)

Boldly deleted Horton as recovering the link to the joint statement revealed the low levels of interesting original thought in that paper. Flounder fillet (talk) 13:52, 13 April 2024 (UTC)

The Horton paper is the best peer reviewed scholarly source we have on the Cass Review. It's an entire paper devoted to thematic analyses of multiple documents produced by the Cass Review and was published in the International Journal of Transgender Health, which has been going for almost 3 decades and is a leading journal in the field[3]. Cal Horton has published quite a bit of peer reviewed papers on trans healthcare herself[4] It is not just opinions.

Now, here's the removed text[5]:

A 2024 article in the International Journal of Transgender Health reviewed the publications produced by the Cass Review including their initial Terms of Reference, the NICE reviews into puberty blockers and hormones, an online panel, a survey of healthcare professionals, and the interim report. The paper found four areas of concern:

• Prejudice: Healthcare professional views that demonstrated ignorance, dismissiveness or hostility to transgender youth were presented as valuable inputs and quoted, without discussion of potential anti-trans prejudice among professionals.
• Cisnormative bias: By design, the Cass Review prioritized cisgender professionals without experience in transgender healthcare. Transgender children are consistently misgendered in reports, with the interim report consistently conflating transgender youth sure of their identity with those exploring it.
• Pathologization: The Review frames transgender identity as a "clinical condition" and uses language indicative of disease such as "epidemiology", and states a research priority should be the etiology of transgender identity without justification. This approach is counter to the global trend of depathologization of trans identities as supported by the World Health Organization, WPATH, and the American Psychiatric Association, among others.
• Inconsistent standards of evidence: The two 2020 NICE reviews considered only "high-quality" research as designated by the GRADE approach, which defines it as randomized control trials (RCTs). However, GRADE encourages the consideration of other evidence. Additionally, RCTs are considered unethical and infeasible when applied to puberty blockers and hormones, due to requiring a control group to be subjected to what some consider conversion therapy; while non-affirming treatments were not held to the same standard of evidence. The interim report framed non-affirmative and affirmative approaches as equally valid, despite the former lacking any evidence of effectiveness.

While the paragraph should be collaboratively trimmed, it should not be removed or ignored entirely. We don't pick and choose what peer-reviewed academic analyses of the Cass Review we like - we include all of them. This paper identified these 4 concerns with the Cass Reviews - how should we include them?

I'm open to something like A 2024 article in the International Journal of Transgender Health thematically analyzed the publications produced by the Cass Review including their initial Terms of Reference, the NICE reviews into puberty blockers and hormones, an online panel, a survey of healthcare professionals, and the interim report. The paper found four areas of concern: platforming of anti-trans prejudice, cisnormative bias in the Review's design, pathologization of transgender identities, and inconsistent standards of evidence between non-affirming and affirming approaches. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 17:04, 13 April 2024 (UTC)

On your new paragraph, I'd recommend saying which side of the affirming and non-affirming care is getting benefitted from the inconsistent standards of evidence. Just as at the moment it is not explicitly obvious. LunaHasArrived (talk) 17:20, 13 April 2024 (UTC)

Good note thank you! In that case it should be ... and inconsistent standards of evidence between non-affirming and affirming approaches as the former lacks any evidence of efficacy but was not held to the same scrutiny. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 17:33, 13 April 2024 (UTC)

I believe I have sufficiently justified the removal in my edit summary. To elaborate on that: Horton's criticisms minus the explicit accusation of cisnormativity are a subset of the criticisms in the joint statement. Flounder fillet (talk) 19:49, 13 April 2024 (UTC)

The statement in question as it appears in the article: In November 2022, WPATH, ASIAPATH, EPATH, PATHA, and USPATH issued a statement criticizing the NHS England interim service specifications based on the interim report. It stated several points of contention with the report, including the pathologization of gender diversity, the making of "outdated" assumptions regarding the nature of transgender individuals, that it "ignores" newer evidence regarding such matters, and that it calls for an "unconscionable degree of medical and state intrusion" into everyday matters such as pronouns and clothing choice, as well as into access to gender affirming care. It also stated that "the denial of gender-affirming treatment under the guise of 'exploratory therapy' is tantamount to 'conversion' or 'reparative' therapy under another name"

Addressing your two points in the summary

1) Horton being much lower profile than any of these medical organisations - a peer reviewed paper on the topic is still a peer reviewed paper on the topic. We can have both the positions of the medical orgs as well as a summary of the paper.

2) Horton's criticisms minus the explicit accusation of cisnormativity are a subset of the criticisms in the joint statement.

2.1) the explicit accusation of cisnormativity is a central theme of this paper - this paper said XYZ but someone more prominent said XY is not a reason to remove paper said XYZ or paper said Z

2.2) Horton's criticisms are nearly identical to the criticisms in the joint statement mentioned above

2.2.1) Horton's point 1 was the reports included examples anti-trans prejudice but did not adequately frame them (like recording that many psychiatrists did not believe transgender children exist, without pointing out this is 1) ridiculous 2) dangerous to trans kids). This is not mentioned in the statement.

2.2.2) Horton's point 2 was the reports expressly sidelined transgender voices and researchers from the start. Also not mentioned in the statement.

2.2.3) Horton's point 3 was pathologization of trans identities - this was mentioned in the statement

2.2.4) Horton's point 4 was there is no evidence denying transition is helpful but it was equated with the "low quality" evidence allowing transition is helpful. This was not mentioned in the statement.

In short, of Horton's 4 points, only the 3rd is nearly identical to the criticisms in the joint statement mentioned above, the other 3 are peer reviewed criticisms that were not covered by the WPATH statement. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 20:24, 13 April 2024 (UTC)

Given that afaik this is the only peer reviewed study on any part of the Cass report has to be considered when deciding to include it. In fact if any claims are shared between this study and international response it should probably be stated in the international response that this is backed up by a study (i.e not just the organisations opinion) LunaHasArrived (talk) 20:31, 13 April 2024 (UTC)

If the approach of these systematic reviews was as outrageous as some trans activists are suggesting it to be, do you really think the BMJ would have published it, or that Cass and their Clinical Expert Group (who assessed the evidence) would not have gone "Hold on a sec, this is demanding the infeasible and is totally unethical"? These are Trumpian-level arguments that sound great to the activist base but should ring alarm bells

Colin, can you please stop pushing your openly anti-trans POV on this talk page. It just continues to showcase that you shouldn't be anywhere near this topic area. Silverseren^C 16:43, 13 April 2024 (UTC)

Having been on the wrong side of a disagreement with Colin more times than I care to remember on GENSEX matters, he is always scrupulously even-handed IMO, and I strongly suggest you strike that comment. Void if removed (talk) 17:00, 13 April 2024 (UTC)

No thank you. And I really don't think you should be anywhere near this topic area either, considering how and why you first started editing on Wikipedia and how it nearly got you banned. Silverseren^C 17:28, 13 April 2024 (UTC)

Silver seren, seriously, you need to strike that right now. I'm in camp evidence-based-medicine, which one might have guessed from the fact I created WP:MEDRS. Anyone with a problem with that shouldn't be editing medical articles on Wikipedia. The personal attack you just made, is the sort of thing that will curtail your editing in this area. Please strike it now. I won't ask a second time. -- Colin°^Talk 17:38, 13 April 2024 (UTC)

Then why do you keep making commentary across two separate talk pages where criticism of the Cass Review is being made by "trans activists"? You're the one making those comments. And pointing out those comments as being POV is not a personal attack. It is a comment on your editing, ie your own comments being made on these talk pages. Silverseren^C 17:40, 13 April 2024 (UTC)

Silver seren you really should strike that comment. Leaving aside that it's uncivil, and that talk pages are a place to comment on content not the contributor, your reading of Colin and his contributions are wrong. While I have disagreements with some of what he's said, he has not said them because of an anti-trans POV. Sideswipe9th (talk) 17:50, 13 April 2024 (UTC)

Fine, I'll do it because you asked. But the repeated commentary from Colin on criticism being trans activists and comparing said criticism to homeopathy and fringe topics on the other talk page is not helpful and is not just statements on evidence-based medicine. Silverseren^C 17:54, 13 April 2024 (UTC)

I also think your original statement was too strong and striking it was the right thing to do. Which is not to say I don't agree with the comment I'm directly responding to: I agree that many of Colin's statements in this topic area have also not been great, and I wish that he would stick to just the evidence-based medicine stuff rather than, for example, getting into long disputes about whether or not the UK as a country is more anti-trans than other countries. Loki (talk) 18:34, 13 April 2024 (UTC)

Thanks for striking that, Silver seren.

If there's a correct shorthand way of referring to activists in camp-trans (vs camp-gender-critical or camp-wingnut or camp-religious) I'm all ears. I am not referring to the gender identity of these activists, which should be obvious for example from the fact that Horton is an advocate/parent. There are people who say dim things in all these camps, and right now, there's a lot of dim stuff being said about these systematic reviews by people who clearly haven't the first clue about how systematic reviews work, and are spreading disinformation. We must not pick up that disinformation and repeat it here.

And yes, the kind of arguments we are seeing are the kind of arguments made by proponents of homeopathy and fringe topics. Does that mean I think affirmative trans healthcare is like those fields. No. But it does mean that we should be sceptical of sources that stoop to that level of naivety and confusion.

I mean, who here is comfortable with this talk page claiming that "the report choses to ignore 100 of the 102 studies into puberty blockers and hormones". I don't see anyone else calling out that bs misinformation. Or the continued confusion of randomised controlled trials with blinded randomised controlled trials. Misinformation. Or above the continued pushing to include paragraphs of the opinion of one random person who did not review the actual Cass Review, but only the tiny bits of it they could see and that were published months if not years ago. This person's opinions on the cis-normativity and pathologization of trans healthcare doesn't magically become notable on Wikipedia because they included the words "Cass Review" in their article title.

Loki, I'm not the one who keeps bringing up the Terf Island trope on these pages. If there's criticism to be waged on that front, please address it towards the few editors who seem to think nationality is a basis by which to discredit first-class evidence based research published in the BMJ. Colin°^Talk 18:57, 13 April 2024 (UTC)

if there's a correct shorthand way of referring to activists in camp-trans (vs camp-gender-critical or camp-wingnut or camp-religious) presumes there is a camp-trans - framing the debate as camp-minority vs camp-people-who-don't-think-the-minority-exists-because-"feminism" / camp-undefined-radical / camp-people-who-don't-think-the-minority-exists-because-religion is part of the issue. There is no "camp-trans" apart from a nebulous bogeyman lumping together any and all criticism of the review as "activists".

Or above the continued pushing to include paragraphs of the opinion of one random person who did not review the actual Cass Review, but only the tiny bits of it they could see and that were published months if not years ago. This person's opinions on the cis-normativity and pathologization of trans healthcare doesn't magically become notable on Wikipedia because they included the words "Cass Review" in their article title.

- Are you by any chance referring to the short proposed paragraph above by a scholar on transgender healthcare who wrote a peer reviewed thematic analysis of multiple publications from the Cass Review in a famous transgender healthcare journal? Because framing that as "opinion" and speaking like we shouldn't include it at all is not how RS works. We don't ignore reliable sources we don't like. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 19:22, 13 April 2024 (UTC)

YFNS, I'm not going to take the bait. You say "thematic analysis" I say "opinion piece". What it isn't is science. Or medicine. Many if not all of the authors making these claims self describe as "activists".

Silver seren, Loki, Sideswipe9th, et al, have a look at what User:WhatamIdoing, wrote here. Maybe you prefer their style, but they make the same points. Just because some sources we can find are on Our Side, doesn't mean those writers aren't being spectacularly dim, or enthusiastically not letting the facts get in the way of their argument. I firmly believe Wikipedia articles are stronger and better when we trim out the shit stuff. There's hateful shit stuff on the gender-critical side (just glance at The Telegraph) but there's also well meaning shit stuff on the pro-trans side. Throwing shit on the page and seeing what sticks is not how to write a great article. Let's rise above that. Colin°^Talk 19:28, 13 April 2024 (UTC)

I realised I hadn't said what exactly I disagreed with in the quoted text, and that maybe has given the wrong impression. Specifically I disagree with do you really think the BMJ would have published it and or that Cass and their Clinical Expert Group (who assessed the evidence) would not have gone....

On the BMJ, there are right now a sizeable number of academics I follow on social media, all of whom have published in this or an adjacent medical topic, who are incredibly dissatisfied with comments made by the BMJ's editor in chief since the publication of Cass' review. There is at least one group of academics who are currently writing an article about the severe flaws in the systematic reviews published in the BMJ, with the implication that it will in part be questioning how those papers passed muster.

On the ethics question, we know from Appendices 4, 11, and 12 that six of the seven trusts within NHSE that host adult gender clinics refused to cooperate and hand over patient data for adult patients who had transferred from GIDS to their respective clinics, to Cass for use in a study on the follow-on outcomes of patients. Included in the reasons why those clinics refused to hand over the patient data were that the study had severe ethical concerns (appendix 4, page 8, PDF page 302), and that the study's design may not have been fully independent and may suffer from interference by NHS England, the Cass Review Team and government ministers whose interests do not align with those of providers and users of gender identity services (appendix 4, page 9, PDF page 303). Now yes, Cass and her team did dispute those concerns, however that they disputed them does not automatically mean they are incorrect any more than the fact that the issues were raised automatically make them correct.

Now I don't have an opinion on article content with regards to the above, I don't know who is right and who is wrong, and there are no reliable sources as of yet either way. However the concerns by both the academics about the BMJ's editor in chief, and the clinicians within the NSHE trusts do not exist in a vacuum. The only opinion I have right now is that we should be treating all content relating to the review, whether it's from the review report itself, the papers published in the BMJ, or the criticisms and praise of the review and related content, with a large degree of caution. We need to let the academics and reliable sources sort themselves out with regards to this review, and decide whether it is reputable or not, and whether it is good science or not. Sideswipe9th (talk) 20:02, 13 April 2024 (UTC)

I very much agree with the point about holding off and waiting for responses. Whilst waiting for study's of equal medrs Is of course unreasonable due to the time taken of these studies. I think at least waiting for international medical organisations to comment and being conservative with what to editis worth doing (probably could do with more talking on the talk page before making contributions, I get the feeling you'll get a sort of speedy response). (Also I'm majorly aware I could probably do with more of this myself.) LunaHasArrived (talk) 20:22, 13 April 2024 (UTC)

Sideswipe9th, can you find the bit in MEDRS where it says "A peer reviewed systematic review published in the very top tier of medical journal should be treated "with a large degree of caution" or "holding of" because, let me get this right, an editor's social media feed says so. If this was really as bad as some activists are making out, you can all tell me you told me so when the BMJ sacks its editor and retracts the paper and WPATH rush out a systematic review showing the evidence was all high quality after all, published in the New England Journal of Medicine because clearly Old England is run by terfs. But until them, there's not a single policy or guideline to support your position. And wrt holding off, let's be clear what I'm talking about.. I'm talking about things like what Wikipedia should say at puberty blocker wrt evidence. I'm not talking about how NHS England should care for trans adolescents. That's something reasonable people can come to radically different ideas on and mired in politics and funding and the basic problems of recruiting people into a toxic subject when the NHS pays shit. -- Colin°^Talk 20:35, 13 April 2024 (UTC)

Well, the issue is, large WP:MEDORGs have already said that the Cass Review ignores the consensus of major medical bodies around the world. I agree it's not normal to wait on secondary opinions for a big systematic review, but that's because most big systematic reviews aren't this controversial within their field. Loki (talk) 20:42, 13 April 2024 (UTC)

This did also include a systematic review of the guidelines produced by those MEDORGS and found them mostly inadequate. So when this review is explicitly critical of this international consensus controversy is to be expected. Void if removed (talk) 21:32, 13 April 2024 (UTC)

I mean, sure they did. It doesn't make it not the consensus in the field, though.

Otherwise, any crank could post a "systematic review" of the guidelines on regular vaccination, find them to be "mostly inadequate", and on that basis say that vaccines are bad and you should take his special protein supplements. The scientific consensus in a field has special weight in Wikipedia policy for a very good reason, and one paper cannot override that no matter how strong it is. If the consensus changes as a result of this paper, that's fine, but we would need a significant amount of time to assess that. Loki (talk) 01:36, 14 April 2024 (UTC)

I'm talking about things like what Wikipedia should say at puberty blocker wrt evidence. So am I. While the specifics are of course a discussion for that article's talk page, while we can report on the findings of the review I would advise caution on using the review in a broader sense than that, for example using it as the basis of a substantive section on the use of puberty blockers for trans youth. There is at least one other major review and set of guidelines due for publishing within the next few weeks to a month; a joint German, Austrian, and Swiss guideline, and as I said on the puberty blocker talk page a couple of days ago, the early indications from a press briefing by the authors of the guideline is that they have assessed the same evidence and take a diametrically opposed stance to that of the Cass Review.

It's not out of the realm of possibility for top-tier journals to publish bad science. Though the specifics of the situations differ we've seen this sort of thing happen before with Wakefield and The Lancet. Now I'm not saying this is a Wakefield situation, it's possible that this is a storm in a teacup amplified by social media being social media, but it's also possible that the issues being raised by senior and well respected academics and clinicians on their respective profiles are valid. Whether we like it or not, or agree with it or not, both the Cass Review and the systematic reviews commissioned by it have been received highly controversially by other experts within this field, and that should give us pause while they and the sources they write figure everything out.

can you find the bit in MEDRS where it says Of course not, because MEDRS doesn't say anything like that or in that manner. However, WP:MEDSCI tells us that our articles must present whatever the prevailing medical consensus is. The problem is, as multiple MEDORGS have now stated, the Cass Review and the reviews commissioned by it have seemingly gone against the prevailing medical consensus. The PATHA statement even states this exact terms that mirrors MEDSCI: this review ignores the consensus of major medical bodies around the world. Now perhaps that is because the previously prevailing consensus was wrong, and Cass is right, or perhaps Cass is wrong and the previously prevailing consensus is right. Either way we don't know for certain. All we do know is, as I said in the previous paragraph, this review and its commissioned systematic reviews have been received highly controversially by other experts within the field, and that reception is why we should be cautious when including content from it. We need to let this controversy play out, because per non-negotiable policy we describe conflicts, and do not partake in them ourselves. Sideswipe9th (talk) 21:35, 13 April 2024 (UTC)

Indeed. I note there are still no responses to that bmj article. Zeno27 (talk) 09:07, 14 April 2024 (UTC)

I think we are continuing to confuse systematic reviews with guidelines and the sort of recommendations in the Cass Review. MEDORGS may well criticise the Cass Review but multiple systematic reviews (of which this latest is no revelation) report the same findings wrt evidence for certain things. These are academically uncontentious and I do not expect the BMJ reviews to receive any serious attack. Whereas I expect the Cass Review to maintain ongoing debate. Let's not confuse information-gathering exercises like what a systematic review does, with policy and possibly ideologically-based recommendations. One can look at a systematic review like in the BMJ and still decide that you think gender affirming care is the correct approach. And Wikipedia can still report on what the consensus is and any significant deviations from that. But what Wikipedia can't do is claim there is evidence there is not. These are the highest MEDRS sources for evidence and cannot be trumped by a MEDORG press release. If a MEDORG seriously disagrees about this evidence, then they should commission their own systematic review. MEDRS is quite clear about the hierarchy of evidence. But these systematic reviews in the BMJ are not clinical guidelines, which is what Cass is doing and what WPATH do. Do you see the separation? -- Colin°^Talk 10:44, 14 April 2024 (UTC)

You say "thematic analysis" I say "opinion piece" - but only one of is right, and the peer reviewed journal which accepted it said the former. They did not say it was a "letter to the editor" (which they do publish and would be an "opinion piece"), they put it in the same category as their qualitative health research. The paper had methods, findings, and discussion. It is not purely an opinion as you keep framing it.

• I also want to note the article currently contains multiple quotes from people speaking to lay publications about it. It is bad writing for us to assemble those opinions, but completely ignore an actual peer-reviewed paper and handwave it away as opinion.

What it isn't is science. - The Social Sciences are still science. Many if not all of the authors making these claims self describe as "activists". - where does Cal Horton do this? That is who we're discussing. If you refer to their commitment to trans emancipatory research, please explain why acknowledging that trans lives are equal to cis lives, and being attentive to cisnormativity or pathologization of gender diversity makes them a disqualified "activist".

I appreciated WhatamIdoing's statement when I saw it - but it has no relevance whatsoever to the Cal Horton paper: I'm also finding the idea that someone can "do a systematic review on one study" to be evidence that people (and the sources they're relying on) don't know what they're talking about. ... I would be surprised if we didn't see special pleading in social media about why low-quality studies with the Right™ results needed to be included anyway Horton's paper is a peer-reviewed paper, not social media. That is not their main critique of the Review, they found 4, whether or not you agree. They don't say "a systematic review of one study".

Apart from WP:IDLI - Why should a peer-reviewed thematic analysis of multiple Cass Review publications (the only peer reviewed analysis of multiple Cass Review documents we have) be completely ignored and excluded from an article about the Cass Review? WP:NPOV says All encyclopedic content on Wikipedia must be written from a neutral point of view (NPOV), which means representing fairly, proportionately, and, as far as possible, without editorial bias, all the significant views that have been published by reliable sources on a topic. Ignoring the most relevant peer reviewed paper on the topic is not that. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 20:04, 13 April 2024 (UTC)

Quick note, the article says Writing for The British Medical Journal, editor-in-chief Kamran Abbasi responded to criticism that the requested standard of evidence was infeasible, saying, "In fact, the reality is different: studies in gender medicine fall woefully short in terms of methodological rigour; the methodological bar for gender medicine studies was set too low".[6] - the editor of a journal wrote his own editorial in it supporting the review and is quoted in our article. The double standard that blatant opinion like that is fine, but peer reviewed independent analysis is not, is weird. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 20:10, 13 April 2024 (UTC)

YFNS, if you think "peer reviewed" means we must include it on Wikipedia, I've got a guideline to point you at called WP:MEDRS. Nearly all peer reviewed sources are unsuitable for use on Wikipedia. We include opinions, in quotes typically (vs paragraphs of unquoted text we had before), if those opinions are notable and have weight. Getting an opinion piece published in a minor journal doesn't automatically make it notable for Wikipedia, since, em, we don't write paragraphs of text, or even one sentence, quoting every single paper ever published in your "famous transgender healthcare journal". So there must be something else? I have never said being an activist disqualifies anyone's opinions. Writing stupid things disqualifies them (and activists on all sides are doing that) so you'll excuse me if I decide to respond increasingly less often to your posts, as arguing about things nobody ever said is a game for immortals, and life is too short. -- Colin°^Talk 20:47, 13 April 2024 (UTC)

Proposal

At the moment, this article does not include any reference to The Cass Review: Cis-supremacy in the UK’s approach to healthcare for trans children, a peer-reviewed thematic analysis of Cass Review publications between January 2020 and May 2023 published in the International Journal of Transgender Health(impact factor) with the results Four concerns are presented and explored: (1) prejudice; (2) cisnormative bias; (3) pathologization; and (4) inconsistent standards of evidence. Each of these concerns impacts the Cass Review’s approach to trans children’s healthcare, with negative repercussions for trans children’s healthcare rights and well-being. The author is Dr. Cal Horton, who has written on transgender people's healthcare, family, and education.[7][8]

I believe the paper is due for inclusion, and propose the following text: A 2024 article in the International Journal of Transgender Health thematically analyzed the publications produced by the Cass Review up to the interim report and found four areas of concern: platforming of anti-trans prejudice, cisnormative bias in the Review's design, pathologization of transgender identities, and lower standards for evidence for non-affirming approaches compared to affirming ones.

I'd appreciate people's brief non-excessively threaded thoughts on whether the paper is due and whether the proposed text adequately captures it. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 21:27, 13 April 2024 (UTC)

WPATH is the partner organisation of the International Journal of Transgender Health, so it is not an independent source of critique. Zeno27 (talk) 22:42, 13 April 2024 (UTC)

I don’t think it’s particularly a bad source, but there are better, and I think the WPATH criticism is already fairly comprehensive as is. I could perhaps see adding the paper as an extra citation as Luna said, to show that there are studies that agree. Snokalok (talk) 00:30, 14 April 2024 (UTC)

I do think that a brief reference to this paper is WP:DUE. I don't think it's the strongest paper I've ever seen, but it is a peer-reviewed paper reacting to the Cass Report and we frankly could use more of those. A major question in this article is how the consensus of the field is going to change, if at all, in reaction to the Cass Report, and this paper does give some evidence of that. Loki (talk) 01:42, 14 April 2024 (UTC)

Im my experience, it's usual to see a declaration on each paper about the peer review it's been subjected to. There is none on the Horton paper and all I can find for the journal itself is where it says "All manuscripts published by IJTH, including those in special issues, have undergone rigorous, anonymous peer review, and editor screening." In contrast, the systematic reviews published in the bmj each say, "Provenance and peer review Commissioned; externally peer reviewed." Zeno27 (talk) 10:01, 14 April 2024 (UTC)

Yes, this article should be included. There is no good reason to exclude it, other than disagreeing with its findings and conclusions. Matters of ethics, prejudice, and bias are inherently important in medicine, and articles like this are needed for such a report. Especially when dealing with a small gender minority that has been historically marginalized. Hist9600 (talk) 00:55, 19 April 2024 (UTC)

Zeno, let's not confuse the BMJ with IJTM. For a start, Horton is not criticising the systematic reviews: they can't as they weren't finished never mind published when they wrote their critique. They are criticising Cass's approach, which is an ideological opinion, not some hard physical fact like "we studied 23 people and 1 died of suicide". Things like Horton's opinion piece (thematic analysis if you prefer) are assessed on quite different grounds to the BMJ systematic reviews, and simply saying it was "peer reviewed" doesn't mean anyone necessarily agrees with Horton, just that they didn't find it deranged and full of obvious mistakes. There will be people who reasonably disagree with Horton's opinions, likely on ideological grounds, but there aren't people who can reasonably say that if a systematic review looked at 50 studies and selected 34 then in my opinion they only selected 1.

If there is consensus that Horton's opinions are DUE (for the interim report sub-section) then we cannot present them the way YFNS has. This isn't how medical articles should be written. The style of "In 2022 Big Famous Journal found that XYZ" is what we get in the cruft sections of contentious medical topics and the more dubious wellbeing websites. It isn't encyclopaedic. For example, for all the systematic reviews that Cass commissioned, would you find it acceptable to name drop the British Medical Journal for each? We aren't to play pissing contests in front of our readers about who has the biggest journal. In the end, this is the opinion of Cal Horton, a pseudonymous researcher and parent of a trans child. It isn't the opinion of International Journal of Transgender Health (that would be expressed in an editorial). Replacing the views of an obscure author with the name of a journal is not done on Wikipedia, as Cal Horton is not the editor.

We can't say they "found four areas of concern" in Wikivoice. It would be like citing someone from the Labour party looking at the latest Tory immigration policies and saying, in Wikivoice, they "found four areas of concern". We need to somehow indicate that these are Horton's concerns. -- Colin°^Talk 10:37, 14 April 2024 (UTC)

I agree with @Colin that we should mention that this analysis was produced by Cal Horton. So, taking @Your Friendly Neighborhood Sociologist's text as a basis, we could change the first sentence so it reads: "Horton (2024) thematically analyzed the publications produced by the Cass Review up to the interim report and found four areas of concern". Cixous (talk) 17:52, 14 April 2024 (UTC)

@Cixous travelling today so typing from my phone, no issues with that change. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 20:47, 14 April 2024 (UTC)

Great! I think it's settled then: we include YFNS's proposal with this small amendment :). Cixous (talk) 08:05, 15 April 2024 (UTC)

If Horton is to be mentioned (and I don't think it adds anything) then the link with WPATH must be mentioned. Zeno27 (talk) 18:05, 14 April 2024 (UTC)

Why would WPATH need to be mentioned if we decide to use Horton's name? I don't really why one necessitates the other. Besides, the main reason why I argue in favour of the inclusion of Horton's name is because it is more in line with APA citation guidelines (i.e., the study is more verifiable and the text more concise). Cixous (talk) 18:42, 14 April 2024 (UTC)

It's WPATH partnership with the journal Horton's paper is published in: this is a potential for bias that readers should be made aware of. Zeno27 (talk) 18:47, 14 April 2024 (UTC)

Isn't that remedied by the fact that the paper was anonymously peer-reviewed? I think that already solves the main issue. Anyways, how would you suggest rewriting the sentence (or do you simply want to keep it as it is)? Cixous (talk) 18:53, 14 April 2024 (UTC)

I fail to see why the journal being the official journal of WPATH is an issue here. Horton's work was peer reviewed per the journal's usual process, and neither she nor her work are connected to nor funded by WPATH in any way beyond this being the journal it was published in. Unless you're implying that WPATH are exercising improper and undue editorial influence over the journal's content and publishing process, in which case the Sagan standard applies. Sideswipe9th (talk) 01:30, 15 April 2024 (UTC)

Sideswipe9th is correct. There is no reason to think that this journal isn't independent. Editors who are intuitively feeling like something's "off" will probably find it helpful to contrast independence (which affects whether a source is reliable) with WP:RSBIAS (which does not). The journal might be biased (though if so, that's not obvious to me), but a publication doesn't become non-independent just because the author and the owner happen to hold the same viewpoint.

YFNS, I have no strong views whether to include this, but you might copyedit your proposal in light of WP:MEDSAY. In particular, naming journals sometimes comes across as WP:PUFFERY. We usually want to see something closer to "Alice Expert said..." than "The Famous Journal of Important Things published...". WhatamIdoing (talk) 05:58, 15 April 2024 (UTC)

Whether the journal or Horton are biased isn't our concern, particularly when we are explicitly attributing opinions to them. We include viewpoints that have weight for inclusion, it isn't like anyone else being included in the "response" section is without a bias. And it isn't really our job to try to credit (puff) or discredit (diss) individuals in front of the reader. But again, we can't say, in Wikivoice, that Horton actually found four areas of concern, as though Horton climbed a mountain and found four new species of moss. Horton had four areas that they were concerned about. Clearly other people don't share those concerns. It is just a viewpoint. -- Colin°^Talk 09:30, 15 April 2024 (UTC)

I would prefer we didn't do the "Horton (2024)" style as we shouldn't really mix citation styles in an article. It isn't really important to date in front of the reader, the point we should make clear (by its position in the article, say, or explicitly) is that their critique was at the interim stage. Something like Cal Horton analysed the Cass Review at interim report stage and criticised it for platforming anti-trans prejudice, having cisnormative bias in its design and pathologising transgender identities. Horton also felt that the standards for evidence for non-affirming approaches were lower than for affirming ones. Something like that. Perhaps WhatamIdoing can finesse it.

But I still don't feel that Horton's opinion has weight to be due for inclusion. It repeats some of what we already document in detail about what WPATH said. So it is a bit like: here's a whole paragraph about what the international clinical guideline authority thinks and here's a short paragraph about what some parent thinks. We seem to be including it because some want those opinions repeated on this page, rather than that Horton is an authority worthy of note. -- Colin°^Talk 09:54, 15 April 2024 (UTC)

I feel that Horton's inclusion does matter. Of date, Horton is the only academic source on the Cass Review that analyses the Cass Review's study design. It goes to show that there are academic responses next to medical organisations that take issue with the Cass Review. Besides, if "Horton (2024)" feels off, we could change it into sth like "Cal Horton, researcher at Oxford Brookes University," (though I'd say that "Horton, 2024" is preferable). Lastly, if we take YFNS's text and simply change the subject into Horton, the reader will surely understand that this is her analysis (and, by extension, that she thinks there are four areas of concern, regardless of whether or not the reader agrees). Cixous (talk) 10:45, 15 April 2024 (UTC)

As I noted elsewhere, if we take these arguments, that the source is "peer reviewed" (wooo) and "academic" and "the only" and consider them sufficient for inclusion... would you guys would be so keen for Hal Corton (Cal Horton's evil nemesis, and parent of a non-binary ROGD child) who had recently completed a phd in gender-critical-feminism. Hal has just published their gender-critical thematic analysis at some similarly low ranking journal, claiming the Cass Review was epoc making and surely spelled the end of trans ideology, mutilation of vulnerable children and a long needed good-riddence towards wokeness in modern healthcare. For such opinions very very much exist and that they can be coherently made (whether one agrees with them or not) is all that is required to publish such in a social science journal. You are setting a low bar, imo, just because you like the opinion. -- Colin°^Talk 12:31, 15 April 2024 (UTC)

To be fair, I'm not very interested in what Horton says, as I haven't read her paper in depth, The main point I'm arguing for is the fact that her article analyses the processes behind the Cass Review and should therefore be included. I'm not claiming to be an arbiter scientiae in any sorts here, nor that I believe that Horton's analysis is or is not convincing. My main point is that not including it doesn't make much sense here. It is an academic response to the Cass Review and it adds to overall topic without being off the f*cking rails (if it indulged into any kind of conspiracy theory about a plot to deliberately destroy trans healthcare, that'd be a different story; then your ROGD example would be more applicable). It simply goes to show that not only international organisation take issue with Cass's methods. In an article about a medical review, criticism of the processes behind that review are relevant. Cixous (talk) 13:30, 15 April 2024 (UTC)

Oh, you mean it is Wikipedia's job to say that not only international organisations take issue with it, but someone's mum also? This isn't how we measure WP:DUE. The fact that someone writes up their opinions of the Cass Report and gets a social science piece published in a minor journal does not itself make that notable, as my example of the opposite should make clear. How is Horton's personal views notable to our readers? For example, many orders of magnitude more people will have read opinions in The Telegraph and The Times and there's a section below asking for those sources to be excluded for their anti-trans bias. But bias is not a reason to exclude, otherwise we'd be excluding WPATH's journal here.

My point is that any old criticism (or any opinion) of the Cass Review is not automatically relevant for this page, and it doesn't automatically become due because it was peer reviewed. WPATH's views, as a major organisation, are clearly due. Someone's mum? -- Colin°^Talk 13:58, 15 April 2024 (UTC)

That' not what I'm saying, though I have to say it's a hilarious way of putting it (I gotta admit I chuckled while reading your reaction). I don't care whether Horton's mother, father or non-binary parent. I don't care whether she's got no children, one child or fifteen children and a pet giraffe. I simply care about her inclusion, because she's currently one of the only independent academics to produce relatively decent criticism of a high-profile review. I see where you're coming from, and if better sources pop up in, say, two months, I'll be more than happy to remove her analysis. For now, I'm in favour of inclusion, you're not, and that's fine. Let's just see what the broad consensus about this is. Cixous (talk) 14:30, 15 April 2024 (UTC)

FWIW, I have read it and I don't think it is especially good, and it was a response to the interim review, not the review.

For example, Horton says on the point of the unethical nature of randomised-controlled trials:

RCTs are widely recognized as inappropriate for trans children’s healthcare, with a wide range of experienced healthcare researchers, ethicists and clinicians recognizing RCTs as both infeasible and unethical in this field

Widely recognised is a strong claim. This strong and definitive statement has 3 citations.

The first, Brik et al. says:

many would consider a trial where the control group is withheld treatment unethical, as the treatment has been used since the nineties and outcome studies although limited have been positive

So, not that definitive actually, just that some say it is, because they are already convinced of the benefits.

The second, Giordano et al says :

If we look at the licensing of GnRHa for puberty suppression in children with central precocious puberty that use has been licensed in Europe and the US based on relatively short open-label studies with small groups of patients (MHRA), because it is impossible and unethical to perform a Randomized Controlled Trial (RCT) for this indication. The same would apply to puberty delay in adolescents (see below).

This is just an assertion, but if you do see below they say:

it might be unethical

So again, not definitive, just "might".

The third citation is Horton themselves, saying in an earlier publication that denying anyone puberty blockers is like conversion therapy.

So we have two cites that don't really support the claim (some say, it might), and the author's personal opinion squared.

I'd say just because you can get your opinions in a journal doesn't make them due. So a) not due, and b) if people think it is, it can't possibly be due for anything other than the interim review. Void if removed (talk) 15:01, 15 April 2024 (UTC)

I've no interest in whether to include it at all. If we do, I suggest that the reason should be that we think it's the best source that is presently available, rather than the best source that could be imagined, and that we keep an eye out for better sources in the future (e.g., one that covers the final report, or one that talks about whether Horton's criticisms were taken into account).

I'm more interested in compliance with MEDSAY. Omit the (puffy) journal name and the (superfluous) year and the (hype-y) institution name. Nobody cares whether this was published in 2023 or 2024. The date is irrelevant because the material is not time-sensitive. Nobody will look back from some future date and say "actually, the interim report has changed during the last few years, so this one criticism no longer applies..." If we need to add some context (probably?), then the normal thing to do would be to provide a brief indication of the person's job, which in this case appears to be "postdoctoral researcher Cal Horton". WhatamIdoing (talk) 17:40, 15 April 2024 (UTC)

I agree with this with two caveats:

1) I do specifically want to include this source.

2) I think the year is more relevant than you do. The report isn't going to change in the intervening time, but the scientific consensus on the report might, and it's relevant in that context that this was one of the first papers to comment on it. That's actually a big part of why I think it's important to include: we currently don't have many other academic sources on the report, and if we had lots of those I don't know I'd be so strongly for inclusion of this particular one. Loki (talk) 18:49, 15 April 2024 (UTC)

It really wasn't the first paper to comment on the Cass Review. It commented on some material that was publicly available after the interim report was published. It's a bit like a review of a movie trailer, where you are sure that because Tom Cruise was in it and Christopher McQuarrie directed it, it will suck bigtime if you perform your thematic analysis from a feminist/pacifist/intellectualist pov. The mere fact that they were commenting at the interim report stage meant the clock was ticking on the relevance of their paper even before this wiki article got created. And we have literally zero sources suggesting Horton's opinion represents scientific consensus today, never mind in future. We aren't selecting it because Horton's opinion represents scientific consensus, and that's not why it got published in WPATH's journal. I don't think the same editors would be going on about this if the only academic publication they had was gender critical.

Sometimes less is more. The more points an article makes the more opportunity there is that those points have huge weak points. Making a statement about the Cass Review coming from WPATH has big importance. Making a statement about the Cass Review coming from some unknown researcher makes it look like you are scraping the barrel. It actually weakens the case. -- Colin°^Talk 21:09, 15 April 2024 (UTC)

sources for consideration

• Vinter, Robyn (11 April 2024). "Trans children in England worse off now than four years ago, says psychologist". The Guardian.
• "The Guardian view on the Cass report: rising numbers of gender distressed young people need help". The Guardian. 11 April 2024.
• Barnes, Hannah (10 April 2024). "The Cass review into children's gender care should shame us all". New Statesman.
• "The Observer view on the Cass review: children were catastrophically failed by the medical profession". The Observer. 14 April 2024.
• "RCPCH responds to publication of the final report from the Cass Review". RCPCH.
• "Cass Review 'should mark a watershed moment' – charity chief". www.shropshirestar.com. 9 April 2024.
• Hansford, Amelia (10 April 2024). "Cass report urges 'caution' in prescribing puberty blockers to trans youth". PinkNews | Latest lesbian, gay, bi and trans news | LGBTQ+ news.
• Dyer, Clare (9 April 2024). "Guidelines on gender related treatment flouted standards and overlooked poor evidence, finds Cass review". BMJ: q820. doi:10.1136/bmj.q820.
• Abbasi, Kamran (11 April 2024). "The Cass review: an opportunity to unite behind evidence informed care in gender medicine". BMJ: q837. doi:10.1136/bmj.q837.
• Abbasi, Kamran (11 April 2024). "The Cass review: an opportunity to unite behind evidence informed care in gender medicine". BMJ: q837. doi:10.1136/bmj.q837.
• Abbasi, Kamran (9 April 2024). ""Medication is binary, but gender expressions are often not"—the Hilary Cass interview". BMJ: q794. doi:10.1136/bmj.q794.
• Cass, Hilary (9 April 2024). "Gender medicine for children and young people is built on shaky foundations. Here is how we strengthen services". BMJ. 385: q814. doi:10.1136/bmj.q814. ISSN 1756-1833.
• "Evidence for puberty blockers and hormone treatment for gender transition wholly inadequate | BMJ". BMJ.
• Penna, Dominic (16 April 2024). "Chris Whitty: Debate around transgender issues 'too vitriolic'". The Telegraph.
• Reed, Erin. "Why Hilary Cass' NHS report is wrong about trans health care". www.advocate.com.
• "Gender care review: Children 'let down' by research amid 'exceptionally toxic' debate". ITV News.
• "Hilary Cass: Ideology on all sides directed gender care of children". ITV news.
• Horton, Cal (14 March 2024). "The Cass Review: Cis-supremacy in the UK's approach to healthcare for trans children". International Journal of Transgender Health: 1–25. doi:10.1080/26895269.2024.2328249.
• "Gender Identity Service Series". Archives of Disease in Childhood.

Haircuts

Requiring clinical approval for haircuts and wardrobe changes is intrusive, inappropriate, and a waste of money and time. I’m sorry @Snokalok but this is just garbage - a ridiculous straw man of a “requirement” that is not proposed anywhere in Cass. Just because a supposedly reputable organisation said it doesn’t mean it’s not misinformation. We’re not obliged to repeat misleading nonsense even if the person who said it should have known better. Barnards.tar.gz (talk) 15:56, 13 April 2024 (UTC)

"We refer to social transitioning as changing your name and/or pronouns, appearance or expression (such as clothing or hairstyles), the washroom you use, and so on." [9] Nova Scotia Health Library

---

"Social Transition

Presenting in public part- or full-time in your identified gender, may include:

• Changing your wardrobe or hair style" [10] University of California San Francisco

---

"Social transitioning is changing the way you present yourself to the world so that your gender expression matches your gender identity. That can include changing your hair or clothes, using a new name, and being called by the correct pronouns for your gender identity."[11] Mt. Sinai Hospital (really top tier hospital in NYC if you're not aware)

---

"social transition, in which a transgender or gender diverse child would be able to use a name, pronouns, and gender expression (including haircut or clothing) that aligns with their gender." [12] WPATH

---

Clothing and haircut explicitly fall into the agreed upon definition of social transition. Thus, this isn't a strawman, this is the definition of social transition - which the Cass Review said needed clinical involvement. Snokalok (talk) 16:07, 13 April 2024 (UTC)

Quotes from the Cass Review:

There is no single definition of social transition, but it is broadly understood to refer to social changes to live as a different gender such as altering hair or clothing, name change, and/or use of different pronouns. p 31

Recommendation 4: When families/carers are making decisions about social transition of pre-pubertal children, services should ensure that they can be seen as early as possible by a clinical professional with relevant experience. p 32

From it's section on social transition in children:

Social transition may not be thought of as an intervention or treatment, because it is not something that happens in a healthcare setting and it is within the agency of an adolescent to do for themselves. However, in an NHS setting it is important to view it as an active intervention because it may have significant effects on the child or young person in terms of their psychological functioning and longer-term outcomes p 158

Parents should be encouraged to seek clinical help and advice in deciding how to support a child with gender incongruence and should be prioritised on the waiting list for early consultation on this issue. p 164

Clinical involvement in the decision-making process should include advising on the risks and benefits of social transition as a planned intervention, referencing best available evidence. This is not a role that can be taken by staff without appropriate clinical training. p 164

The Cass Review says social transition must be considered an active intervention and stresses that parents should receive clinical guidance on it as a planned intervention covering all the risks. Which is ridiculous, if a kid says "I'm trans" and starts going by a different name and wearing different outfits - the active intervention is stressing their family needs a doctor to counsel them on whether it's the right move and if it should be respected, it is not respecting their basic human rights to free gender expression. PATHA's criticism is not misinformation for pointing out one of the worst takes of the Cass Review. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 16:30, 13 April 2024 (UTC)

Unless the Cass report has a markedly different definition of social transition to common parlance (in which case that should be noted in the article) Or it explicitly states what parts of social transition should be stopped (yet again should be noted). This is in fact what the report says and I think you get why people find it so silly and find social transition "bans" so silly. LunaHasArrived (talk) 16:30, 13 April 2024 (UTC)

As YFNS has pointed out, this criticism is in fact a fairly direct paraphrase of the Cass Review's recommendations on social transition, and the fact that you think they're so ridiculous that they must be a strawman is perhaps indicative of why they're being criticized. Loki (talk) 18:37, 13 April 2024 (UTC)

Social transition is not only haircuts and wardrobe changes. It is those things (and maybe more, and sometimes not even) as part of an effort to live as a different gender. The PATHA statement makes two errors: 1) in saying that Cass demands clinical approval for haircuts. It’s not haircuts, it’s social transition, of which haircuts might be one part but actually the critical part is the intention to live as a different gender and really the haircuts are neither here nor there. 2) in saying that Cass demands clinical approval for social transition at all. Seriously folks, have you actually read the report? It’s not in there. YFNS has provided full excerpts and page numbers and it’s plain as day that “clinical approval” is not to be found amongst those sentences! What she has written is significantly more nuanced, and concerns dialogue on risks and benefits, and prioritisation for early consultation - not “clinical approval” or any other heavy-handed straw man. She is certainly critical of the evidence for the purported benefits of social transition, and she wants to encourage parents to seek clinical guidance, but she stops well short of the haircut-police that PATHA would like you to imagine.

By the way, our article is currently wrong in the Findings section on social transition, probably being mislead by The Times who wrote about “the need” for clinical involvement, which is not the language of the report. Barnards.tar.gz (talk) 21:31, 13 April 2024 (UTC)

By the way, our article is currently wrong in the Findings section on social transition

You are correct, we should revise this. The points Cass makes are that within an NHS setting it should be viewed as an active intervention because it can impact gender identity development, and there's an association between social transition and intensifying gender dysphoria or desire to transition.

The bullet points on page 164 are, roughly:

For children

• Encourage parents to seek clinical advice for supporting a child with gender incongruence
• Advise on the risks/benefits of social transition as a planned intervention
• Ensure the child is heard and parents are not unconsciously influencing their decision
• Maintain flexibility and keep options open

For adolescents

• Exploration is normal, rigid binary stereotypes are unhelpful
• Given that adolescents have greater agency and waiting lists are long, try to ensure those involved in their welfare have support and information

For both

• Supportive family is best
• The child or young person needs help and support if they change their mind

Void if removed (talk) 21:52, 13 April 2024 (UTC)

I mean it says directly that professionals with clinical training should advise on the risks and benefits on social transition. Which means the theoretically a doctor could recommend against wardrobe changes and/or a haircut. Whilst not quite as severe as stated I do think it is possible people could see this as requiring medical approval (i.e. parents saying let's get the doctor to say whether you get a masculine hair cut or not.) LunaHasArrived (talk) 21:59, 13 April 2024 (UTC)

I will go even further than Luna and say I think you're just plain reading the section incorrectly. It clearly advises going to a clinician before allowing children to socially transition, and it clearly, if somewhat euphemistically, advises that clinician to reject a full social transition in children at least some if not most instances:

For those going down a social transition pathway, maintaining flexibility and keeping options open by helping the child to understand their body as well as their feelings is likely to be advantageous. Partial rather than full transition may be a way of ensuring flexibility, particularly given the MPRG report which highlighted that being in stealth from early childhood may add to the stress of impending puberty and the sense of urgency to enter a medical pathway.

I don't know what you would call that other than Requiring clinical approval for haircuts and wardrobe changes. It doesn't matter that they don't say the words "clinical approval". They don't say the words "clinical approval" in the puberty blockers section either, yet they clearly advise clinicians to not give approval for puberty blockers there, right? Loki (talk) 01:55, 14 April 2024 (UTC)

It encourages parents to seek clinical involvement. It doesn't mandate anything. Doctors have no signoff. Nothing is framed as "allowed" or "disallowed". Parent and child remain free to ignore the clinical advice, or to not seek it in the first place. It recognises that there are risks, and that the best people to advise on those risks are those with clinical experience. None of this is even close to "approval required", and "approval required" is not an accurate paraphrase of anything in Cass. That PATHA sentence is hyperbolic, and makes them look like amateur activists. It's not encyclopedic to amplify it. Barnards.tar.gz (talk) 08:05, 14 April 2024 (UTC)

“ This is not a role that can be taken by staff without appropriate clinical training. “

That reads very clearly in the context of the UK as a statement about people such as teachers and GP’s in the child’s life using their preferred name and pronouns, and it’s not unreasonable for professional orgs to agree. If it seems like a ridiculous requirement, then you understand why it’s being criticized. Snokalok (talk) 10:09, 14 April 2024 (UTC)

The fact is that while requiring clinical approval for social transition may not be how you read it, it is a reasonable reading, and thus PATHA’s criticisms are worth including. Snokalok (talk) 10:16, 14 April 2024 (UTC)

I personally find it an obtuse reading, and I suggest excluding the sentence to spare PATHA the embarrassment of having written it. Void if removed (talk) 12:24, 14 April 2024 (UTC)

It’s not our job to determine what embarrasses PATHA or to spare them from it Snokalok (talk) 13:51, 14 April 2024 (UTC)

@Snokalok, how would you feel about changing the PATHA quote from and that "Requiring clinical approval for haircuts and wardrobe changes is intrusive" and "inappropriate" to and that "Restricting access to social transition is restricting gender expression, a natural part of human diversity."? I was sidetracked but meant to recommend it earlier as I think it captures the essence of the issue in a clearer way. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 22:33, 16 April 2024 (UTC)

It feels less… direct to the heart of the criticism for me, but if you think it’d be better, I don’t feel strongly enough to dispute it. By all means go ahead. Snokalok (talk) 22:57, 16 April 2024 (UTC)

To me the difference is the former points out how ridiculous the practicality of it is, the second is more so criticizing the idea behind it - that gender expression should be restricted and isn't natural. I think part of the issue was that was the only place we defined social transition in the article, the findings section talked about restricting access to it without saying what it was so we needed that voice of sanity in the article saying "we're talking about haircuts and outfits ffs". I just added Cass's definition to that subsection which should fix the issue and let PATHA's main criticism shine through. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 23:34, 16 April 2024 (UTC)

PATHA is obviously ridiculing the recommendation, and they've published something that will feed the internet outrage machine. It worked; their made-for-retweeting soundbite is getting attention for their views.

I think the first question for us is whether we want to include a reaction from PATHA at all (e.g., are they notable? If not, that might suggest a lower priority for including them. On the other hand, we tend to prioritize organizations from English-speaking countries, which suggests that including them is desirable), followed by whether we should do so by quoting their statement or by summarizing their views in a more encyclopedic style (e.g., "expressed concern about the medicalization of some parts of social transition, such as changing hairstyles or clothing preferences").

One thing I appreciate about the article's current state is that there is slightly more content describing the subject than criticizing the subject. I wonder whether it would be useful to integrate the Wikipedia:Criticism section into the subject matter. For example, instead of "PATHA said something tweetable about social transition", we might have a paragraph that says "The report suggested that families be prioritized for an early evaluation before beginning social transition. PATHA thought that this was ridiculous, the Anxious Parents Club thought queue jumping was a great idea because it'd be easier to get the school on board if they had a letter from a doctor in hand, and the United Hairstylists Association posted a list of their 10 favorite transitional hairstyles". WhatamIdoing (talk) 06:41, 15 April 2024 (UTC)

Separating 'Reception' into public and scientific responses?

What do editors think of separating the Reception section into two categories: scientific reactions (i.e., peer-reviewed articles and statements organisations) on the one hand and public opinions (published in news papers etc.) on the other hand? It might be beneficial to create this distinction because of differences in international applicability, scientific generalisability etc. Obviously, this is simply a suggestion which we perhaps cannot realise at this stage, not in the least because the Cass Review has been published only a few days ago. Further scientific responses may take a while. Another issue would be that the two cannot be distinguished at this stage (or even, at all): would an email response of WPATH in a newspaper article classify as a scientific or public statement? As of now, this approach may be fraught with all kinds of problems, but I wanted to initiate a discussion on this. After all, public opinion and scientific statements do significantly differ in crucial aspects.

PS: Slightly off-topic, but including page numbers when citing sources is generally advised. I hope to add page numbers when I've finished reading the report and its responses from the medical community (e.g., Norton 2024 etc.). Cixous (talk) 10:51, 14 April 2024 (UTC)

My question is where would we place the opinions of medical professionals? What about those with relevant experience? What about those without? That is, I could see putting Sallie and Ada in scientific and Kamran in public, but really there are arguments for all manner of organization Snokalok (talk) 10:54, 14 April 2024 (UTC)

That is indeed one of the most difficult questions here. It may be better to move all citations that are not derived from (a) peer-reviewed articles or (b) statements of scientific organisations to the public section. I think I'd prefer that, but you can really argue both ways. Some sort of separation seems warranted, though, as the British press seems to generally appreciative of the review, whereas it is scrutinised much more critically by health professionals. I'd actually recommend mentioning that in the introduction, like: "Generally lauded by British media, the review has received criticism from various medical organisations, such as WPATH." Cixous (talk) 11:08, 14 April 2024 (UTC)

I believe I said this somewhere else but the fact that (afaik) only British sources seem to support the Cass report, seems noteworthy. Especially considering the international criticism. Although I do accept this is probably OR and should be more conservative on any statement making it to the page.LunaHasArrived (talk) 11:24, 14 April 2024 (UTC)

I don't think there are enough HQ responses to warrant such a split, and I really wouldn't start bringing the already hotly contested arguments over the response section into the lede anytime soon. Void if removed (talk) 11:24, 14 April 2024 (UTC)

I see. For now, the best option might be just to wait with the split until responses to the Cass Review have consolidated - after all, it's been less than a week. At the end of the day, however, a split may eventually be beneficial, not in the least because I expect more responses from the medical community (e.g., from WPATH, perhaps in a joint statement with EUPATH).

To come back to your last point: I agree with @LunaHasArrived: I believe there is sufficient ground to include such a sentence in the lead. We've seen a joint response of WPATH, ASIAPATH, EUPATH, APATH and UPATH when NHS England provisionally suggested that puberty blockers would not be routinely prescribed any more. We've seen a joint response of WPATH and EUPATH criticising the exclusion of various studies by the NICE Review and NHS policiy which was based on the Cass Review. Lastly, we most certainly will see a joint response by WPATH and sister organisations about the Final Review and the final NHS England recommendations. This excludes multiple studies that mention that, for instance, ROCs are ethically unsound in transgender medicine, directly citing the NICE Review (e.g., Asley et al., 2023). I believe that this provides sufficient ground to mention its contested status in the introduction. Cixous (talk) 11:44, 14 April 2024 (UTC)

I wouldn’t call this hotly contested. The puberty blocker talk page was hotly contested. This is… a back and forth. Snokalok (talk) 12:09, 14 April 2024 (UTC)

I agree with including the split in the summary, I think enough orgs and UK sources have weighed in to justify it Snokalok (talk) 12:07, 14 April 2024 (UTC)

Okayy, I'll add it :). Cixous (talk) 12:07, 14 April 2024 (UTC)

I've added the sentence. I'm not sure if I did the citation right - I ran into some issues trying to cite the EPATH and WPATH joint statement -, so if somebody could check it (and change if necessary), that'd be really great. Cixous (talk) 12:30, 14 April 2024 (UTC)

Lede follows body anyway, as long as the underlying article supports it, you’re probably fine. Snokalok (talk) 13:06, 14 April 2024 (UTC)

The problem with the sentence now is that it elides the most relevant responses, which are not whether the British media like it, but the fact it was immediately welcomed by NHS England, and the two main political parties. That is more relevant. As presented it sounds like media vs medicine, which is wrong. Void if removed (talk) 07:46, 15 April 2024 (UTC)

I see. We could always add that it was also welcomed by NHS England (and by Labour and the Tories, if necessary). On a semi-related note: does anyone know if NHS Scotland issued a response? They are technically unaffected by the report and its recommendations (emphasis on 'technically' :/), but I could imagine them issuing an offical statement about it. Cixous (talk) 08:09, 15 April 2024 (UTC)

That both the current and (likely) future government immediately welcomed the report and committed to implementing it is one of the most significant aspects, given how politically polarised this topic is usually. Whether the Telegraph and the Mail thought it was great is neither here nor there, IMO. How NHS Scotland and the Sandyford clinic respond will no doubt play out in time. Void if removed (talk) 08:15, 15 April 2024 (UTC)

So, what would editors think if we changed the subclaused into sth like: "Welcomed by NHS England, the Labour and Conservative Party, ..."? Cixous (talk) 08:24, 15 April 2024 (UTC)

Perhaps it should be members of the labour and conservative party. I don't think there's been any party statements (and it would be usual for there to be) LunaHasArrived (talk) 09:25, 15 April 2024 (UTC)

Noted. So that 'd make it "Welcomed by NHS England as well as Labour and Conservative Party MPs..." Cixous (talk) 09:34, 15 April 2024 (UTC)

Wes Streeting is shadow health secretary and made clear party commitments in that capacity. Void if removed (talk) 11:14, 15 April 2024 (UTC)

Yes but given that there are labour MPs that oppose the recommendations being followed, without a party vote or new manifesto it's difficult to say the party as a whole supports it. LunaHasArrived (talk) 13:18, 15 April 2024 (UTC)

You are over complicating it. This is the health secretary remit. Speculating that the Labour party might decide to have a vote on it and that whether it is or isn't in the manifesto isn't relevant. Something not in the manifesto, for example, doesn't mean they don't intend to do it. Anyway, it is enough that he's the shadow health secretary. -- Colin°^Talk 13:47, 15 April 2024 (UTC)

This is specifically about what comment to put in the lede, I can't see any part of the body where the labour party welcomed the Cass report. I can see where a couple of labour MPs welcomed it. Unless there's a source that says the labour party welcomes it (in which case it should be added) this feels more accurate at the moment. This is mostly because it's still only been a few days, if Streeting and/or other labour MPs had been saying this for weeks/months that would be a very different situation. LunaHasArrived (talk) 14:09, 15 April 2024 (UTC)

Wes Streeting was practically first politician out of the gate, committing the Labour Party to the recommendations in full. There was a sky news source that's been lost along the way IIRC. This will do for now so I'll add it and make clear this is a party commitment. Void if removed (talk) 14:18, 15 April 2024 (UTC)

That's much much clearer LunaHasArrived (talk) 14:20, 15 April 2024 (UTC)

It's good to have a source that says so explicitly, but honestly if the (shadow) health sec says "we are committed to..." on a health issue, they'd get the sack if that wasn't either (a) their call to make or (b) something the (shadow) leader agrees with and (c) the rest of the party don't usually get a say in very much actually. Cabinets call the shots and if the (shadow) minister for department X says something about X then that's (shadow) government policy. You'd really need a source explicitly saying Streeting was out on a limb to think otherwise. -- Colin°^Talk 18:12, 15 April 2024 (UTC)

I don't think there is anything special about a peer reviewed source to indicate "scientific". And we have sources here such as newspapers quoting endocrinologists, so the type of source doesn't indicate who the speaker is. Different people have different ideas of what constitutes science. Someone writing a peer reviewed article in a soft science might be considered appropriate to talk about the various ideological approaches, but it wouldn't be accurate to pretend to our readers that this was a scientist who knew about how systematic reviews worked or what flaws they might have.

At some point there will need to be a cull of biomedical claims that fail to meet MEDRS. For example, Ada Cheung's disputing the puberty blocker systematic review, saying "four studies rated as high quality already showed those treated with puberty blockers had less depression, less anxiety, less self-harm suicidality, and fewer problems interacting with peers". It is one thing having differences of opinion over treatment guidelines and attitudes towards trans children, and discussing the various viewpoints on this. But for biomedical evidence claims we do not juxtapose systematic reviews in the BMJ with viewpoints of individual doctors the Sydney Morning Herald interviewed. -- Colin°^Talk 15:47, 14 April 2024 (UTC)

Perhaps instead of naming one of the separated sections 'scientific response' we could name it 'academic responses'? After all, you do raise an interesting point that not all peer-reviewed sources are per se scientific. That doesn't mean that they shouldn't be included - after all, criticism of the review process is relevant to add -, but does distinguish them from systematic reviews. When it comes to the 'public response', I'd advise simply to include editorial responses from various news outlets and/or noteworthy commentators. For the rest, I agree that, eventually, some of the sources will need to disappear and/or moved to different sections: not all responses and critiques are created equally. Cixous (talk) 17:39, 14 April 2024 (UTC)

I think we need to put a limit on "reception" here. I understand that the review is highly controversial, but if we add one more opinion/quote to the article, there will be more prose on the reception than on the actual report. Draken Bowser (talk) 19:03, 14 April 2024 (UTC)

I question though how much it being an MEDRS source comes into play with an article about the review itself. That is, the review's only capacity here is as the subject of the article. We cite the review only as a verified source of what the review is saying. We're not using the review as an MEDRS citation in service of a separate topic, thus we're not contrasting it with criticism from a weaker source, we're writing a section about the responses to the subject, and in that context sources like The Guardian and the SMH are perfectly reliable.

Additionally, I feel like if we remove individual criticisms of evidence findings, we have to remove individual praise for the evidence findings as well in the name of NPOV. Snokalok (talk) 04:51, 15 April 2024 (UTC)

I think we need to be careful to judge all inclusions and exclusion based on author and publisher, to weigh wether they are due. We only need to consider the actual content in order to decide how to best phrase it and/or what to quote. Draken Bowser (talk) 06:25, 15 April 2024 (UTC)

I think something we can do right now to adress this somewhat is to put the more scientific sources first in each section. Currently the first person we quote in the reception section for the final publication is a conservative politician, that doesn't strike me as the most sensible way to sort the responses. --Licks-rocks (talk) 09:39, 15 April 2024 (UTC)

Yeah, good idea. Draken Bowser (talk) 10:15, 15 April 2024 (UTC)

@Void if removed I don't agree with you that a politician's take on a medical issue is more important than a medical organisation's, and I think I have WP:DUE on my side in that. Care to comment? --Licks-rocks (talk) 11:06, 15 April 2024 (UTC)

This is a government-initiated review of domestic health services.

Whether the government then accepts the recommendations is relevant. Whether the opposition also accepts them is relevant. That this has bipartisan support is hugely significant. The domestic politics are more relevant than whether a New Zealand trans organisation doesn't like them based on asinine comments about haircuts. What is spinning out as a result is demands for further reviews, and insistence that adult clinics turn over data they had previously stonewalled on. Void if removed (talk) 11:12, 15 April 2024 (UTC)

I'm going to turn that around on you, the reaction of other medical organisations (many of which we regularly quote as MEDRS) trumps local-level politics in this case, based on the fact that this is about a medical publication, and thus at least partially falls under the remit of WP:MEDRS in terms of order of priority. I don't know what you mean with "adult clinics turn over data", and I don't particularly see how that changes the discussion about what order we should place the responses in. --Licks-rocks (talk) 11:16, 15 April 2024 (UTC)

I have to agree with @Licks-rocks here. Responses from international medical organisations, even if one disagrees with them, trump the reactions from UK politicians. Medical stances on the science behind and recommendations of the report clearly have more weight here. Cixous (talk) 11:22, 15 April 2024 (UTC)

Hm, I guess I would like to add the caveat that if there is broad political agreement over the interpretation of the report – in the country where it was ordered, and where such sentiments would directly influence the enforcement of its recommendations – I won't object to briefly mentioning this first under "reception". Followed by all the "academic responses", and only thereafter any other reactions that couldn't qualify as expert opinions. Draken Bowser (talk) 12:14, 15 April 2024 (UTC)

Fair, but in that case I'd still argue that separating 'public responses' and 'academic responses' is preferable Cixous (talk) 12:18, 15 April 2024 (UTC)

I think this strikes a very reasonable compromise between the "government body" and "medical claims" perspectives on this, and would support this. --Licks-rocks (talk) 13:38, 15 April 2024 (UTC)

A further suggestion - move the NHS & conservative/labour commitments to the "recommendations" section, as this is the domestic bodies acting upon the recommendations. Void if removed (talk) 12:41, 15 April 2024 (UTC)

I mean, for actions the NHS has said they'll take based on the recommendations sure but with what's currently in the article I do not think anything should be moved. Politicians opinions certainly shouldn't be in there and I don't think the NHS wanting to launch an investigation into an adjacent area should be in their either. LunaHasArrived (talk) 12:53, 15 April 2024 (UTC)

I agree with Void. You have to remember this is a review for NHS England, not a review for the USA or Denmark or Australia. That people outside have comments is interesting but really the primary concern for a government-commissioned review is whether the government of the day (or the impending government in six months) is intends to implement it and whether they succeed. Many times such independent reviews either gets shelved and never see the light of day, or are published and promptly ignored, or is explicitly rejected by the government, or superficially accepted and then ignored, and so on. So really the most important thing about the Cass Review today and in the coming years, is whether our government and future government actually implement its recommendations.

Put it another way, suppose Biden commissioned a review into some healthcare reform in the US. Do you think such an article would waste much time on the opinions of some doctor in the UK or healthcare organisation in Australia? No, it would focus on what that means for US healthcare and about how Trump then overturned everything in January 2025.

I don't support public/academic split. If anything I'd be veering towards domestic vs international. -- Colin°^Talk 12:22, 15 April 2024 (UTC)

I see, but I'd still argue for a public/academic split. In the public section, more weight could be given to the obviously more relevant English response. A domestic/international split is interesting, but potentially obfuscates things even further. For example, where would you put Horton (2024) [assuming we include her study, which we most likely will]. She's an English academic, but she published in an international journal. What about international organisations specifically criticising the NHS recommendations? Technically they criticise a distinctly domestic policy, but they do so from an international scientific perspective. I'd personally say such an approach makes categorising sources even harder Cixous (talk) 12:29, 15 April 2024 (UTC)

Per Void's comment above, maybe we need some place for official reactions from the people who the report was aimed at and matter, and a separate place for all the other responses. And wrt your comment about fallout into e.g. adult services and so on, yes they should be here. This Cass Review exists within the healthcare and political world around it and that commissioned it. If there's a Cass Review II for adult services, then it is highly relevant that this one spawned it. And just because the NHS says they will take action doesn't mean they can, because the recommendations really will require an injection of money into child mental health, which I don't think our current government is remotely likely to do. -- Colin°^Talk 13:02, 15 April 2024 (UTC)

I feel like that'd be a decent compromise. Section A for official responses from UK political figures and NHS England, section B for international organisations, academic responses and other responses we care to include.

PS: I don't remember bringing adult services into the discussion. Might have forgotten that or you're confusing me with another editor. Generally I see why one would want to include a Cass Review II on adult services here (although there's also a case to be made for separating the two when this article gets too long). Cixous (talk) 13:38, 15 April 2024 (UTC)

Yes the adult services was what I thought "I don't think the NHS wanting to launch an investigation into an adjacent area should be in their either" referred to, which came from LunaHasArrived. I probably thought both you red-link usernames were the same. -- Colin°^Talk 18:16, 15 April 2024 (UTC)

Ah that makes sense, I know it wasn't explicitly obvious in my comment but I wasn't talking about a place in the article but a place in the recommendations section. LunaHasArrived (talk) 19:12, 15 April 2024 (UTC)

I think you've hit on an important point here although I have doubts it will ever be covered sufficiently that we can mention it hence I'm making this small and won't object if some hats it or outright deletes it. While there may be significant disagreement on the aspects like the existing evidence and need for clinical trials and whether puberty blockers should only be given as part of a clinical trial, when and how to guide social transitioning, and whether mental health support should be purely affirming or something else; I think one area where both advocates and organisations like WPATH etc agree with Cass is the need for far more resourcing and especially mental health support. Indeed one thing there seemed to be agreement on before the review is that the old system was seriously broken in part because it was taking so long for most patients to get any sort of real care.

The problem for the earlier group is that while Cass may have said it's needed, even if we put aside concerns about what form the mental health support may take, the group feels probably correctly that it's simply not going to really happen in a significant degree. Probably even under Labour things won't be that much improved. So the areas where the Cass review has advocated for improvements is probably only going to happen to a limited degree at most. But the areas she's advocated for change that they disagree with is probably going to happen much more, indeed we're already seeing it's affecting not just the NHS in E&W but private healthcare and healthcare in Scotland too.

So they're expecting, probably correctly, what they consider the positives from the review to have little effect but the negatives to have substantial effects. So the end result of the review is pretty much all bad. Indeed some of the issues raised like the need for clinical support for transitioning is made much more acute if it takes ages to get that clinical support. (As it seems unlikely this is something that be just from a GP but instead specialised support.)

Cass was of course between a rock and a hard-place. She couldn't exactly say, 'This is what needs to happen, if you're just going to cherry pick parts of my review that you want to implement this isn't actually going to work and who knows if you might make things better or worse so pretty please with a cherry on top do not do that.'

I'd say the big unknown is what actually happens with puberty blockers. While you're right the NHS has done some good large scale clinical trials, I'd say it's very unclear at this stage how much they're actually going to do them with puberty blockers. Frankly given the way things are in the UK in the moment, even with a Labour government I'd say there's reason to think the other European countries who've suggested clinical trials are needed might be a more fruitful place to hope for progress; along with those who already feel the evidence is good enough but accept there sufficient disagreement to justify further research e.g. those associated with WPATH. OTOH, clinical trials are much more politically "sexy" so it's possible real progress may be made, regardless of disagreement on whether that progress is needed.

Edit: IMO the timing of the infected blood scandal investigation [13] is also unfortunate since I suspect all sides are going to read from that what they will into trans healthcare in the UK.

Nil Einne (talk) 21:40, 20 April 2024 (UTC) 22:09, 20 April 2024 (UTC)

Condensing the individual responses

I think that we should perhaps look at condensing the medical and academic responses of individuals (Sallie, Kamran, Ada, Portia, Cal, and Aiden) into something like "The report was praised by some academics and professionals in the UK, who agreed with its findings stating a lack of evidence;[Sallie, Kamran] while others both in the UK[Cal, Aiden] and in the the international community[Ada, Portia] criticized the report, saying that it ignored high quality evidence already available,[Cal, Ada] and that its required standard of evidence for the studies it did evaluate would be "infeasible and unethical" to achieve.[Cal, Portia] Snokalok (talk) 04:41, 15 April 2024 (UTC)

So would, anyone be opposed if I went ahead and did this? Snokalok (talk) 16:08, 15 April 2024 (UTC)

I'm fine with it, go ahead. Loki (talk) 17:03, 15 April 2024 (UTC)

I am fine with condensing most of them and any future ones, but the BMJ response is important on its own. This is a spokesperson of the parent journal of the published evidence specifically rejecting claims about the evidence base. It isn't just bystander commentary, it needs including on its own.

I also think adding in Horton to the final review is simply untenable, since the paper was about the NICE review and the interim review. It says absolutely nothing about the final report or its evidence base. Void if removed (talk) 09:43, 16 April 2024 (UTC)

I agree with Voice if removed on all points. Anywikiuser (talk) 11:28, 16 April 2024 (UTC)

On Cal, fine fine.

On Kamram, at that point though does it become an NPOV and weight issue? Because suddenly we’re left with “Some people said XYZ, but the editor of the BMJ said ABC” which frames it as though that’s necessarily an authoritative rebuttal when, really it’s someone with less experience in the field of medicine in general - much less transgender health - being given excess weight vs those with extensive experience in both medicine and trans health. And while there is an argument that his inclusion is notable, I don’t dispute that for a second, what I’m disputing is him being weighted more heavily than the criticisms to which he is responding, from far more qualified names in the field Snokalok (talk) 13:19, 16 April 2024 (UTC)

The quote from Kamran Abbasi is useful as it demonstrates one argument, agreeing with the Cass report that there is a lack of evidence on the treatments. I'm not sure how that could have made it unbalanced. Before it was removed, there was the quote from Abbasi and an earlier one to the contrary, from the Canadian Paediatric Society. One could argue that Abbasi was getting the last word, but equally, one could argue that he was missing out on the first word.

Even if Abbasi isn't a specialist in that field, that doesn't mean he isn't qualified to speak on it. Ultimately, the article should explain the roles of any medical figures cited for quotes and leave the reader to decide how qualified they are to speak on the matter. Anywikiuser (talk) 15:52, 16 April 2024 (UTC)

You ultimately miss the point and context. We had several relevant medical personnel with each about two lines dedicates to their comments. We had the editor of the BMJ, a neuropsychology professor from UCL who (I’m told) wrote papers on the subject, the head of trans health research at the university of melbourne, and the vice president of AusPATH. They were all condensed as above into a single paragraph due to space concerns. So why then, is Kamran so exceptional in this regard as to warrant his own standout lines? Canada we put because it’s a medical organization, and thus it bears its own piece. An individual medical professional with an involvement in the field or - worse, one without - may still be notable, but not enough to privilege his view over and the other (more qualified) individuals also condensed into the paragraph. Snokalok (talk) 21:38, 16 April 2024 (UTC)

I agree with Snokalok, and would suggest if we want to break out Kamran we should break out everyone and just make the condensed version a bit longer.

Something like:

The report was praised by some academics and professionals in the UK, including the editor of the BMJ[Kamran] and a professor of neuropsychology[Sallie], who agreed with its findings stating a lack of evidence. Others in the UK, including the director of an independent gender service[Aiden] and a postdoctoral researcher[Cal], and in the the international community, including the head of trans healthcare research at the University of Melbourne[Ada] and the vice president of APATH [Portia], criticized the report, saying that it ignored high quality evidence already available [Cal, Ada] and that its required standard of evidence for the studies it did evaluate would be "infeasible and unethical" to achieve[Cal, Portia].

Personally, I think I prefer Snokalok's version because this version feels like it has a lot of WP:PUFFERY. But I don't think we should be privileging Kamran Abassi's response just because he's loosely associated with the papers themselves. Loki (talk) 22:29, 16 April 2024 (UTC)

++ to not privileging Kamran. I lean towards expanding/elaborating the condensed paragraph slightly but would also be ok condensing his.

Wrt Horton, I think their criticism should be slightly expanded but put in the section on the interim report as opposed to the final one. As a well sourced academic criticism of certain methodologies in the Cass Review from the outset as reviewed midway through it deserves some more elaboration, but we should make it clear to readers it was not a response to the final report. While it's a peer reviewed sociological critique of how the Review was organized, communicated, and carried out (presenting prejudice without noting it's prejudice, exclusion of trans expertise, pathologization in language and framing, etc), the others are high-profile medical professional's critiques of Cass's take on the evidence base, so I think it's also good to group them by field/expertise rather than lumping them by praise/criticism. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 23:15, 16 April 2024 (UTC)

Your last sentence in green makes no sense. How could "it did evaluate" studies that 'would be "infeasible and unethical" to achieve'. Both systematic reviews on the evidence base for drug treatments actually performed a narrative synthesis on the majority of the relevant studies (they included the moderate quality and the couple of high quality studies, while ignoring the low quality, which is what every systematic review ever conducted in history does).

I think we need to be really careful with this "infeasible and unethical" line as it as pure misinformation. Not a single line in the systematic reviews or Cass report insists on RCTs never mind blinded RCTs. Where the Cass Review mentions RCTs is because, while it was aimed for healthcare professionals, Cass realised the report had to be accessible to the public. So they spent a few pages giving a really good background on the strengths and weaknesses of various trial designs, and which kinds of trials we have in the literature on trans therapy for children and adolescents. These issues are simply facts, like the sky is blue. It is simply a fact that a control group strengthens the evidence and simply a fact that without one, all sorts of other reasons could explain one's "results". These reasons why the evidence base in this field is mostly low and moderate with only one or two high quality are all just facts of life.

Since in fact the majority of studies were included in the synthesis and those mostly moderate with one or two high quality studies actually really do exist and really didn't fail the ethics board when they were proposed, it is in fact a lie that the evidence base for the Cass Review needs "infeasible and unethical" evidence. It is entirely possible that these mostly moderate with one or two high quality studies could have produce convincing positive results, but they didn't. Why do you think activists don't like to mention that fact, but instead deflect the reader onto thinking Cass is both ignorant and evil.

Repeating the line '"infeasible and unethical" to achieve' is pure misinformation wrt the Cass Review. They actually reviewed the majority of relevant studies, not the "1 out of 100" that some on this page earlier claimed. How does anyone here square that fact with the claim. It would be a bit like saying that expecting women's football to attract large crowds and get headlines in the newspapers and on TV news is infeasible. Em, it already happened. There are studies that were good enough to be included as evidence. Those studies didn't produce the results some wanted to hear. We need more research for sure, and better research, but this guff about infeasible and unethical blinded RCTs wrt the Cass Review needs to be put in the "5G causes Covid" bin. -- Colin°^Talk 08:53, 17 April 2024 (UTC)

here is a good example of misinformation. The article says

It is notable, then, that one of the evidence reviews (in this case a review of the efficacy and safety of gender-affirming hormone therapy) commissioned to support the Cass Review questions the quality of many of the studies that demonstrate the clinical effectiveness of treatment with gender-affirming hormones based on a ‘lack of blinding’ (as can be found from page 109 onwards of the evidence review).

For a blind trial to be run, a patient/assessor must be unaware of what medication is being administered. The problem here is that running a blind trial with gender-affirming hormones or puberty blockers is highly challenging: when receiving gender-affirming hormone therapy or puberty blockers, obvious changes occur which alert the patient/assessor to that fact.

Put simply, the review sets an unreasonable standard for the kind of evidence it will accept — one which, given the nature of the research being done, cannot be met — then uses the resulting lack of evidence to suggest that existing medical interventions have no evidential basis. This undergirds many of the recommendations the review makes regarding changes to internationally established medical practice.

Additionally, the evidence review was prepared in October 2020 based on searches made in July 2020. This is not an inherent problem, but should be taken into account: it represents a moment in time, like any other review, and the speed of progress for research in this area is extremely quick.

But it becomes clear that what they are talking about are the NICE reviews from 2020 (here and here) and not the more recent reviews published alongside the Cass Review in the BMJ, which explicitly take into account any relevant research up to January 2024. It is clear then the author wishes to misinform the reader that the Cass Review is dependent on research from 2020. This is a lie.

But they also setup the strawman that the Cass Review ignores any evidence that didn't come from a blinded RCT. If you read the Cass Review or the two 2024 systematic reviews, they don't mention blinded RCTs at all and in fact include the majority of relevant studies in their evidence base. The older NICE reviews do mention blinding but only in the same way anyone following a standard checklist of good/bad points in a systematic review does. The older NICE review is particularly harsh but also entirely typical of this style of assessment. One cannot magically make a statistically weak study into a good quality one by good wishes and intentions.

This is the sort of shit that MEDRS prevents, where solid MEDRS compliant sources are juxtaposed in the press and other websites with the opinions of people with no knowledge of how systematic reviews typically work and who have found a hook (here the unreasonable/unethical claim) that sounds convincing to the uneducated but is eye-rollingly dim to any experts in the room. In practice the Cass Review included the majority of studies published and looked at studies right up to January 2024. -- Colin°^Talk 11:25, 17 April 2024 (UTC)

I expect we will eventually have a section of the article covering the misinformation put out by various individuals and organisations, but for now the very least we can do is to decline to amplify it by including it in the article here. Barnards.tar.gz (talk) 12:07, 17 April 2024 (UTC)

Kamran Abbasi may not be a specialist in this particular field, but an editor of a major medical journal does have expertise on medical research and evidence gathering. For example, Wikipedia has on multiple occasions cited comments from Richard Horton, the longtime editor of The Lancet, on medical research unrelated to his original specialty (liver medicine). A search for "Richard Horton editor" reveals some examples. Anywikiuser (talk) 11:40, 18 April 2024 (UTC)

Don't use sources by The Telegraph and The Times

The following discussion is closed. Please do not modify it. Subsequent comments should be made on the appropriate discussion page. No further edits should be made to this discussion.

---

They are extremely inappropriate in the context of this article about transgender issues. LilianaUwU ^{(talk / contributions)} 05:52, 15 April 2024 (UTC)

I think it'd be fair only to cite the documents relevant to the Cass Review in the 'Findings' and 'Recommendation' sections (including page numbers). Citing newpapers in tandem that got their information from the Cass Review is pretty dull and redundant. For other purposes, I agree that The Telegraph and The Times, and British media in the broad sense, tend to be generally biased when it comes to trans issues ("We're being pressured into sex by some trans women" comes to mind). Media sources are important when we want to know about their editorial stance on the Cass Review, but for other purposes we should approach and use them with caution. Cixous (talk) 09:25, 15 April 2024 (UTC)

I don't mind The Guardian and even the BBC (despite the fact the latter had "We're being pressured into sex by some trans women") because their nonsense is mostly a byproduct of British media being like that as a whole. The Telegraph and The Times are the very papers that give British media their transphobic reputation. I'm almost tempted to simply strip the Times and Telegraph references from the article, which seems to keep the article pretty much intact for the most part, (un)surprisingly enough. LilianaUwU ^{(talk / contributions)} 11:25, 15 April 2024 (UTC)

I agree that removing The Telegraph and The Times references (and all other references on the findings of the Cass Review that aren't actually referencing the Cass Review) should be removed. It's more logical to cite the Cass Review for what's in the Cass Review instead of a newspaper regurgitating the Cass Review.

Slightly off-topic, but BBC is really hit or miss. Their publicising on a study that 'saw a mental health change in participants on puberty blockers' without the study even being peer-reviewed, let alone of decent quality, was so so silly. Cixous (talk) 12:22, 15 April 2024 (UTC)

If the article text is WP:BIOMEDICAL the WP:MEDRS applies and no newspaper cuts it. If the text is mundane stuff like when it got published or political stuff like how there's now going to be a review for adults, then newspapers are acceptable. Personally I'd prefer that the Telegraph and Times were excluded from all trans topics, as they have completely lost the plot on this matter, but I recall previous RS requests were met with people bleating about them being newspapers of record. Clearly if we have multiple sources for uncontensible facts then we can cull the weak ones. -- Colin°^Talk 14:04, 15 April 2024 (UTC)

Of course attempts to change the reliability of those rags haven't been successful. Unless you give WP:RSN 30 reliable sources about how using this normally reliable source for an issue might be bad actually, they won't budge. LilianaUwU ^{(talk / contributions)} 15:15, 15 April 2024 (UTC)

I'm reasonably confident the previous RFCs went that way exactly because the filer wanted them to go that way, and therefore presented no evidence of unreliability nor gave anyone else time to gather such evidence. Loki (talk) 17:04, 15 April 2024 (UTC)

Yes there was a bit of that but it is still a hopeless case. -- Colin°^Talk 18:22, 15 April 2024 (UTC)

... I think we might actually be able to put together 30 sources for this. Anyone wanna collaborate to compile an RSN request? Snokalok (talk) 19:15, 15 April 2024 (UTC)

Wait no I misread. Snokalok (talk) 19:26, 15 April 2024 (UTC)

I mean, regardless of the intent, this has inspired me to collect sources for a future RSN RFC. So yes, I'd want to collaborate. Loki (talk) 19:29, 15 April 2024 (UTC)

Oh. Yay! Then let's do so! Right, do we just need sources from the telegraph and times themselves demonstrating their unsuitability, or do we need other outlet to directly say "The Times and The Telegraph write anti trans propaganda"

For the latter, PinkNews is probably our best place to start. They covered the two outlets' coverage back when it was more sporadic, and I remember a statistic somewhere saying how many pieces The Times wrote on trans people per month.:::::Snokalok (talk) 20:01, 15 April 2024 (UTC)

I'd argue we could also perhaps get the BBC to yellow on trans issues. There's a ton of info on the trans rights in the UK page as to why Snokalok (talk) 20:04, 15 April 2024 (UTC)

Hell, "We're being pressured into sex by some trans women" is so egregious it's notable enough for its own article. That ought to be something. LilianaUwU ^{(talk / contributions)} 21:24, 15 April 2024 (UTC)

Should we take this to draftspace, or... Snokalok (talk) 22:01, 15 April 2024 (UTC)

What, the sources against those rags? Sure, if you want to. LilianaUwU ^{(talk / contributions)} 22:02, 15 April 2024 (UTC)

Right now I'm looking for two things:

1. Cases where the Times or Telegraph said something that is either clearly false or very dubious.

Example A: This article calls trans women "men" in the article voice. Our article on trans women says explicitly that "a trans woman is a woman" and this is based off loads of reliable sources.

Example B: This article is about a really dubious poll (of all scientists rather than of biologists, explicitly carving out intersex people, and not publishing the actual poll itself) commissioned by the Telegraph itself.

Example C: This is an opinion piece, so it's not subject to the same factual standards as the others, but even so "Joseph Mengele tried to transition children" is a real chonker of a lie.

Note here that I'm not just looking for articles that are biased, but specifically articles that make false or clearly dubious claims.

2. Overviews, especially scholarly overviews, of problems with Times or Telegraph coverage in general.

Example A: this article about British media coverage of Mermaids.

Example B: this article is about British media bias about trans people in general.

Loki (talk) 22:05, 15 April 2024 (UTC)

I'll start digging for the BBC meanwhile. Snokalok (talk) 22:17, 15 April 2024 (UTC)

I don't think we should bother with the BBC yet. They're not good, but they're nowhere near as bad as the Times and Telegraph and I feel like including them will instantly shut the minds of some editors that would be open to unWP:GRELing the other two. Loki (talk) 22:46, 15 April 2024 (UTC)

I think it's time to take this somewhere else and finish this discussion of with a link to there. :) Draken Bowser (talk) 23:04, 15 April 2024 (UTC)

@LilianaUwU @Snokalok I've made a page for collaboration at User:LokiTheLiar/Times and Telegraph RFC prep. Loki (talk) 04:58, 16 April 2024 (UTC)

Hi all, please take a moment and consider the principle of neutrality. Please read: WP:NPOV.

As you well know, there are different points of view here, and the use of "men" to refer to adult human males is long established. So Example A is accurate reporting from that perspective. Its at odds with the point of view that trans women are women. To be neutral, we need to navigate these two perspectives and present them in a balanced way. See WP:DUE.

On the larger point, as you know, in the UK press PinkNews and to some degree The Guardian tend to support the side of trans rights activists, in terms of what they choose to report, and similarly, the Times and Telegraph tend to report more on the side of gender critical feminists, roughly speaking. I think there are few factual inaccuracies, but terms themselves are contested and so they report the same events in different ways. Our job as neutral editors is to synthesise balanced summaries. Anyone, self included, should consider whether our own allegiances may ever cloud our judgments of what's best for Wikipedia. AndyGordon (talk) 09:01, 16 April 2024 (UTC)

“ As you well know, there are different points of view here, and the use of "men" to refer to adult human males is long established. So Example A is accurate reporting from that perspective. Its at odds with the point of view that trans women are women. To be neutral, we need to navigate these two perspectives and present them in a balanced way. “

I really, cannot overstress how many editors have been sanctioned for choosing this exact hill. Snokalok (talk) 09:46, 16 April 2024 (UTC)

There is "whether discussion and language on talk pages and articles adheres to the norms and rules of Wikipedia" and there is "whether a source - which is not governed by those norms - not adhering to those norms makes that source de facto unreliable".

The former is how we can function and disagree (sometimes strenuously!) and build consensus in good faith. The latter is a swift route to insular groupthink and something to be very, very careful of. I can see it being a valid argument in WP:COMMONNAME disputes (ie, just because an inflammatory rag voluminously refers to someone in offensive terms, doesn't mean we should follow that example), but when talking about whether something is valid for facts, what matters is factual accuracy. Void if removed (talk) 10:03, 16 April 2024 (UTC)

I agree with User:Colin. There is no reason to set special rules on sources here; Wikipedia's existing rules and policies should be sufficient. That means that the popular press should not be cited for medical information, because WP:MEDRS applies to them. The Times and The Telegraph are the sort of popular press outlets that are accepted as reliable sources for current affairs, by virtue of not being tabloid trash. So they can be cited for covering political reactions to the Cass Report. Note that 'reliable' does not mean 'unbiased' or 'suitable for a naïve reader'; The Telegraph especially has a conservative angle, so when covering controversial issues, I recommend checking The Guardian especially for alternative angles. Anywikiuser (talk) 11:08, 16 April 2024 (UTC)

Agreed. Zeno27 (talk) 11:14, 16 April 2024 (UTC)

Can I suggest discussion on this matter ends on this page. If someone agrees, lets mark it closed. It's gone way off topic and there's now a user space for folk to continue dreaming they'll get The Telegraph cancelled. Let's keep this talk page focused on the Cass Review. -- Colin°^Talk 09:06, 16 April 2024 (UTC)

By all means Snokalok (talk) 09:47, 16 April 2024 (UTC)

The discussion above is closed. Please do not modify it. Subsequent comments should be made on the appropriate discussion page. No further edits should be made to this discussion.

Kamran Abassi

@Void if removed

Kamran Abbasi, according to his page, did five years in internal medicine and then spent the rest of his career as a health writer.

Five years is, I’d be willing to bet, easily the length of Cal Horton’s doctorate on trans kids or whatever it was. It’s far less almost certainly than Ada Cheung’s career in transgender medicine. Kamran’s statements do not warrant privilege over those with directly relevant field experience that outpaces his own medical experience entirely, and especially not with those of higher recognition in this specific branch of medicine (such as Ada Cheung) Snokalok (talk) 10:05, 16 April 2024 (UTC)

Reading Horton's paper, which was published in the month before the final report of the Cass Review came out, it only deals with the earlier stages of the Cass Review, including its terms of reference and interim report. It is not a response to the final report. Anywikiuser (talk) 11:24, 16 April 2024 (UTC)

I don't think we need to estimate are compare careers in this detail. It is comparing apples and oranges. This is a review for public health policy and clinical care and guidelines for such. Those topics are in-scope for experts in those fields to comment on. The fact that someone has a phd looking at social issues affecting trans kids doesn't really make them a public health expert, have the first clue about whether a systematic review is well done, or how to transform evidence and clinical experience into guideline practice. The problem with Cheung is the source is a newspaper, and even if Cheung got a letter to the editor of the BMJ it doesn't mean we can suggest to the reader that they are in any shape or form a counter to the systematic review. MEDRS doesn't let us do that. The world is full of people with a medical degree and an opinion. If there are four better studies, someone needs to do a systematic review that includes them. -- Colin°^Talk 12:32, 16 April 2024 (UTC)

Okay putting Cal aside for a moment, this is why we shouldn’t be singling out names, we should have them consolidated into a generalized paragraph as I implemented. Snokalok (talk) 13:14, 16 April 2024 (UTC)

WPATH statement

Is there really no better source for WPATH's response to this than a passing reference in a mediocre website? Screenshots of the actual statement are circulating on social media, but it's been 5 days and there's nothing better? Void if removed (talk) 22:58, 16 April 2024 (UTC)

Recommendations

I have cut down the "recommendations" for continuity of care which was previously a mix of quotes from the report assembled largely by the Telegraph. I've added a citation to the relevant pages in the review. Can we expand from there please, without the Telegraph editorialisation as to "why" or "on the basis of" that aren't necessarily stated in the report? Void if removed (talk) 10:46, 17 April 2024 (UTC)

The Telegraph article is behind a paywall, so I can't access it myself and assess whether the summation that has been appearing in this article sums The Telegraph article accurately. That summation has significant differences to both the BBC article on the Cass Report and to the report itself, which is available to read here.

If the Cass Report actually had suggested stopping medical transitioning for 18-24 year olds, that would have been quite a headline-grabbing bombshell. But there is a good reason why the BBC article does not mention such a suggestion, because that isn't any of the report's 32 recommendations. Cass is more concerned with the organisation of services and only a few recommendation discuss when treatments can and can't be used (recs. 3, 7 and 8). A few do have implications for adult care and clinics (recs. 5, 23 and 24) but it does not propose stopping any adult treatments. Cass recommends a follow-up service (rec. 23) but does not propose they offer any different treatments to what is available now. Nor does the report address what to do with adults who first consult on gender aged 18-24, rather than before 18, as that wasn't within its scope. Anywikiuser (talk) 13:09, 17 April 2024 (UTC)

@Anywikiuser, the extension "Bypass Paywalls Clean" can be used to read Telegraph articles. But I wouldn't trust them to accurately report which recommendations came from where and which were true and which were fantasy. -- Colin°^Talk 16:20, 18 April 2024 (UTC)

Right, I read back over the review, this more than anything comes down to a difference in interpretation of the word “recommendation”. If you go strictly by the words listed in the 32 glowing RECOMMENDATION boxes, then you’re right, but if you go by what is said in the rest of the paper in a recommendatory manner that anyone would reasonably read as recommending something, then everything the Telegraph wrote is there.

So suggested compromise, we both - citing page numbers - restore our respective content, yours in the rec section, mine in the findings section.

Also - how in the year of our lady 2024 do you not know how to get around a paywall? That is honestly not a solid reason to discount a citation, the info is still easily verifiable. Snokalok (talk) 11:20, 19 April 2024 (UTC)

Sorry, that was meant for @Anywikiuser Snokalok (talk) 11:21, 19 April 2024 (UTC)

I still stand by my comment that I don't trust the Telegraph to report trans health issues accurately. And no newspapers meet MEDRS so if the recommendation contains a reason (e.g., insufficient evidence of benefit) then that's a WP:BIOMEDICAL claim that needs a MEDRS source.

If we are citing the 400-page Cass Review directly, and for the lengthier journal papers also perhaps, we need to use page numbers. One technique is the {{sfn}}. I used this in Vaccine ingredients which is a short enough article that it should be easy to see how it works if anyone here hasn't done that before. I recommend we do that for the Cass Review. It's only really needed for long journal papers if the specific fact one is citing it for is on a very specific page rather than in the conclusions. So if one is merely citing a 40 page systematic review for its concluding remarks, there's no need to give a page number for one sentence. -- Colin°^Talk 13:35, 19 April 2024 (UTC)

I agree with prioritizing page numbers over news when available, I STRONGLY disagree with sfn. I understand it’s the style of citation in vogue with a specific sect of editors, however all it does imo is make editing and citing 1000x more inaccessible for all involved. It undemocratizes the encyclopedia Snokalok (talk) 14:02, 19 April 2024 (UTC)

I just added my first sfn ever and it was quite simple. Now anyone can add more sfns to the review by simply pasting {{sfn|Cass review final report|2024|p=[page number]}}. Flounder fillet (talk) 15:25, 19 April 2024 (UTC)

Report used AI generated images of children

I'm not sure where to include this

• https://www.404media.co/uk-gender-affirming-care-ai-generated-children/

John Cummings (talk) 13:18, 17 April 2024 (UTC)

I mean, "report uses licensed stock images" is surely WP:NOTEVERYTHING. Void if removed (talk) 13:48, 17 April 2024 (UTC)

I think that that description is not accurate, I think its a reasonable thing to include since they have used fake images of children to illustrate a scientific paper. John Cummings (talk) 16:58, 17 April 2024 (UTC)

No part of the scientific content of the report depends on the illustrations, no part of the report claims that the images are of real children, and nobody has put forward any reason why it should be necessary to use images of real children in such a report.

The primary purpose of the source seems to be to introduce the word “fake” into a headline about the report. As a gotcha, it’s desperately weak. Barnards.tar.gz (talk) 16:08, 18 April 2024 (UTC)

Agree per WP:NOTEVERYTHING. I mean, we're nearly at the point were it will be hard to find a publication that doesn't used AI generated stock photos. -- Colin°^Talk 16:24, 18 April 2024 (UTC)

I don't really see the relevance to including this here, it has little to do with the content of the report. GnocchiFan (talk) 16:57, 18 April 2024 (UTC)

It's maybe worth a short mention if it gets more coverage. But probably nothing off just the one article. Loki (talk) 17:41, 18 April 2024 (UTC)

We'd need something stronger than 404media to say that it's DUE to include. If other news media reports on this aspect, then a sentence inclusion would be relevant. Silverseren^C 17:43, 18 April 2024 (UTC)

Even if other "news media" reports on this, it still would fail WP:NOTNEWS. Do you really think that an encyclopaedia article on a "major review into a health matter in England that significantly changes health policy in several countries" should trouble the readers with "slow news day" / "gotta meet my 300 word target" cruft in newspapers. A sentence here would never "be relevant". It's at the level of Daily Mail Catherine, Princess of Wales was once photographed in a way that showed some cellulite on her thighs. Not something that would ever appear in the wiki article. Let's be focused on the review. -- Colin°^Talk 07:43, 19 April 2024 (UTC)

This isn't a big rat dissilced situation, these images weren't used to convey any information. If someone were to criticise the report for typos, that wouldn't be included, and this shouldn't be either. Flounder fillet (talk) 10:00, 19 April 2024 (UTC)

I mean, I’d agree it’s sort of the cherry on top to the wide array of criticisms, but much like the cherry on top, there’s little of actual substance here. Not worth including without strong secondary coverage imo Snokalok (talk) 13:17, 19 April 2024 (UTC)

Missing key findings

We are missing some of the key findings of the report. i News, Pink News, and the Guardian all summarised its key findings. Several they mention are missing from this article, with other stuff in the "findings" section instead. Some are mentioned elsewhere, but you'd expect to find the key findings of the report in the findings section of the article. Namely, we are missing the findings that:

• care for children and young people questioning their gender identity should be holistic, including screening young person seeking help for gender-related distress for neurodevelopmental conditions
• finding that there is “no clear evidence” that social transition in childhood has any positive or negative mental health outcomes and “relatively weak” evidence for effects in adolescence
• there should be different approaches for the youngest children seen vs teenagers (specifically, though the clinical pathways point is close)
• professionals have been reluctant to engage in the clinical care of gender-questioning children and young people due to the weak evidence in the area, toxicity, and fear of mistakes (leading to a lack of people to care for gender questioning young people and the present waiting times)
• recommending creating a follow-up service for 17-25 year olds in adult gender identity clinics (and resulting concern this could restrict access to HRT for adults between 18 and 25)
• widespread toxicity of debate exists, and it hinders helping trans and gender questioning children and young people

some further points that were reported less widely include:

• proposal that all referrals should come via secondary care (services for which a GP referral is needed)
• the NHS should consider setting up services for people wishing to detransition and support everyone who has been or is gender questioning
• GPs shouldn't be pressured to share care with private puberty blockers after they have been banned in the NHS nor to prescribe hormones after private providers have done so
• change in profile of patients from mostly AMAB to now AFAB in vast majority

13tez (talk) 15:28, 17 April 2024 (UTC)

More International Responses

Scotland: Sandyford Clinic halts puberty blockers. https://www.bbc.co.uk/news/uk-scotland-68844119

Amsterdam UMC: Claims to already be doing what Cass Recommends in terms of assessment and gatekeeping, and that RCTs are unethical. https://amsterdamumc.org/nl/vandaag/een-reactie-van-amsterdam-umc-op-de-cass-review-over-transgenderzorg.htm

Norway: clinician quoted here welcoming the result and saying its in line with Norwegian guidelines (translated archived version) https://web-archive-org.translate.goog/web/20240417164023/https://www.aftenposten.no/verden/i/9zg9L5/england-foelger-etter-norden-strammer-inn-paa-kjoennsbehandling-for-mindreaarige?_x_tr_sl=no&_x_tr_tl=en&_x_tr_hl=en-US&_x_tr_pto=wapp

Anne Wæhre, senior physician at the National Treatment Service for Gender Incongruence at Oslo University Hospital. - This is probably the most thorough work that has ever been done in this field, says Wæhre [...] Young people have been treated for many years, but it is now clear that there is little evidence that the treatment is effective and safe.

The British conclusion points in the same direction as the conclusion drawn in Norway over the past year, following last year's report from the National Commission of Inquiry into the Health and Care Service.

Void if removed (talk) 15:06, 18 April 2024 (UTC)

Of these, I think the Sandyford response is notable, as is the Dutch one (as originators of the protocol).

The Norwegian one is more of one clinician's opinion and probably not adding much as yet. Void if removed (talk) 15:10, 18 April 2024 (UTC)

I think your summary of the Amsterdam UMC source is not great. This is going by Google Translate, but, here are a few quotes:

As a basis for the recommendations, Cass and colleagues simultaneously published 7 reviews of the scientific basis of transgender care, which found insufficient evidence for the various steps in this care. Amsterdam UMC disagrees with the conclusion that there is insufficient scientific evidence for the use of puberty blockers. Cass indicates that many studies lack an untreated control group, so the certainty of these studies is considered low to moderate. However, double-blind randomized placebo-controlled studies, the type of research that leads to the highest level of evidence in healthcare but which is not possible in many types of care, is not considered feasible by Amsterdam UMC from an ethical point of view for evaluating transgender care for young people.

Puberty blockers have been offered for about 20 years. Various studies show beneficial effects of hormonal treatment on psychological well-being and quality of life, in the Netherlands but also in other countries. Puberty inhibition, provided that it is preceded by careful assessment, is considered an effective intervention.

Cass recommends that from now on puberty blockers should only be offered to young people in a research context. However, there are doubts about the ethical issues surrounding it. If diagnosis, assessment and possible prescription of puberty blockers are only possible through participation in scientific research, people will not have access to necessary care if they do not participate in scientific research. Amsterdam UMC does not think it is ethical to ask patients this.

My overall summary here is that they agree with the Cass Review in the parts about local care and disagree with the meaty bits about evidence and about restricting access to puberty blockers except for research. Notably for Colin, who keeps complaining about this, they specify that it's only double-blind RCTs that they ethically object to and even suggest waiting-list controlled trials. (But on the other hand they do take a snipe at England, and notably they say England specifically and not the UK, for politicizing trans healthcare.) Loki (talk) 03:22, 20 April 2024 (UTC)

From what you quoted in green, it looks like classic strawman. That they supposedly found insufficient evidence because they excluded too much with unethically high standards. But the moderate quality studies were actually included in the systematic reviews (of hormones and of puberty blockers) and in fact the majority of studies were felt of sufficient quality to be worth drawing from, but this press release wouldn't tell you that. They setup the strawman of a blinded RCT despite none of the two BMJ systematic reviews and nowhere in the Cass Review demanding such. As you note, but didn't quote, they do say Waiting list control groups and comparisons between clinics could possibly be used as alternatives. Overall, they don't really give any good reason for why they disagree that there is evidence for puberty blockers, so I can only repeat that maybe some of these organisations claiming there is evidence should publish their own systematic review with that as its finding, rather than just waving hands about. It's what Wikipedia would need for us to say, in Wiki voice, that there is evidence: no amount of press releases from various international groups can dismount a solid systematic review in a top tier journal. Expert opinion is low down on the evidence pyramid.

They endorse the request for more research, and there's far far more to the research requirement that Cass is now insisting on than trying to figure out how to do a control. Just following the patients up and ensuring we have data on their long-term health would be a start, which isn't something England did. In fact, overall the press release has the air of a group boasting about how they did it right, per Cass, and rubbing their English colleagues noses in their mess.

The NHS has done some astounding research some of which is only possible due to the nature of our system. See RECOVERY Trial. We shall have to see what NHS England do in this regard. But offering treatment only as part of a clinical trial is I'm afraid absolutely routine in the NHS and I'm sure elsewhere too. I think their ethical complaint on that regard doesn't really stand up to evidence. Unlicenced drugs (as these are for this group) are quite typically offered only as part of a trial. Totally normal. In fact, the idea of giving out these unlicenced drugs but not including the patients in a trial, with long-term follow up, is something Cass and many others have commented on as being astoundingly abnormal. -- Colin°^Talk 10:24, 20 April 2024 (UTC)

Perhaps one of the things is this is fairly unique to the UK and that's why it's causing so much controversy? My impression is it's very common elsewhere that approved drugs are prescribed off-label without including the patients in a trial. See e.g. [14] for NZ. (While it doesn't definitely say they're not being given as part of a trial, the fact there's no mention they must only be given as part of a trial and it's clearly targeted at those making such prescriptions strongly suggests they're not. In fact it mentions concern about some widespread practices.) Likewise in the US [15] [16]. Indeed in the US AFAIK it's been a significant controversy when manufacturers seem to have aggressively promoted off-label use e.g. Quetiapine#Lawsuits but notably the Opioid epidemic in the United States is often blamed in part on manufacturers heavily promoting their use both over prescribing but also off-label usage. (The examples do demonstrate that excessive off-label usage can be problematic or at least highly controversial but also that they often happen without requiring a clinical trial. And I didn't even touch on the highly controversial off-label usage of ivermectin and some other drugs during the worst parts of COVID-19 pandemic in some countries, which I'm fairly sure is still happening in at least some places.) Nil Einne (talk) 22:00, 20 April 2024 (UTC)

Yeah, the idea of prescribing a drug off-label is completely routine in the US. Our own article on the practice says Off-label use is very common and generally legal unless it violates ethical guidelines or safety regulations. The ability to prescribe drugs for uses beyond the officially approved indications is commonly used to good effect by healthcare providers. Loki (talk) 22:26, 20 April 2024 (UTC)

Cass q&a

I don't think this is worth a mention just on this source (there might be more coverage later or more similar things.) but I wanted to give notice that the kite trust (Scroll down past the response) met with Cass and her team and had this q&a with common questions. LunaHasArrived (talk) 18:51, 19 April 2024 (UTC)

I agree that this source is very, very primary, but I think the content itself bears weight because it potentially reframes a lot of the Cass Review’s findings and recommendations Snokalok (talk) 20:50, 19 April 2024 (UTC)

Hopefully other sources will cover it, but given the way the UK media is, I don’t have high hopes Snokalok (talk) 20:50, 19 April 2024 (UTC)

IMO, while we cannot use the source directly, we can use it to guide our coverage. In particular in cutting down on nonsense. For example, any suggestion that the Cass Review recommended against medical transition for 18-24 (or whatever) years old is at best a misunderstanding. I don't think there's a reason to think it a misunderstanding significant enough to be mentioned in the article so it's something which we should just exclude. Nil Einne (talk) 17:36, 20 April 2024 (UTC)

As mentioned, in it's current form with this source it shouldn't be included. I think it was done with multiple other charities though. Although I think this kind of source could prove very useful (an opinion from Cass on common criticisms.) LunaHasArrived (talk) 18:07, 20 April 2024 (UTC)

I don’t think we can do that though, for the reason that what’s said in the interview reads as directly contradictory to a lot of what’s said in the report.

If we had weightier sourcing then we could perhaps add in the kite trust interview and say “In a followup interview, XYZ contradictory thing was said”, but right now, it bears neither weight nor reliable sourcing - certainly not to the level needed to make BLP claims about Dr. Cass herself. Snokalok (talk) 00:58, 21 April 2024 (UTC)

At the very least, we need very strong source to repeat claims which Cass herself has said is a misunderstanding of what her review recommended. I don't know what such sourcing may be, but perhaps criticism coming from WPATH may be it. But some random expert IMO is clearly not that. To put it a different way, I'm not sure why it's productive for us to get into some fuss just because some people failed to recognise that the word transition can have multiple meanings and so when someone says "Taking account of all the above issues, a follow-through service continuing up to age 25 would remove the need for transition at this vulnerable time and benefit both this younger population and the adult population" they are not saying this would remove the need for "social transition" or "medical transition" but instead referring to remove the need for a "Transfer to adult gender services" which is what the section is titled and when read in context with the rest of the paragraph seems to clearly be what the read transition was referring to in this entire section. I mean it earlier says "surrounding transition from children and young people’s gender services to an adult Gender Dysphoria Clinic (GDC)" and I don't see how in any context that can be understood as referring to a social or medical transition. It also quotes the NHS Long Term Plan 2019, which I think we can assume for many reasons is referring to providing services to young people in general which says "“Failure to achieve a safe transition can lead to disengagement, failure to take responsibility for their condition and ultimately poorer health outcomes.". So I'm even more confused why until we get better sources, we should take this as a contradiction between her report and what she later said instead of people just not properly understanding the report. (I mean I strongly suspect whoever wrote the Long Term Plan thing didn't even think the word might be misunderstood in this way since it wasn't at all relevant to what they were talking about.) Nil Einne (talk) 01:47, 21 April 2024 (UTC)

As the Amsterdam UMC response pointed out, even reading it as transition to adult services it carries implications of restricting medical transition in young adults, because the report already advocated for restricting medical transition in teenagers, so if it says that young adults should be treated by the same places as teenagers, that implies that it would at least become more difficult for young adults to transition. Loki (talk) 02:39, 21 April 2024 (UTC)

GenderGP Response

GenderGP, the only private-sector provider of transgender youth healthcare in the UK, has issued a response to the Cass Review. It's pretty critical. Loki (talk) 22:33, 20 April 2024 (UTC)

I only got 3 paragraphs in and it felt like a "Cass Review Disinformation Greatest Hits Album" of everything that has been discussed on this page. We've got dismisses a very large number of studies - false, extensively discussed. omits studies from the past two years - also false (did they even read the report?). The reason for dismissing this evidence is that it did not come from randomised controlled trials - also false, also discussed above.

Pretty much what you'd expect from a source that doesn't pass the the Upton Sinclair test though. Barnards.tar.gz (talk) 11:22, 21 April 2024 (UTC)

NPOV, MOS:CLAIM, and BLP oh my!

@Barnards.tar.gz

Okay since this is too much to say in an edit summary, I’ll say it here.

”identified disinformation” is both MOS:CLAIM by use of the term ‘identified’, and NPOV by the use of the term “disinformation” given that we have countless major medorgs in the responses saying the same thing. Conversely, “said that disinformation had been spread” is perfectly reasonable, because that properly attributes it to the opinion of one person.

As for BLP and NPOV, citing conservative sources to name a specific labour MP in article not about her has so many BLP and NPOV concerns I don’t even know where to begin, not to mention using those sources to say that she definitely spread disinformation as opposed to, the opinions of every major medorg listed above; and this alone merits immediate deletion pending talk on its own, but then there’s also the question of how much WEIGHT it’s owed relative to just “repeated by labour MP’s”. Naming her specifically reads as almost punitive, which is a terrible thing for a wikipedia article to read as.

You’re at three reverts, which means this thread is your next stop. Snokalok (talk) 10:39, 21 April 2024 (UTC)

1. MOS:CLAIM is a warning to take care, not a prohibition. In this case, the claim is objectively false and so there's little value in soft-pedalling it as just an opinion. If a major medorg is also spreading the same false claims, we should not be treating them as a reliable source for this article. Are you referring to PATHA? The one that also published misleading statements about haircuts? It's clear what such press releases are: hastily cobbled-together knee-jerk responses from PR teams in order to stake a position during the current news cycle. They carry very little MEDRS (or even RS) weight and do not represent a considered viewpoint. I'm sure we will see more substantial and measured responses in due course.

2. I didn't just add the text back in, I upgraded it with additional citations including to a non-conservative source (The Independent). Additionally, the actual source of this naming is Cass herself, not the editorial voice of The Times or The Independent. She was the one that called Dawn Butler out, and Cass's views are eminently relevant. Barnards.tar.gz (talk) 11:17, 21 April 2024 (UTC)