Talk:Cass Review/Archive 5

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The view that "Cass is not a reliable RS on biomedical facts and claims": a snapshot of the For and Against from Talk so far

Licks-rocks (talk) said: "this and other discussions on this page are almost unreadable". Taking that lead, how to make the talk page more readable/useful, I spent a couple of hours collecting the widely spread comments on this issue where consensus seem not to be reached

that: "Cass is not a reliable RS on biomedical facts and claims.”

Your mileage may vary, but I hope at least editors will find this collection useful. All comments come this Cass’s Talk page. To make this list more useful, side-issues in paragraphs have been ‘…’ed out. I’ve double checked that no meanings have been changed, but apologies in advance if one slipped through.

It is only a snap-shot in time -as of now.

In full: View that: “Cass is not a 1st-class MEDRS compliant secondary source on biomedical facts and claims.”

Grouped under headings

A) “not top tier medical evidence”
B) Concerns over it being Primary

A) “not top tier medical evidence”

FOR

“It is not the most credible and important source out there. WPATH for example publishes similar reports, which are read and used worldwide, and released at regular intervals to keep up with the state of the science.” (Licks-rocks)

“ I think a very important thing to say that Cass's report whilst based on systematic reviews is not top tier medical evidence” (LunaHasArrived)

“The reviews are high quality peer reviewed academic studies. The report isn't. It is compiled by a qualified group of people but it's not the reviews, it's a professional opinion about the reviews” (Loki)

“I 100% agree that the systematic reviews covered and considered all the evidence. I think one can argue that Cass's recommendations do not… the recommendations which aren't more than peer reviewed medical expert opinion. ” (LunaHasArrived)

“About the final report, .. it is ultimately just the professional opinion of the authors. It's not systematic, it's not even a study. It's a government report” (Loki)

“While the breadth of the studies considered is important, it is only one factor, and the review is only one review. It was also endorsed universally by gender-critical organizations, and international medical organizations in the field have criticized its methodology and findings. We should take care when covering this review and be sure to use independent reliable sources… Determining whether the Cass Review as a whole is "correct" is not our role as Wikipedia editors. ” (Hist9600)

“Just because something's a good source does not mean other good sources are automatically worse.” (Licks-rocks)

“I said ..that “the Cass Report is kind of dodgy about what it's actually arguing”, specifically regarding whether or not it thinks that more RCTs should have been conducted. This is "dodgy" in the sense of "evasive", and not in the sense of "poor quality". (Loki)

“As far as I'm aware, the Cass Review was only prepared for NHS England, and is mainly relevant for the NHS, and not for other countries.” (Hist9600)

AGAINST

“The Cass review is afaik the most thorough review of the subject matter since the SBU review of 2022. Saying the Cass review is only important with respect to the NHS is like saying the SBU 2022 was only important to the Swedish healthcare system. Sure, the recommendations are with respect to the NHS, but the ramifications of an in-depth review considering the international body of research are more far reaching.” (Draken Bowser)

“What is it that let's us write about their (Cass) findings as though they really did find them? Well, that's because the document and supporting documents are WP:MEDRS compliant sources for these.” (colin)

“We shouldn’t be presenting any views in a way that serves to offset, undermine or contradict the findings of the systematic reviews unless those views are based on equivalently weighty research.(Barnards.tar.gz)

We should also make clear that some of these responding organisations were directly criticised in the report (most notably WPATH). That makes their views more relevant but also more WP:MANDY. (Barnards.tar.gz)

“I am saying that currently these systematic reviews represent the best MEDRS sources for Wikipedia's voice on whether certain therapies work and are safe. “ (colin)

“This is pretty much what we're weighing up here: the findings from systematic reviews carried out by an actual MEDORG vs conventional wisdom from professional associations.” (13tez)

“The whole report is not dodgy in the sense of poor quality and I never said that it is.” (Loki)

B) Concerns over it being Primary:

FOR

“The whole Cass Review is a primary source on this page. Anything (Helen) Cass says about the Cass Review (in any medium, to be clear: a New York Times interview would have the exact same problems) is also a primary source here. I would have assumed that this is obvious, and that the WP:INDEPENDENCE problems with citing a source in the article about that source would also be obvious”. (Loki)

“(Re FAQs)...Ultimately, this is a primary source and can only really be taken as the review responding to criticism, that is - it can be taken as one side in the debate, not as objective fact. “ (snokalok)

“I think this is probably the best example of why we can't always use Cass about itself. We have medorgs saying the Cass review has a higher bar of evidence for some care over others, then we have Cass saying no it is the same bar. We have 2 distinct opinions here about what the findings and recommendations said and I think saying it's a false criticism is unhelpful.” (LunaHasArrived)

“(Helen) Cass herself not necessarily being a reliable source for even the contents of the report. The sourcing guidelines on Wikipedia are there for good reasons and those reasons don't stop applying in MEDRS cases no matter how strong the evidence is within the context of MEDRS” (Loki)

AGAINST

“As discussed, the consensus is that the report falls under BMI, so MEDRS sources are needed. The NHS and the report qualify as MEDRS sources.” (13tez)

“What is it that let's us write about their (Cass) findings as though they really did find them? Well, that's because the document and supporting documents are WP:MEDRS compliant sources for these.” (colin)

“As with any (vaguely) similar government report, it will be secondary in the parts that analyze, evaluate, criticize, draw conclusions from, etc. previously published sources” (WhatamIdoing)

“It will be important to remember that primary is not a fancy way to spell 'bad'. (In particular, for direct quotations, primary sources are often best. Original documents can't misquote their own contents.” (WhatamIdoing)

“For example: if the Cass report is cited in support of the sentence "Based on moderate-quality evidence, puberty blockers neither change nor worsen either gender dysphoria or body satisfaction", then the Cass report is:

secondary if it's in this article,
secondary if it's in another article, and
secondary if it's on another website entirely. (colin)

“the Cass review can be BOTH a primary source for certain things on this page AND a MEDRS compliant secondary source for other things on this page. (colin)

… primary source if you want to write a sentence like ... "The report recommends that families of pre-pubertal trans or gender-questioning kids get at least one appointment with a ...
… secondary .. ... "Based on moderate-quality evidence, puberty blockers neither change nor worsen either gender dysphoria or body satisfaction"

“It's a follow-up by a report commissioned by the NHS, a reputable major and national medical organisation that defines the guidelines for and carries out almost all medicine in the UK. If we're using MEDRS sources here - as is the consensus - we're not delving into normal practice of requiring mostly secondary sources etc set out at WP:PSTS. (13tez)

================== end of quotes ========== Peckedagain (talk) 17:37, 6 May 2024 (UTC)

I don’t think these are the quotes that those in the FOR side would choose to represent or encapsulate their arguments, they feel specifically as the quotes that sound the weakest out of context.

If I were to choose my own quote cited here, for example, it’d be

“The FAQ is not a reliable source to censor criticism with because it's effectively somewhere between "Nuh uh" and "We've investigated ourselves and found no wrongdoing"”

And for the wider text

“A text is inherently a primary source on its own contents, that’s simply a fact”

While the use of direct quotes is ultimately better than not, this does to some degree still feel as though you’re speaking for your opposition without their input.Snokalok (talk) 19:04, 6 May 2024 (UTC)

I think that trying to decide which WP:LABELS to stick on the Cass Review is a misguided exercise. I think a list of what we agree on would be more useful to editors than trying to pigeonhole the report into various keywords. I dislike the model that you'll see at Talk:COVID-19 pandemic#Current consensus, but it does seem to have had the beneficial effect of not having editors re-re-re-discussing basic points.

For example, I suspect that editors from all sides would be willing to agree that if a source says that the Cass Review excluded 98% of the evidence and does not issue a correction, then that specific source (whether you define that as the author, the document, or the publisher) should be considered unreliable in Wikipedia's terms. Nobody wants to see misinformation in the article, and a source that gets such a basic factual point wrong can't be relied upon to get everything else right.

Similarly, it looks to me like there is at least the possibility of an agreement that the WPATH statement, if any ever appears, should replace the early statements from PATHA and AusPATH, rather than being added to them, but that until WPATH decides to issue its own statement, these two should be kept. An encyclopedic summary provides the most important points from the most salient groups, rather than a laundry list of everyone who ever wrote about it (regardless of whether they wrote in favor or against it). WhatamIdoing (talk) 23:38, 6 May 2024 (UTC)

I agree and what I've been saying all along is that using PSTS or MEDORG or any other labels about "the whole Cass Review" and "anything one might use it as a source for" is entirely wrongheaded and over simplistic. These things only make sense when one is examining actual words in a sentence on the page, the point we are trying to make there and the exact text from the source we are relying on. I see some comment above about it being a government report and just the opinion of its authors. Oh, well, I guess we'll need to bin all the NICE guidelines, because they are just the opinions of some non-departmental public body. These aren't helpful arguments.

The statement "The FAQ is not a reliable source to censor criticism with because it's effectively somewhere between "Nuh uh" and "We've investigated ourselves and found no wrongdoing"" has problems on so so many levels. Playing the censor card when we are talking about basic biomedical misinformation is the sort of diff one might cite in a topic ban. Can we try harder please. This isn't twitter or a forum to trash Cass. A random line one heard from activists isn't necessarily a good one to repeat on this talk page.

One useful trick to try is if one takes one's argument and tries to imagine using it in another situation or if people with opposing POV tried to use it. Can people see themselves arguing that a CDC FAQ responding to "Should I inject bleach to clean out the COVID from my body" or "Does 5G cause COVID" should be regarded as unreliable because "It's just some government document and the opinions of its author". Or if the government responded to "Did Bill Gates put microchips in the COVID vaccine?" with a "No, the vaccines contain no microchips" and editors here argued this was a case of "We've investigated ourselves and found no wrongdoing". Can you see how that kind of argument looks?

Or imagine that the Cass Review came out with recommendations that you really liked and got the gender critical people fuming mad. How would you feel then about how much room we give to criticism from random Canadian gender-critical doctors that the Telegraph found or some US republican politician. How would you feel if we gave room to misinformation from LGBA or some transphobic Tory MP? Would you instead be banging on about how the author is a highly respected paediatrician and took four years and is built on half a dozen systematic reviews, and that in your view the gender critical twitterati can all go take a running jump. -- Colin°^Talk 10:50, 7 May 2024 (UTC)

The difference between this and the vaccine example is that, this is major MEDORGs criticizing the report. That is to say, the criticisms are credibly and bear weight, and excluding them simply because the FAQ that the source being criticized put out saying “no” is an incredibly conflict of interest on a basic level. Let’s pose another example: let’s say that the Saudi health ministry put out a report in which they said “It is our opinion that women lack the neurological capacity to drive a car”, and that report was thoroughly criticized by a number of reliable and relevant MEDORGs. I think we can all agree that the criticism there would bear weight. Now let’s say the Saudi health ministry put out an FAQ in response to the criticism saying “The criticism is fake and nonsensical because we never recommended that women not drive” and then you look at the report, and it has the above quote directly. Would we use this FAQ as reason to exclude MEDORG criticism, given that the authority that published it said “nuh uh”?

“How would you feel then about how much room we give to criticism from random Canadian gender-critical doctors that the Telegraph found or some US republican politician. How would you feel if we gave room to misinformation from LGBA or some transphobic Tory MP?” The difference here is that we’re not saying activist groups or politicians, we’re saying MEDORGs should not have their criticism excluded simply because the ones being criticized said no. There is very much a difference.

Like how we implemented the Cass Review’s criticism on the WPATH SoC page. That’s a medorg criticism that bears weight (the others are correct imo that while the sources cited in the report are systematic reviews, the report itself is an NHS report and thus a MEDORG source)

EDIT: To clarify, I also agree with the consensus point regarding excluding the 98% statistic and whatnot. Also I will likewise be limiting my interactions because I feel my involvement has been a tad disproportionate. Snokalok (talk) 11:44, 7 May 2024 (UTC)

@Snokalok, an argument that "major MEDORGs criticizing the report" is reasonable but only on that points where that is specifically the case. I think you are making an argument about the FAQ and should perhaps re-read the FAQ. Which specific things have a major MEDORG claimed that the FAQ counterclaimed and are in dispute? Rather than wikilawering about how the FAQ may or may not be regarded as reliable for our purposes, what on earth is it that anyone thinks the FAQ got wrong?

I think you are overstating the criticism with a claims that major MEDORGs criticise the report. The report specifically called out WPATH for criticism, to the point where "discredited" now appears in news headlines, so I would very much understand that they are unhappy, defensive and looking for points to score. The WPATH section in our article currently focuses on the recommendations, which they disagree with, not the evidence, which is an area they are weak on. Their comment on mental illness is somewhat disingenuous in that while being trans itself is not regarded as a mental illness by WHO, Cass's review and the supporting research, demonstrates the patient population group currently being referred to and on the waiting list for appointments at gender clinics overwhelmingly have multiple mental health issues, often of the most serious and disabling kind, along with neurodivergence and child-abuse/in-care factors. Cass was asked to examine how this group is being treated by the clinics and other services, and found huge failings that are undisputed. The idea this population group would benefit from a holistic approach rather than ignoring their mental health problems is widely regarded as a good thing (the story being that once referred to GIDS then CAHMS didn't want to know and no longer helped, and once the few eventually arrived at GIDS, who are psychiatrists, all anyone wanted was a referral to endocrinology). Do you see there might be some nuance in what is welcomed and what is disagreed with that is being lost in the social media witch burning.

I think reducing things down to "major MEDORDS criticise the report" is an over simplification. The FAQ is dealing with the nonsense that gets spread on social media and we need to take care not to repeat. That WPATH and NHS England might develop treatment guidelines that take different approaches is not really what that FAQ is looking at. Kneejerk press releases playing political games about mental illness aren't helpful either. Let's hope a full response is more considered than that. -- Colin°^Talk 13:18, 7 May 2024 (UTC)

I don't think the FAQ is an unusuable source but I do think that, just like the 98% number is reason for strong skepticism because it's obvious BS, some of the things Snokalok has identified about the claims in the FAQ are very concerning and make it look like the FAQ is probably making claims that are either false or very easy to misinterpret into a false claim.

Specifically I'm thinking about the claim that they didn't use an uneven standard of evidence, but they recommend psychosocial intervention and not hormonal intervention despite coming to nearly identical conclusions about the evidence base for each being weak. This seems to me a claim in the FAQ that, if not definitely false, is at least questionable enough to call its reliability into question.

Also: the general RS guidelines still do apply in the case of COVID or vaccines or any other MEDRS area. Of course they do. If a FAQ of a high quality systematic review into COVID said something that directly contradicted the review we'd obviously exclude that. Loki (talk) 17:37, 7 May 2024 (UTC)

Apologies for not keeping up with this subject (my news feed, fortunately for me, is mostly filled with baked goods), but Loki, do we actually have a statement from WPATH or any similar MEDORG that says something like "The Cass Review set a higher bar for evidence than would normally be expected"? I don't remember anyone mentioning such a thing.

It sounds to me like we have one source (Cass' FAQ) saying one thing ("We did not use a higher standard for evidence than normal"), and other sources (e.g., various types of orgs) saying something quite different ("Yeah, you didn't use a high standard, but you also didn't use the same standard for everything. You used the normal standard of evidence for puberty blockers and a lower standard for psychological support. If weak evidence is good enough for talk therapy, then it should be good enough for drugs, too."). WhatamIdoing (talk) 20:17, 7 May 2024 (UTC)

I'm concerned you are saying "some of the things Snokalok has identified about the claims in the FAQ are very concerning" when I still haven't got a reply from Snokalok that the things they are concerned about are actually in the FAQ Could you both read it carefully and point me to the sentence that talks about "uneven standard of evidence", which WAID addresses. As I have said, what experts do in the absence of evidence is often going to vary from one perfectly reasonable person to another. Cass falls back on evidence for psychological therapies being useful in related areas (and needed, anyway, for this population group) and this isn't that dissimilar to the trope about puberty blockers having a safety record in precocious puberty so presumably safe for teenagers. Both arguments are open to criticism but also both have some reasoning to them that isn't completely stupid. These are areas where I hope we can have solid expert and carefully written sources to describe the difficult decisions being made, why they were made, and why some disagree with them. But please, read the FAQ, and I don't think there's anything there that will be disagreed with by any reasonable person.

Btw, Snokalok, your Saudi health ministry example demonstrates prejudice as your reasoning rather than offering a fact-based counter example to women's driving skills (pretty easy to find which sex has the most accidents and drives dangerously). If the UK or US had made a statement about the poor driving standards of men, and felt they had to defend that statement from complaints from some Top Gear presenter, nobody here would be going "oh, we can't trust that FAQ because it is a primary source from a government and just somebody's opinion". These arguments are bogus, if you shift them to a different example.

It is pretty clear a lot of talk on the internet is prejudiced against Cass (middle aged woman from the UK: obvious TERF) Let's have the FAQ criticised, if necessary, because of sourced evidence that what it says is clearly wrong, not because of editors wikilawyering about primary which continues to waste our time (hint: please stop). -- Colin°^Talk 20:42, 7 May 2024 (UTC)

First question: "Did the Cass Review set a higher bar than would normally be expected"

Stated answer: "No, the approach to the assessment of study quality was the same as would be applied to other areas of clinical practice – the bar was not set higher for this Review. Clarification: The same level of rigour should be expected when looking at the best treatment approaches for this population as for any other population so as not to perpetuate the disadvantaged position this group have been placed in when looking for information on treatment options."

This is questionable for two reasons.

1. According to this systematic review, less than half of all medical treatments are backed by moderate quality evidence or above [1], meaning that requiring such for puberty blockers is a higher bar than would normally be expected.

2. The Cass Report itself says on page 196 "research on psychosocial interventions and longer-term outcomes of those who do not access endocrine pathways is as weak as research on endocrine treatment" And yet then elsewhere, it says "For the majority of young people, a medical pathway may not be the best way to achieve this. For those young people for whom a medical pathway is clinically indicated, it is not enough to provide this without also addressing wider mental health and/or psychosocially challenging problems"[page 30] and "Standard evidence based psychological and psychopharmacological treatment approaches should be used to support the management of the associated distress and cooccurring conditions."[page 31] and "In addition to treating co-existing conditions, the focus on the use of puberty blockers for managing gender-related distress has overshadowed the possibility that other evidence-based treatments may be more effective. The intent of psychosocial intervention is not to change the person’s perception of who they are, but to work with them to explore their concerns and experiences and help alleviate their distress regardless of whether or not the young person subsequently proceeds on a medical pathway."[page 31] Very clearly stating hormone treatment as the undesirable option for the majority of patients while stating psychosocial intervention as the best for both those on hormones, and those not. This is all despite them having the same quality of evidence. That's a double standard.

Regarding your comparison to the puberty blockers for precocious puberty argument, this I feel misses a key point to that argument that biologically there is no difference between administering for precocious puberty or gender dysphoria. Your body doesn't know the difference. It blocks puberty the same regardless. Whereas psychological treatment for general anxiety and depression vs for gender dysphoria is inherently different because they're two fundamentally different psychological scenarios thus requiring two different treatments even if remaining strictly therapeutic. That is, your mind does know the difference and does respond differently.

"If the UK or US had made a statement about the poor driving standards of men, and felt they had to defend that statement from complaints from some Top Gear presenter, nobody here would be going "oh, we can't trust that FAQ because it is a primary source from a government and just somebody's opinion" Are you saying that a Top Gear presenter is equivalent to a MEDORG in this scenario? Because that's, a very bold take if so. Regardless, if we were to elevate a top gear presenter to the level of a MEDORG in that scenario, we would reasonably include the criticism in the article - and then if the US or UK govt said "nuh uh", we might include the nuh uh as well, but we would not use it to exclude the criticism itself.

Anyway regarding "when I still haven't got a reply from Snokalok " as I said, I'm trying to reply less frequently so that my voice doesn't inadvertently smother all others on this page.

EDIT: Regarding PRIMARY source concerns, how is that wikilawyering? I read over the essay and I, genuinely do not see it, I haven't been citing the exact wording of policies or technically misinterpreting them or anything, I wouldn't even know where to begin with that. Snokalok (talk) 02:02, 8 May 2024 (UTC)

@Snokalok, I've only read your #1 point ("According to this systematic review..."). What I'm not seeing here is a reliable source that says this about the Cass Review. PMID 32890636 (the review article you linked) is a very nice source, and I hope it's been used in Evidence-based medicine, but it was published in 2020, and it doesn't mention the Cass Report, or trans people, or anything else that's relevant.

Consequently, it looks like this point represents a Wikipedia editor engaging in WP:Original research, rather than a reliable source saying – I'm not sure what they'd be saying, actually. Maybe "The median medical intervention has moderate quality evidence behind it, and we think treatments for trans kids don't need to rise even to the average level"? I certainly hope not.

Do you have a reliable source that directly connects these two? WhatamIdoing (talk) 05:43, 8 May 2024 (UTC)

You’re allowed to engage in OR in talk pages, especially for evaluating sources.

See “ This policy does not apply to talk pages and other pages which evaluate article content and sources, such as deletion discussions or policy noticeboards” Snokalok (talk) 08:41, 8 May 2024 (UTC)

Snokalok, you were asked "Which specific things have a major MEDORG claimed that the FAQ counterclaimed and are in dispute?", not for some OR citing papers from 2020. -- Colin°^Talk 13:00, 8 May 2024 (UTC)

“I still haven't got a reply from Snokalok that the things they are concerned about“

Well no actually, you asked what I’m concerned about in terms of evidentiary reasons and again, as the policy says, OR is perfectly valid and acceptable under WP:OR for analyzing the reliability of sources and info through the lens of a talk page, per the quoted text. It only becomes a problem if you add info to the article that is OR. You can’t accuse me of wikilawyering for disagreeing on a source’s reliability, and then turn around and directly misapply the OR policy against that disagreement.

And again, it doesn’t matter if a MEDORG is criticizing the FAQ or not, we’re fully allowed to evaluate sources as unreliable based on our own dissections - which is exactly what this talk page - including you yourself - did for any source saying 98% , even before the FAQ came out. Why is it suddenly now not acceptable to do that? Snokalok (talk) 15:32, 8 May 2024 (UTC)

Oh, sorry, I must have misunderstood. I thought the reason you posted that information was because you were trying to help us improve the article. WhatamIdoing (talk) 16:13, 8 May 2024 (UTC)

WP:AGF. Using an unreliable source to exclude relevant and well sourced content helps no one, that’s what I’m arguing against. Kindly strike your personalization. Snokalok (talk) 16:20, 8 May 2024 (UTC)

@WhatamIdoing Snokalok (talk) 17:35, 8 May 2024 (UTC)

@Snokalok, I think you are reading more into the report than it actually says. None of the recommendations actually recommend using psychosocial interventions instead of puberty blockers. There are three groups of treatment under consideration:

1. Psychosocial interventions

2. Standard evidence based psychological and psychopharmacological treatment [for mental health]

3. Puberty blockers

Cass notes that the evidence base for 1 and 3 is poor, but the evidence base for 2 is good. Therefore 2 should be leveraged to treat the comorbidities that occur in the majority of cases (Recommendation 3, on page 31). She notes that the focus on 3 has overshadowed the possibility of 1 being more effective. The purpose of the explanation of psychosocial intervention ("The intent..."), is to distinguish it from "conversion practices" and position it as an approach worthy of further investigation (she states elsewhere how harmful it is to equate the two). This leads to Recommendation 6 (page 35), that the "evidence base underpinning medical and non-medical interventions in this clinical area must be improved", and Recommendation 20 (page 40), that a "unified research strategy should be established". That is, she wants to see more research and better evidence for both medical and non-medical interventions.

At no point does she actively recommend psychosocial intervention. Therefore much of the noise here is being expended on a straw man. Barnards.tar.gz (talk) 11:16, 8 May 2024 (UTC)

The evidence base for 2 in the general population for normal anxiety and depression is good. The evidence base for using general anxiety and depression treatments for gender dysphoria, is non-existent, which is specifically why the report instead extrapolated from genpop treatment. That means that both group 1 and group 3 are being held to a higher standard for dysphoria than group 2.

And yes, the report can say that they want to see better evidence for both 1 and 3, but the fact is it still says group 3 shouldn’t be given to the majority of patients while group 1 should be given to all, despite them having the same level of evidence. That’s giving one a higher standard than the other. Snokalok (talk) 15:38, 8 May 2024 (UTC)

using general anxiety and depression treatments for gender dysphoria That's not what is being recommended. Cass does not state or imply that treating the cooccurring conditions will cure the dysphoria. One might believe that "anxiety in association with gender dysphoria" is a completely separate condition from "anxiety", and that the established methods of treating anxiety are not transferable to this new condition... but do any MEDRS sources make that criticism? I've not detected that this is a common line of argument.

group 1 should be given to all It really doesn't say that, but if you think it does, could you provide a citation / page ref? Barnards.tar.gz (talk) 16:06, 8 May 2024 (UTC)

According to this systematic review, less than half of all medical treatments are backed by moderate quality evidence or above, meaning that requiring such for puberty blockers is a higher bar than would normally be expected.

I think this is missing the point - Cass used an appropriate bar for evaluating quality. The conclusions were not based on the quality of the studies, but on their findings. The findings of moderate/high quality studies did not give clear indication of psychological benefits and some indication of negative physiological side effects.

The review does not say "the benefits are inconclusive because there aren't many MQ/HQ studies", it says "there aren't many MQ/HQ studies and the ones that do exist are inconclusive".

Critics plead to include the LQ studies because without them, the evidence base for the treatment vanishes. That's not a robust finding, and not a situation you can directly compare to the aforementioned systematic review.

This is why this meta review does not apply - they didn't just look at systematic reviews with favourable outcomes. Many of the reviews simply reached no conclusion. What this review is looking at is whether evidence quality is improving. This review is not saying that "medical treatments" are backed by low quality data, they are saying that the conclusions of most systematic reviews are based on low quality data - irrespective of if those conclusions are favourable or not - and there's not much improvement in quality over time. Void if removed (talk) 17:05, 8 May 2024 (UTC)

Specifically I'm thinking about the claim that they didn't use an uneven standard of evidence, but they recommend psychosocial intervention and not hormonal intervention despite coming to nearly identical conclusions about the evidence base for each being weak. This seems to me a claim in the FAQ that, if not definitely false, is at least questionable enough to call its reliability into question.

I cannot locate this claim within the FAQ. Flounder fillet (talk) 22:47, 7 May 2024 (UTC)

See Snokalok's reply, they answer it better than I would. Loki (talk) 03:25, 8 May 2024 (UTC)

No, the approach to the assessment of study quality was the same as would be applied to other areas of clinical practice – the bar was not set higher for this Review.

This does not imply that the standards of evidence for everything that was evaluated were equal within the review at all. That is, unless one were to assume standards are equal for everything in all other areas of clinical practice. Flounder fillet (talk) 04:11, 8 May 2024 (UTC)

Note the words "higher" in the FAQ question and the response specifically commenting on the York systematic reviews. Snokalok and others are claiming major MEDORGs disagree with the report in a way that the FAQ is controversially responding to. But no evidence of this has been given, just some OR citing old old papers. There's NOTHING in the FAQ about "uneven" standards of evidence. At the moment, it seems some editors are getting worked up about a misunderstanding of their own making. Could we drop this "FAQ is unreliable" attack front completely as a total waste of everyones time please. -- Colin°^Talk 12:58, 8 May 2024 (UTC)

No, I never said major MEDORGs dispute the FAQ - which would be interesting to see given that the FAQ has been out for what, a week? Are they expected to put out a statement every time the Cass Review team opens their mouths? No, I’ve consistently said here is why I and other editors see the FAQ as not reliable to exclude content based off of. Please do not misrepresent me or my points. Snokalok (talk) 15:39, 8 May 2024 (UTC)

I think we've reached the stage in this discussion where it is now just a meta argument about people complaining they never said the things someone says they said even though those things are on this page. Life is too short for that. I'm not interested in any more wikilawyering about Cass, her interview on BMJ or the FAQ because those are not directly concerning improving this page (WAID's point above). I propose this section be abandoned as the waste of all our time it is. Let's have a normal discussion involving actual or proposed article text and actual or proposed sources, rather than folk arguing about what policy may or may not say about this or that source that may or may not even be used. -- Colin°^Talk 08:45, 9 May 2024 (UTC)

… Fuck it, sold. Though if a certain editor is reading this, I’d still like them to strike what they said. Snokalok (talk) 10:20, 9 May 2024 (UTC)

I think your top point hits the nail on the head with this entire section. It depends on what we're citing the Cass review for on whether primary and Medrs applies. I would also like to apologise for previous comments that are probably part of some of the latter part. I am a new editor still and I think I'm going to limit myself to a maximum of 3 comments on the talk page whilst it's still in it's current popularity to help curb the problem. I would also argue that we do currently have quotes from MPs people find transphobic and lgba level Organisations. Also that a lot of comments are coming from medorgs not a US republican or Canadian gender critical doctors. LunaHasArrived (talk) 11:46, 7 May 2024 (UTC)

Add comments from Cass she believes she has seen treatments work well?

Although the review found insufficient evidence to support making the treatments it examined standard practice, Cass has since said that although she thinks they have been applied inappropriately in some instances, she also has seen them have a positive effect on young people who have benefitted from them and believes they are the right option and helpful in some cases. Should we include this fact? The following sources can substantiate this:

13tez (talk) 13:19, 9 May 2024 (UTC)

In Cass Response possibly, I'd say, but not in findings. Snokalok (talk) 14:38, 9 May 2024 (UTC)

On that note, how do we feel about adding in the bit from the Holyrood interview about general anxiety and depression medications? We do also have "Standard evidence based psychological and psychopharmacological treatment approaches should be used to support the management of the associated distress and cooccurring conditions."[page 31] in the report itself. Snokalok (talk) 15:08, 9 May 2024 (UTC)

@13tez and others: The BMJ interview is available through Wikipedia:The Wikipedia Library. Login (click the button for OAuth) and then search for the BMJ's entry (use the sidebar, not the search box at the top). Once you've clicked through to the BMJ's website – the resulting URL will start with https://www-bmj-com.wikipedialibrary.idm.oclc.org/ – search for any paper you want in the BMJ.

Nature journals are also available through TWL. WhatamIdoing (talk) 21:41, 9 May 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)

The Cass review didn't look at adults and Cass themselves are not doing the adult review. Any commentary on that aspect is likely speculation/misinformation. I agree that "transition" is the word the NHS use to describe moving into adult care it is a fraught time for any longterm medical issue, not just trans medicine. There is often a gap where one hospital refuse to take you (as you are leaving anyway) and another refuse to take you (as you aren't old enough) and so on. -- Colin°^Talk 12:29, 21 April 2024 (UTC)

For everyone interested: I found The BMJ podcast episode where Abassi interviews Cass very helpful at dispelling some other myths too (https://thebmjpodcast.podbean.com/e/improving-nhs-gender-identity-services-hilary-cass/). Just like Luna mentions, it is not a proper secondary source, but it can help making more sense of what Cass is actually on to. For instance, Cass mentions somewhere that the psychological interventions are (obviously) not meant to get rid of gender incongruence, but of comorbidities that may obfuscate a proper diagnosis. (This is actually the standard in some other guidelines. The Amsterdam response also commended them for this recommendation, though they also noted that they fear the NHS won't receive enough funding to meaningfully implement this change). Cixous (talk) 18:11, 21 April 2024 (UTC)

You're probably right, but I'm always frustrated when important information is in podcasts or videos without transcripts. It makes it harder to verify the citation later.

That's my own gripe though. More relevant to this article is that anything Cass says is still a primary source, and has WP:ABOUTSELF problems to boot. So we should be careful when citing it, especially if/when Cass makes claims about third parties (like what they're saying about her study). Loki (talk) 00:55, 22 April 2024 (UTC)

I get that. Podcasts or videos are not great sources, especially not for Wikipedia. And you are completely right about WP:ABOUTSELF. We should watch out for that Cixous (talk) 16:01, 22 April 2024 (UTC)

That the BMJ interview with Cass was on a "podcast" doesn't fundamentally change its reliability status or PSTS status than if the BMJ had written it down and published it on their website. If anything, it is better than the snippets of her interview that the Times published, which doesn't give an accurate view of her response/reaction to questions. WP:ABOUTSELF is about questionable sources like Twitter, not about interviews in the BMJ website, even if in audio form. So the claim that "anything Cass says is still a primary source, and has WP:ABOUTSELF problems" is ripe nonsense and I don't understand the "not a proper secondary source" (see Wikipedia:Secondary does not mean independent).

There is no difference, for example, about what Cass says about third parties vs what third parties says about Cass. If one is critical of the other, it may or may not be worth noting here, with attribution and quotes as required, but there's no asymmetry. If Cass clarifies something in the review and we find that helpful as a source when writing our summary of the review, we can cite that along with the review citation no problem. -- Colin°^Talk 08:05, 24 April 2024 (UTC)

The whole Cass Review is a primary source on this page. Anything Cass says about the Cass Review (in any medium, to be clear: a New York Times interview would have the exact same problems) is also a primary source here. I would have assumed that this is obvious, and that the WP:INDEPENDENCE problems with citing a source in the article about that source would also be obvious. Loki (talk) 15:55, 24 April 2024 (UTC)

"The whole Cass Review is a primary source on this page." this is oversimplistic and makes me very concerned. @WhatamIdoing: who is our expert on such matters.

See my earlier comments about the mix of PSTS that the Cass Review is. Let's look at an example of article text and assume it is all sourced to the Cass Review:

The report stated that the evidence base and rationale for early puberty suppression remains unclear, with unknown effects on cognitive and psychosexual development.
A systematic review examined 50 studies on the use of puberty blockers using a modified version of the Newcastle–Ottawa scale and considered only one to be of high quality, along with a further 25 being of moderate quality, and the remaining 24 being of low quality.
The review concluded that the lack of evidence means no conclusions can be made regarding the impact on gender dysphoria and mental health, but did find evidence of bone health being compromised during treatment.
The review disagreed with the idea of puberty blockers providing youth patients with "time to think", due to the finding that nearly all patients who went on blockers later decided to proceed on to hormone therapy.

For #1, the CR is a primary source for whether or not it stated these things. But it is tertiary source for commenting on the evidence base and the "unknown effects on cognitive and psychosexual development" is a WP:BMI fact we can state in wikivoice per WP:MEDRS. For #2, the CR is a secondary source for what the York reviews studied and selected and graded. For #3 I think "review" is meaning the York systematic review, not the Cass review. Here the CR is a secondary source for whether or not the York review found these things and that it offered a conclusion, but it is again a fine tertiary source for the medical facts for what there is and isn't evidence for wrt various issues, which we can state in wikivoice. For #4 I think we are back to discussing what the Cass Review said about the "time to think" idea (could be wrong, but don't think that was what the York reviews commented on). For the first clause, the CR is a primary source that it disagreed with this idea, but a tertiary source for the medical fact that nearly all patients who go on such blockers (in studies at least) later went down the hormone pathway, which we can state as a fact in Wikivoice.

I think, Loki, you need to be specific about what claim you wish to comment on wrt PSTS and independence/third-party and so on, because you are waving crude generalisations about in a discussion where, once again, I don't think you are actually specifically addressing the debate. Wrt your claim "Anything Cass says about the Cass Review .... is also a primary source here" doesn't appear to undestand PSTS at all. For example, if Cass said in an interview in the times "Well in fact, the York reviews selected 60 papers out of 103" she is actually commenting on the York reviews, not her own report document, so she's a third-party secondary source on what they selected. If Cass said "My recommendations in the report on puberty blockers were..." then her interview is still a secondary source on what the report said but not independent of the report. These things are important because when we get newspapers interviewing some random Canadian GP who says there is good evidence of psychosocial and mental health benefit from puberty blockers, that claim fails every one of our MEDRS requirements and is in no way improved (from a "can we repeat their claim" pov) by being not-Cass. I just get the feeling you are trying to put Cass and their review into some untouchable twitter-trash level of sourcing and the absolute opposite is true. -- Colin°^Talk 09:11, 25 April 2024 (UTC)

I haven't read the report, but it's probably not a tertiary source for anything, unless it has a glossary or similar non-analytical summary of basic information.

All sources are primary for something. As with any (vaguely) similar government report, it will be secondary in the parts that analyze, evaluate, criticize, draw conclusions from, etc. previously published sources ("Seventeen papers met the pre-determined criteria for inclusion, and frankly, we think all of them stink"), and primary for any previously unpublished information it presents ("We interviewed a bunch of patients ourselves, and they said that everything was moderately bad and getting worse") as well as for the fact of its own recommendations ("The Cass report recommended that funding for this area be significantly increased").

NB that conclusions ("There is no good evidence, so this is not actually based in decent science") are not the same as recommendations ("In our view, it's stupid to have teens go to one provider to talk about gender identity and a completely different clinic, with a completely separate waitlist, to talk about anxiety, so everything should be one-stop shopping"). WhatamIdoing (talk) 00:26, 26 April 2024 (UTC)

I agree with this with the caveat that, because this whole article is about what the Cass Review says, even parts of it that would be secondary on other pages are primary here.

To be clear, I'm not saying that the review is a bad source on other pages. Even though the criticisms make me more skeptical of it than I would be of most other systematic reviews, it's clearly a reliable source for Wikipedia's purposes.

I'm saying that on this page where the whole point of any statement is what the Cass Review says, using the review itself to source those statements is clearly using it as a primary source on itself. When we say "The Cass Review says there isn't a lot of evidence for puberty blockers" on other pages, we're citing it for a fact about puberty blockers, but when we say that on this page, we're citing it for a fact about the Cass Review. Loki (talk) 02:57, 26 April 2024 (UTC)

You can use any source as a primary source. To the extent that editors use the Cass Report in this article like one might use a novel to write the ==Plot== section in an article about that novel, then that would be using the Cass Report as a primary source. The article's subject isn't really a determining factor; if you use a statement from WPATH to describe WPATH's statement, then that would be using the WPATH statement as a primary source, too.

It will be important to remember that primary is not a fancy way to spell 'bad'. (In particular, for direct quotations, primary sources are often best. Original documents can't misquote their own contents. ;-) ) WhatamIdoing (talk) 06:51, 26 April 2024 (UTC)

Yes, I agree with all of that. I am mostly just frustrated at the strange insistence that Cass or the Cass Review aren't primary sources on themselves. Loki (talk) 14:18, 26 April 2024 (UTC)

Loki, I don't see how you can say "I agree" and then dig further in on your insistence it be considered only primary on this page. At a superficial level, as WAID says, one can look at statements like we are summarising a plot of a book and using it as a primary source for such. But that would only let us quote or write about what the report said in language that very much distanced ourselves from the facts it claimed. It would be like if we used Wakefield's autobiography and he claimed he found MMR caused autism. For the medical facts we can state them as though Cass is a fine secondary source that meets MEDRS. For the recommendations and advice to NHS England about what clinics to setup and so on, the report is a primary source for Cass's proposals. I suggest you stop banging this drum because it isn't going anywhere helpful. You aren't going to get anyone going "oh, since Cass is a primary source on this page, we have to put everything in quotes and consider their statements as unreliable as some random Canadian GP that the Pink News dredged up. -- Colin°^Talk 08:36, 26 April 2024 (UTC)

You are making some assumptions about my motivations that are not in evidence. I don't think that Cass is a bad source for the things we can use primary sources for. We can definitely source the content of the report to the report. When Cass makes uncontroversial claims about something the report says, we can cite her too, just like any author.

My skepticism here is coming from the fact that you appear to want to ignore ordinary sourcing guidelines in favor of MEDRS when that's not appropriate here. A strong MEDRS source is not exempt from the general guidelines on sourcing. Wakefield is in fact a great example of that; I would have used him as an example before if I wasn't worried that you would think I was equivocating between a quack and a real medical doctor who can nonetheless still make mistakes. Loki (talk) 14:33, 26 April 2024 (UTC)

Loki, stop digging. The PSTS concept is not simplistic or determined at article level as you keep making out. The fact we are discussing the Cass report on this article page doesn't magically stop it being a first class MEDRS compliant secondary source on biomedical facts and claims. If you can agree with me (and WAID) that the Cass review can be BOTH a primary source for certain things on this page AND a MEDRS compliant secondary source for other things on this page, we can all move on. Otherwise, please go post a request at WT:MED for clarification, and I'm sure someone will be along shortly to put you right. I mention Wakefield because his autobiography is entirely unlike this Cass review, whereas you seem to be saying the two are similar in that they are both doctors to not be trusted one bit. Hmm. -- Colin°^Talk 11:25, 27 April 2024 (UTC)

It's very much a secondary source for biomedical facts on other articles. But we wouldn't be citing it for biomedical facts in this article, we would be citing it for what the Cass Review says.

You keep on saying things about PSTS that I don't dispute and have never disputed. What I am claiming is not a fact about the policy but a fact about this article and the claims that are being made in it, and I feel like it is actually a fairly obvious claim: that this is not an article about the underlying biomedical facts but an article about a particular study.

If you disagree with me, I invite you to find any place in this article where the Cass Review is being cited in order to prove a biomedical fact and not in order to prove what the Cass Review says. Loki (talk) 17:01, 27 April 2024 (UTC)

Oh also, please again do not impute my motives and do not accuse me of saying that Cass is exactly like Wakefield because I think the sourcing guidelines that apply to both of them are similar or because I think that the pitfalls of your argument are well documented by the case of Wakefield. Loki (talk) 17:04, 27 April 2024 (UTC)

You're almost at Australia now. Please send us a postcard. Have a look at the language at Lancet MMR autism fraud and the section "1998 The Lancet paper" and compare it with the language in this article. In one case we are describing a doctor who supposedly "found" links between MMR and autism and the reader is left in no doubt whatsoever that the findings were not just unreal but fraudulent. Now compare with this article. We can be comfortable that when the systematic reviews "found" or "stated" things, we can write that in a style that believes they did find them, that there really is insufficient evidence for this and moderate evidence for that.

Have a look at Timeline of tuberous sclerosis. It describes various doctors finding and discovering things over the years. Nowhere is the suggestion that those doctors didn't find and discover those things. We attribute their discoveries just as we attribute the findings of this Cass Review. We simply would not take that approach with a publication from e.g. Sex Matters or Mermaids, for example. We'd need be highly cautious with either organisation's claims and not present them to the reader at face value.

Citing AGF isn't a defence in being suspected of being wrong and then removing all doubt about it by comparing Cass with Wakefield. Can you stop doing that please Loki. I do believe you are here in good faith. You can be wrong in good faith. Can you permit me disagree with you without being hassled by AGF allegations please.

Wakefield's fraudulent paper on a dozen children was primary research that MEDRS would reject and there aren't high quality secondary reviews of Wakefield's work that we could cite because it was recognised as flawed research on publication. All the safeguards we have with MEDRS exist to prevent random research primary papers being used to make medical claims on Wikipedia. Contrast that with this. The BMJ lists seven systematic reviews commissioned by the Cass Review from which the CR draws many of its findings. Those reviews in turn examined hundreds of primary research studies and in turn hundreds if not thousands of patients. The review itself took four years. I can't think of another healthcare review that endeavoured to gather as much information and systematically review it in an evidence based approach, considering all the other guidelines across the world while formulating its own. Can you? I contrasted this review with Wakefield's autobiography as examples of polar opposites. You have now repeatedly said Wakefield is a great example of how cautious we should be and somehow continuing to push your novel concept that this review cannot be a fine secondary source for medical claims on this page. Colin°^Talk 17:51, 27 April 2024 (UTC)

I note that you still have not given me a single example of a claim on this page the review would be a secondary source for.

Instead you continue to grandstand about claims I've never made: I have never once disputed that the Cass Review is a WP:MEDRS-quality source or that it would be a high-quality source on other articles. (I do dispute that "high-quality source" means that it would be incontrovertible or a great bastion of objective truth, to quote Snokalok below, but that's neither here nor there in this particular argument.) I'm not even claiming that the Cass Review is a bad source on this article, just that it is a primary source.

Can you please for once actually listen to the words I am saying and not the phantom that you have made up in your head? Loki (talk) 18:10, 27 April 2024 (UTC)

Loki, I feel like I'm getting mixed signals for you. Up above, you say More relevant to this article is that anything Cass says is still a primary source. Down here, you seem to be saying that the Cass Review is actually a secondary source (at least sometimes). Perhaps a few examples would help?

The review is a primary source if you want to write a sentence like "The final review is 388 pages long and contains 12 appendices" or "The report recommends that families of pre-pubertal trans or gender-questioning kids get at least one appointment with a qualified practitioner right away, without first spending years on a waitlist".

The review is a secondary source if you want to write a sentence like "Based on moderate-quality evidence, puberty blockers neither change nor worsen either gender dysphoria or body satisfaction" or "Post-pubertal autistic teenagers are more likely to discontinue puberty blockers than pre-pubertal kids".

Note the absence of any wording about "in this article" on "in other articles" in my examples. Whether it's being used as a primary or a secondary source has to do with the content of the sentence it's supporting. It has nothing to do with the article that the sentence is placed in. For example: if the Cass report is cited in support of the sentence "Based on moderate-quality evidence, puberty blockers neither change nor worsen either gender dysphoria or body satisfaction", then the Cass report is:

secondary if it's in this article,
secondary if it's in another article, and
secondary if it's on another website entirely.

Does that make sense? WhatamIdoing (talk) 03:00, 28 April 2024 (UTC)

It does but I have a quibble.

I agree that if you wanted to cite "Based on moderate-quality evidence, puberty blockers neither change nor worsen either gender dysphoria or body satisfaction" you could use the Cass Review as a high-quality secondary source, and that in principle it doesn't matter what article you say it in.

But in this article, I don't think that's the sort of fact we care about. Instead we want the similar but distinct "one of the findings of the Cass Review was that puberty blockers neither change nor worsen either gender dysphoria or body satisfaction". Since this is a statement about what the Cass Review says cited to the Cass Review, I believe it's primary for this purpose.

(Now, I don't think it really matters because the Cass Review is obviously a reliable source on its own findings. Which is a big part of why I'm frustrated by this argument: I don't think it has any practical effect on this article. This argument was originally about Cass's statements in interviews about the review, where it might actually matter, not the review itself.) Loki (talk) 04:28, 28 April 2024 (UTC)

What's your point, Loki? Why, argue that Cass's review (and by extension presumably the seven systematic reviews commissioned by it), are to be considered merely primary sources on this page. It can't be merely pedantry. You must have a reason for wanting these documents to be WP:PRIMARY on this page and mysteriously on this page fail WP:MEDRS despite the primary topic of this page falling under WP:BIOMEDICAL. Please can you tell us where in our policies and guidelines we have a sourcing distinction that applies at article level, rather than "What the article text says and the point the article text is making". Please do tell us.

When our readers read the texts on lack of research or increase in referrals or that there are conflicting clinical views and a mixed picture wrt the role evidence has played in forming existing clinical guidelines, we can say all these things because the review and its supporting documents are first class WP:MEDRS. We wouldn't even attempt to spell out anything like this much information, let alone include it outside scare quotes, if it had come from some Sex Matters publication or interview with a LGBA spokesperson in the Telegraph. If that publication or interview was notable enough to have an article, we'd be writing it in entirely a different style even though we could use it as a primary source just like Cass is a primary source for whether or not the report made certain statements and claims. Is this clear?

The primary-source role Cass's report is making on this page is where or not the report actually made those claims and statements and whether our text is a fair summary. That role is insufficient for us to write sections and paragraphs on their "findings" and "conclusions" if they were in fact the findings of a hate group, fringe medicine, political or cultural ideology and so on. What is it that let's us write about their findings as though they really did find them? Well, that's because the document and supporting documents are WP:MEDRS compliant sources for these. -- Colin°^Talk 11:03, 28 April 2024 (UTC)

It can't be merely pedantry.

Oh, it's pedantry. Well, more annoyance that you keep on misrepresenting what I'm saying over and over, so I feel the need to correct you, so you then try to incorrectly guess my motivations again and we go round and round forever.

The original point was about Cass's statements in interviews. I brought up the Cass Review being primary here mainly as evidence that Cass's statements in interviews were also primary. That has led us to this quagmire of an argument where you seem to think I brought up the Cass Review being primary to say it was a questionable source for this page, and I am ripping my hair out to insist that you are blatantly failing to both WP:AGF and even to literally read the words I am writing. No, I think Cass's statements are the questionable source, not the review itself.

I am fine with tabooing the Cass Review in this discussion. It's a fine source for this page and it doesn't matter why it is.

You must have a reason for wanting these documents to be WP:PRIMARY on this page and mysteriously on this page fail WP:MEDRS

They don't fail WP:MEDRS on this page and I've never said that. (They don't even reach the point at which WP:MEDRS matters; we could cite something for its text on a WP:MEDRS page without it being a WP:MEDRS source.) Stop putting words in my mouth and stop assuming the worst of my motives.

We wouldn't even attempt to spell out anything like this much information, let alone include it outside scare quotes, if it had come from some Sex Matters publication or interview with a LGBA spokesperson in the Telegraph. If that publication or interview was notable enough to have an article, we'd be writing it in entirely a different style even though we could use it as a primary source just like Cass is a primary source for whether or not the report made certain statements and claims. Is this clear?

I agree with the conclusion but disagree with the reasoning.

If we had a notable article on a famous work of non-fiction, it'd be written in a similar style to this article. (Compare Das Kapital, as an example of a work whose claims are very controversial in modern economics and yet which is still written about similarly.) The reason a very controversial work would be written about in a different style would be because of the abundance of sources challenging the publication's claims. Again, doesn't even reach WP:MEDRS.

The primary-source role Cass's report is making on this page is where or not the report actually made those claims and statements and whether our text is a fair summary. That role is insufficient for us to write sections and paragraphs on their "findings" and "conclusions" if they were in fact the findings of a hate group, fringe medicine, political or cultural ideology and so on.

See above: we document the factual claims made by all sorts of non-fiction books that wouldn't normally be considered reliable sources for facts. Das Kapital, On the Origin of Species (great work in its time but out of date now), Outliers (book), etc etc.

This is again not to say that the Cass Review is not a reliable source for facts, only that it doesn't matter either way. Loki (talk) 14:41, 28 April 2024 (UTC)

Loki, fiction is one of those things where we assume our readers know it is fiction and Jedi Knights aren't real. We really wouldn't describe the findings of this report in this style if it wasn't also MEDRS. You don't seem to believe me but I've given you an example, Wakefield. And you literally on this page then compared a Wakefield source as being like Cass, and now you are saying "I think Cass's statements are the questionable source". Please stop. And please stop citing AGF as though I haven't been here 20 years. I'm not questioning your motives at all. I'm questioning the words you keep writing, which are wrong. Honestly, turning a "You are wrong and here's why" argument into a "Would you stop questioning my motives argument" is itself a bad faith move. Quit it now. Anyway, you've admitted this is pedantry on your part which is, you know, WP:NOTHERE. So I think it best we end this discussion and go find something actually productive to do. -- 15:31, 28 April 2024 (UTC) Colin°^Talk 15:31, 28 April 2024 (UTC)

I did give you three examples of non-fiction books where we do this. As in, they are not fiction.

Besides that, yes I agree it's best we end this discussion. Loki (talk) 17:38, 28 April 2024 (UTC)

Just wanted to add two cents to the discussion I unintendingly started: a podcast is not an ideal source, but in this case it can add interesting details about the report currently not found elsewhere. From the top of my head, these were:

The team behind the Cass Review actually reached out to the Dutch team at VUmc to extensively discuss their approach (pretty logical considering they came up with this in the first place)
Gender exploratory therapy is not meant to get rid of gender incongruence/dysphoria, but to make comorbidities more manageable. Cass claims that GD may resolve, but that is not the actual goal (gotta admit, very contentious claim)
Cass claims that the psychological interventions she proposes do not have a strong-evidence base either (for which you are obviously allowed to criticise her)
Lastly, she claims that a consensus-baded guideline like WPATH's is actually not bad at all, as she said that such things happen all the time. She does take issue with the fact that the evidence is sometimes presented as stronger than ot really is

PS: I agree with @Colin here that the meta-analysis can be used as a decent medical source. Having read quite some systematic reviews in different fields, I have to say there's nothing off the rails here. Besides, we should not overlook the fact that the meta-analysis has not found anything shockingly new. The Endocrine Society, for instance, has always stated that their recommendations regarding puberty suppression are of low or very low certainty. The question here is whether that warrants a change in practice, about which you can meaningfully disagree. Claiming that this could be a situation like Wakefield's, however, seems to me to absolutely miss the point of all of this. There's really nothing extraordinary about this study in any way, as much as people with different perspective may want to think Cixous (talk) 11:25, 7 May 2024 (UTC)

@Cixous I mostly agree. Wrt the evidence examination, I see no surprises (as you note, previous reviews have also reported low evidence quality). I think one of the problems is the temptation to think even weak evidence is still evidence, and thus fool oneself into thinking it is telling you what you want to hear.

I think Cass was specifically calling out WPATH for being unclear and not open that their guidelines were not in fact based on good evidence but merely a consensus of experts. That they claimed there was evidence but really when examined that claim turns out to be unfounded and in any other field would not be regarded as safe. As you say, there's nothing wrong with openly declared expert consensus and in many fields that's all we have. And I agree that different rational sensible people could meaningfully disagree about what to do in the absence of good evidence. -- Colin°^Talk 12:48, 7 May 2024 (UTC)

@Colin

> (WPATH) guidelines were not in fact based on good evidence but merely a consensus of experts.

Exactly. The WPATH 8 FAQ reveals explicitly how one significant recommendation was changed like that:

A previous version of the WPATH Standards included specific ages for medical procedures. Why were those pages removed in the SOC-8?<
Minimum ages for providing gender-affirming medical care were removed from the SOC-8 … (after) a public open comment period … (which) allowed input and feedback from professionals … who were concerned that the listing of ages would lead to further limitations to care… After comments were reviewed … it was determined that the specific ages would be removed to ensure greater access to care for more people.
==== end of quotation from the WPATH 8 FAQ ======

In the same FAQ WPATH, are bold in their claims about evidence

represent the most expert, in-depth, and evidence-based and consensus-based guidelines internationally.
the most comprehensive set of guidelines ever produced.
represent gold standard, best practices for global health care
clinical guidelines meant to provide the gold standard on how to deliver care
By defining the gold standard of care providers and institutions are now primed
obtaining medically necessary, life-saving gender-affirming care.
Puberty-delay medications are safe and effective and can be stopped at any time, at which point puberty starts back up after being temporarily paused.
Regret in any aspect of TGD healthcare is uncommon and statistically lower than for other medical or surgical interventions and recent studies
One of the primary forms of gender-affirming medical care for TGD adolescents is to introduce medications that delay puberty
Why are the needs of eunuch-identified people included in the SOC-8 for the first time?

SOC-8 provides guidelines based upon the best available research and clinical expertise to provide the safest gender-affirming care to all TGD people.

based on the best available science and expert professional consensus

Peckedagain (talk) 14:37, 7 May 2024 (UTC)

Thanks for your quotes, but we shouldn't extrapolate things too easily. The SOC 8 has been criticised for its guidelines for the treatment of adolescents. That doesn't mean that other parts of the guideline can be regarded the same (or criticised accordingly).

As for the age limit for puberty suppression: the discussion about that has been going on for over a decade. The original minimum age of 12 was chosen because from that age onwards Dutch adolescents were allowed to make medical decision with permission of their parents (I'm not sure whether I read this in a source from the 1990s or in de Vries & Cohen-Kettenis, 2012). The 16-year mark was chosen likewise (i.e., Dutch adolescents are allowed to make medical decision on their own from that age). In some countries this is eighteen years (e.g., in Italy).

In their discussion, de Vries et al. (2014) already pointed out that the ages of twelve and sixteen years may change, because of the nature of puberty onset and the effects of puberty suppression. As a result, the Dutch guidelines from 2017 do not include a minimum age for puberty suppression anymore (but continue to include one for gender-affirming hormone therapy). So, with regards to this specific discussion, the minimum ages were always somewhat arbitrary Cixous (talk) 12:41, 8 May 2024 (UTC)

The point was not about the history of age limits which as you say goes back decades. The point was that in 2022 WPATH decided to remove the limits - with no new research. No new science. The papers you mention were not new data. The change was made simply by asking their members. Peckedagain (talk) 21:37, 9 May 2024 (UTC)

Yeah, you're right about that :) Cixous (talk) 12:44, 10 May 2024 (UTC)

Edit-warring the lede

@Fiona Weber @Moons of Io please take it to the talk instead of edit-warring the lede. Void if removed (talk) 11:56, 10 May 2024 (UTC)

While their revert might have been debatable, their first edit very clearly showed that the revert was just plain vandalism on IO’s part, so I reported it as such and User:ScottishFinnishRadish agreed clearly agreed with my assessment and handed out a week-long block. If you need more evidence, this was their response to the vandalism report.

I consider the matter resolved by that and will reinstate the extended version.

--Fiona Weber (talk) 17:56, 10 May 2024 (UTC)

The offensive comment was vandalism, the revert of your changes was not vandalism, you have edited the lede without consensus and are continually edit warring over it, I've asked you to discuss your bold changes here per WP:BRD now please self-revert and discuss. Void if removed (talk) 18:06, 10 May 2024 (UTC)

Well, so far the only argument that has been presented against the extension to the intro was a slanderous claim that organizations like WPATH make millions of abusing children. Which isn’t surprising considering that the only addition was about what the already previously mentioned heavy criticism was about and that Cass admitted that the standards of evidence she is asking for can indeed not be met by ethical research. All of these are indisputable facts and clearly critical context for the introduction, certainly more important than what some politicians have to say. So if someone wants to revert, they should present actual arguments, for why the fact that actual experts essentially classify the report as junk should be left out. --Fiona Weber (talk) 19:35, 10 May 2024 (UTC)

@Fiona Weber

There is little point in mentioning yet again the vandalism - it can have no bearing to a discussion around RS and evidence.
"previously mentioned heavy criticism" - has already been discussed at length here in Talk from all sides: and there is no consensus for the text you proposed. Two editors have now described your text as: AGF and editorialising.

Peckedagain (talk) 19:56, 10 May 2024 (UTC)

Mother Jones article

A new Mother Jones article has been published with comments from several critical experts. Loki (talk) 20:27, 10 May 2024 (UTC)

This is the same untrue arguments that have been shown to be incorrect in the talk here already, eg:

"The Cass Report’s bar for evaluating research is too high

In scientific research, the randomized control trial (RCT) is often considered the gold standard..." 92.40.215.34 (talk) 14:55, 11 May 2024 (UTC)

I think most importantly you've got various Drs, including the president of USPath (for some reason Turban feels very familiar and Turban et al comes up so it must be for some scientific paper), saying that in Cass's report the recommendations doesn't follow from the findings, Cass uses misleading language (like poor and weak quality studies) and that there are concerns about who helped Cass write the report. Also notable is that a mistake has possibly been identified in one of the systematic reviews. Now this doesn't necessarily mean that it completely merits inclusion for all of this but it does mean it is a lot more than untrue garbage. LunaHasArrived (talk) 15:15, 11 May 2024 (UTC)

widespread, false claims from critics of the report that it had dismissed 98% of the studies

There is more nuance to the claim that the report dismissed 98% of the studies it collected. For example, see footnote 14 here

   Hilary Cass has contested this claim in reporting for the BBC. Her argument is that of the 103 studies analysed for the review, 60% were included in the synthesis of evidence. However, my argument here is specifically that the findings of these papers were broadly ignored in the writing of the report’s recommendations, while less robust material was instead prioritised. As Simon Whitten argues, “The majority of moderate certainty studies were included in the results section but then arbitrarily ignored in the conclusion entirely”.

It should be noted that the original source for the claim that 98% of studies were dismissed was Cass herself, in the press release announcing the final report's release:

   Of the 50 studies included in the review looking at the effectiveness of puberty blockers for gender questioning teens, only one was of high quality, leading the authors to conclude that although most of the studies suggested that treatment might affect bone health and height: “No conclusions can be drawn about the impact on gender dysphoria, mental and psychosocial health or cognitive development.” 
   Similarly, of the 53 studies included in the review on the use of masculinising and feminising hormones, only 1 was of sufficiently high quality, with little or only inconsistent evidence on key outcomes, such as body satisfaction, psychosocial and cognitive outcomes, fertility, bone health and cardiometabolic effects.

I would say a reasonable interpretation of those two paragraphs is that the non-high-quality studies were dismissed - particularly the word 'sufficiently'. The claim is not solely about the systematic reviews that York undertook, but what the Cass Review took from those studies.

As a result, I think it's inaccurate to call the claim straightforwardly false. It would appear to be in the realm of opinion whether the review dismissed 98% of studies or not. I propose rewording to 'misleading', or change 'dismissed' to 'rejected', or including the additional context I mention here. Rattic (talk) 20:50, 8 May 2024 (UTC)

I agree that in our current version it's a bit unclear because the comment is, "the report dismissed 98% of studies", whilst Cass's response is, "the systematic reviews synthesised their evidence from far more studies". These comments don't actually disagree with each other. The problem is I think without a Medrs source saying "we believe the findings of the Cass report ignored the majority of the studies" it might be difficult to include explicitly. I'm also not 100% sure what has been said by various people because I'm certain there probably have been people who have falsely claimed that 98% of the studies where thrown out by the systematic reviews. I think the fix would have to be either making sure that the 98% claim is on the reviews and just is general being clear on what is from the systematic review or what is from Cass's report. LunaHasArrived (talk) 21:06, 8 May 2024 (UTC)

This is straightforwardly false. Whitten is wrong as anyone who can read the Cass Review instead of a press release can confirm, and Pearce is wrong to promote this. Void if removed (talk) 21:40, 8 May 2024 (UTC)

Frankly, a self-published (partisan) blogpost citing a (partisan) tweet is not even remotely close to a reliable source for valid criticism of a systematic review. Void if removed (talk) 09:11, 9 May 2024 (UTC)

Just so we're clear, here is Pearce's actual claim:

You can see, if you read the Cass report, that they looked at over 100 studies, most of which show that puberty blockers and hormone therapy can help young trans people. And they just ignored them.

This is a lie. There's no other word for it, it is flatly untrue. Seemingly aware this was overstating things, Pearce then caveats this in the footnotes as:

the findings of these papers were broadly ignored in the writing of the report’s recommendations

That is a lesser claim, and still false.

Then in the source tweet thread, you get this:

The review found 5 studies of moderate certainty relevant to psychological health. All 5 supported the conclusion that treatment of trans teens with CSH improved psychological health. [...] Our intrepid authors draw no conclusions from this whatsoever, instead declaring the evidence for every outcome for which there was no high certainty study “inconclusive.” [...] This is the sense in which the Cass Review absolutely did ignore almost all evidence on the efficacy & safety of PBs and CSH.

So again, further caveated, and still false. What the paper Whitten is referring to actually gives is extensive discussion of these studies, and in the conclusion says:

There is suggestive evidence from mainly pre–post studies that hormone treatment may improve psychological health although robust research with long-term follow-up is needed.

The original tweet thread is not talking about the cass review, it is making untrue and hyperbolic claims about an underlying systematic review.

And lest we think this can be applied to the Cass Review, instead of the systematic review, the Cass Review on page 184, talking about the systematic review Whitten is attacking here, says:

There was moderate quality evidence from mainly pre-post studies that hormone treatment may improve psychological health in the short-term

AND quotes the conclusions verbatim in para 15.25.

There is no nuance to be represented here, just garbage piled upon garbage. Void if removed (talk) 10:48, 9 May 2024 (UTC)

Yeah, I would agree that there is definitely some nuance involved in navigating this one in particular. I think the main question is what independent reliable sources can be relied upon for analyzing and interpreting such statements. The article should not rely on the WP:OR of individual Wikipedia editors for interpretation, analysis, etc. Hist9600 (talk) 00:29, 9 May 2024 (UTC)

The sentence is currently unsourced, precisely because it’s largely based on Twitter chatter. How widespread the claim is, and what, specifically, the claim is is unclear, and likely varies from person to person. If it belongs in the article, it’s only because Cass has responded to it, but what precisely is being responded to is not stated. 2406:5A00:DC9B:5000:60C3:F2CC:ED70:ABE (talk) 05:37, 10 May 2024 (UTC)

It is not true that Cass is "the original source for the claim that 98% of studies were dismissed". The claim arises from a misinterpretation of Cass's statements. The words "included in the review" are right there. If someone engages in motivated reasoning about the text, that's entirely on them, not on Cass. Barnards.tar.gz (talk) 08:48, 9 May 2024 (UTC)

I think it would be reasonable to say that the low quality studies were "ignored" in the review, iffy wording and lacking nuance but not outright wrong. These low quality studies are mentioned as being "in the review" above so I don't think it's unreasonable for someone to assume that just from the press release above, moderate quality and low quality studies were "in the review" in the same way. Now this person should have read the report and reviews but I think some blame could and should be put on the statement. Also in the 53 statement I can't see any way to read "one was of sufficiently high quality" as apart from only one was sufficient to be 'proper' evidence. LunaHasArrived (talk) 11:43, 9 May 2024 (UTC)

The claim arises from a misinterpretation of Cass's statements.

The idea that the review dismissed most studies did not come from misinterpretations of her statements, albeit maybe they mutated this idea into the "98%" claim on social media after the review was published. However, variants of this claim were going around before that. From this article:

Dr Hilary Cass, 66, told The Times last week that one activist had begun posting falsehoods about her landmark review of the treatment of trans children before it was even published. She was referring to Alejandra Caraballo, an American attorney, transgender woman and instructor at Harvard Law School’s Cyberlaw Clinic. On April 9 — the day before the Cass review was published — Caraballo claimed it had “disregarded nearly all studies” because they were not double-blind controlled ones. 13tez (talk) 12:57, 9 May 2024 (UTC)

I think ‘the claims of one activist are false’ is a far more specific and sourceable statement than ‘widespread claims were made and they are false’ 2406:5A00:DC9B:5000:60C3:F2CC:ED70:ABE (talk) 05:41, 10 May 2024 (UTC)

That wouldn't be true, though. The claims were widely spread and not said only by a single person. "But before the Cass Review was even published, an idea was spreading on Twitter that it was all based on biased information...This idea that 98% of the evidence was ignored or dismissed has been repeated again and again" - https://www.bbc.co.uk/sounds/play/p0hry4wj 13tez (talk) 15:41, 11 May 2024 (UTC)

Sorry if I am being an idiot but I can't seem to find the quotation you used in the press release you linked. Where exactly in the page was it used from. LunaHasArrived (talk) 11:45, 9 May 2024 (UTC)

The press release is here. Two things. Firstly, it is widely discussed online that the source for the misinformation we are discussing is indeed a twitter influencer noted above and actually published they day before when they were confused even about the documents someone was passing to her. Their twitter page doesn't seem accessible any more, but last time I looked it wasn't very nice, personally, about Cass, and the responses from their followers were an order of magnitude worse. The Labour MP got their information from Stonewall who admit they got their information wrong. Second thing, the press release is not written by Cass, so maybe we could strike & amend the above text to make that clear. Press releases are notorious for being misrepresentative of the science or whatever is behind them, and not considered a reliable source. The press release is indeed badly worded in a misleading way and I'm disappointed the BMJ hasn't amended it or issued a clarification/correction. Colin°^Talk 15:28, 9 May 2024 (UTC)

Thank you for the link, It seems that the twitter account in particular has taken a break to improve mental health (something everyone should probably do every so often). I agree the above comment should be struck and let me know if there is anything I posted that you think should be. I do think it is perhaps notable that even the bmj has been misleading about this particular comment. LunaHasArrived (talk) 15:54, 9 May 2024 (UTC)

Wrt twitter breaks: I think someone should break twitter to improve everyone's mental health. -- Colin°^Talk 07:26, 10 May 2024 (UTC)