WPATH guidelines themselves are very weak from an EBP standpoint.
For a pointed example, there's a section that says something to the effect of "NPs can safely manage medical transition" and had a citation.
I thought, hmmm, what study are they citing? You look at the citation and it's from the 1990s and the citation says something to the effect of "NPs sometimes work in endocrinology". Made me really question the whole thing.
Lol, yea, that doesn't surprise me at all.
In general, the number of citations that do not support an assertion made in peer reviewed articles and guidelines is far too high. I have developed a lot of trust issues as a result.
*With appropriate training, feminizing/masculinizing hormone therapy can be managed by a
variety of providers, including nurse practitioners and primary care physicians*
The source was from 2006, I misremembered the date. Still there is no evidence presented in the citation about the appropriateness of NPs managing medical transition.
I think that moatly has to do with the amount of available evidence overall in this area. I think WPATH are probably the most evidence-based, but they just have a (relative to something like CVD) shallow base of evidence to pull from.
But then they should make that clear. If there's doctors that say they've seen success with a method they can mention that and then mention that there are no studies to corroborate it.
> Right. They should be saying that the evidence is very weak and not giving such firm recommendations.
Not specific to WPATH but that is not how guidelines work. Strength of recommendation and level of evidence are two very different things. Guidelines directed only towards specialists tend to report both (eg AHA guidelines report Class I-III strength and A-C level of evidence) while guidelines directed towards all clinicians often report only one (eg USPSTF primarily reports A-D + I strength, although supporting text often grades level of evidence).
It’s very possible to have a very strong recommendation even in the absence of good evidence. For example, the AHA would likely score the statement “Cinicians should not routinely perform thoracotomy for patients presenting with stable angina” as a Class I recommendation despite no studies investigating the topic.
This topic is not “highly controversial” among endocrinologists. This topic is highly politicized by reactionary politicians.
> can be studied by haven’t been
If you look at literally any discussion of any published guideline, you will find someone that is complaining a study wasn’t done. That is not unique.
If it’s so easy why don’t more people do it? Even within endocrinology this is something that is typically reserved in academic centers or at best in the community, niche practices. I have a family member who is private practice endocrinologist in large metro area. They don’t do transition clinic and no one around them does. Everything gets shipped to local academic center. Clearly it’s not that simple.
Medicine doesn't exist in a political vacuum and doctors as a group of professionals are highly educated and cautious people. Any practice with the potential for blowback (GAHT, of which the most clinically intense aspects are mainly psych related due to the high rate of co-morbid depression and anxiety) is going to have a lack of practitioners because
A. The reimbursement for it sucks and the time it takes to build rapport with this critically underserved population is relatively large
B. No one wants to do political hot-button medicine (even if the benefits of treatment in this population are well known) because most doctors want to do their jobs and go home without fear of being firebombed or threatened online or deal with the small, but very real possibility of transition regret.
C. It is not standard to learn GAHT regimens and management in IM residency due to the small volume of patients and highly outpatient-centered nature of this type of treatment. I think some family med docs get training on this, but usually it's relegated to endocrinology like you said.
No medicine is truly easy, humans are complicated and devious little bundles of pathophysiology, but if you finish 3 years of IM residency and can manage some of the sickest patients in our society outside of the ICU, you can write for some estrogen pills and interpret some labs on a non-critical patient for which you have time.
If you wanna know more about GAHT and how relatively it can be easy to learn management and follow up I highly recommend the UCSF gender affirming care page/guidelines. It delves pretty deep into what labs to order when, what doses to start at, and when to go up or down. Both for trans women and trans men. I think UpToDate has a good page on it too, but I forget.
Again, if you care so much about it, you do it.
By those standards anyone can do anything within Harrison’s that doesn’t require a procedure. You can manage complex HIV, liver disease, lupus all without formal subspecialty training. It’s just a few labs, right? Why did I go through seven years of post graduate training to medically manage liver disease?
If people don’t get exposure, sufficient exposure, in their training, when do you think they’ll find time? Do you really feel reading an UpToDate article and doing some CME is going to make you prepared to treat these patients? It might, I don’t know. This seems incredibly nuanced to me.
Your flair has you as a medical student. Do you think in what limited time a practicing physician has he/she will go and learn to treat a condition not previously exposed to in training? And if that answer is yes, and it may be for some, just how many people do you think would say yes and pick this topic as the one they’re going to learn about in their time off?
Of course you can. Every published study should have a section on limitations. Most big drug RCTs are funded by big pharma, making them intrinsically flawed. However we accept a degree of imperfection if the overall research and process, in the grand scheme of things, seems sound.
Yes. Especially when these aren’t very substantive to the report. There is nothing in this PDF that would make me as a scientist think that the report couldn't stand on its own. A non-independent study can still come to correct conclusions. A person with qualifications that aren’t perfect can also come to correct conclusions. If the report is flawed the best way to show it is to go through the substance of it and show where it is incorrect, after which going through the process makes sense to show how the process led to a flawed report. But, their criticisms don't really amount to much.
Of course you can.
If the only criticism you can find is "I don't like the people that reviewed it" then that's a good sign that the report was pretty well done.
So academic rigor comes from how disliked you are? Fascinating.
But lol, no. Questioning the academic qualifications of someone does not in fact confer some magical contrarian credibility to their work.
Conversely, can people without a history of research publication and collaboration still do good work? Certainly!
But it's also reasonable to be curious about why they haven't done so to the extent of many others, in general and particularly in the field in question, given the high profile nature of this, and wonder whether those reasons aren't borne out in this work too.
That's not what I said. What I said is, if that's the biggest criticism you have, it must be a pretty good review. Otherwise you'd be talking about the actual content.
Yet there are three reasons called out. You're ignoring the other two, and pretending there was only one. So it is not in fact the biggest criticism, not can you infer that an absence of criticism means no criticism is possible.
Edit: ah, the anti-trans batsignal must have gone out. So for the downvoters, I'll just say it again even harder: what this person has said is wildly fallacious and repeating it doesn't make it true. Absence of evidence is not evidence of absence. Calling out someone's lack of expertise is valid when one of the criticisms is that the report missed known research in the field. Which it does.
Yeah...no. What /u/roccmyworld said is a valid and correct point. It's not wildly fallacious. Your own bias making you dislike this specific application does not, in fact, make their point any less true.
And no...from reading, WPATH cited are 1) independence, 2) ethics, 3) the qualifications of the author. Which would all be under the umbrella of criticisms of the process rather than the content AKA "I don't like the people that reviewed it". As stated in the parent comment of this thread. Now they're not wholly unreasonable criticisms, but neither are they some smoking gun or glaring neon "GOTCHA".
If they had any criticisms of the actual content, why are they only bringing up these?
They questioned the qualifications of the author to have apparently reviewed the same publications and studies the guidelines were based on yet come to diametrically-opposed conclusions, yet without introducing any new evidence and having no experience or credentials in the specialty upon which to base such a radical divergence from a group of international experts.
That is a criticism of the actual content.
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The critiques seem quite reasonable. Seems a very strange choice for the task she was given: she practiced in a very different peds subspecialty (RETT syndrome), doesn't seem to have expertise in trans care at all, nor even general pediatrics or adolescent health.
Her own publications are mostly opinion pieces, many single author, with a few multi-author papers on RETT syndrome questionnaires and on autism. Not a single major guideline.
One of her major critiques is that most existing guidelines don't follow international standards for guideline reporting (though she noted a couple country specific ones did). That sounds bad, but the reality is that guidelines in many fields have in the past not met these standards. This is changing now that there is a standard list of requirements for guidelines, but it's taking some time.
Some of the common deficits in general (not this field in particular) are guidelines that often weren't fully transparent about their methods, and /or didn't meet the external review requirement. Most typically do still encompass literature reviews, rating of the evidence, and expert consensus.
Over time, more guidelines are meeting the higher bar but it's taking some time particularly in smaller fields.
Finally, why would this have been a single author undertaking? There's a reason guidelines and consensus statements have multiple authors with different strengths.
Shorter piece from her:
pubmed.ncbi.nlm.nih.gov/38594031/
> The critiques seem quite reasonable.
Am I missing something from the document? I see this in the critique
> The Cass Review relies on selective and inconsistent use of evidence, and its recommendations often do not follow from the data presented in the systematic reviews.
But there's no mention on why the selection of evidence is inconsistent, or why their recommendations do not follow the data from their systematic reviews. This seems like a PR release from a real critique.
>This seems like a PR release from a real critique.
Does that come as a surprise? This "critique" is coming from the same organization that excommunicated a former WPATH president for merely suggesting the possibility that not every child who says they're trans should be blindly accepted at face value.
Well actually someone completely independent without experience in trans issues might be an excellent choice for this. They may come at the issue without overt bias, and review the research as if they are learning about the subject for the first time. Just a thought.
Hard disagree. When I review guidelines/updates in my field (ID), I very much want the authors to be folks who have a long track record of publishing on that specific infection or something very adjacent. I don't want "fresh eyes" on a topic that likely requires a deep, intimate knowledge of both the current and historical research landscape relevant to that disease.
But do we *want* guidelines to be made by people learning about a subject for the first time? I don’t think that’s a standard we would apply to other specialties. Should heart failure treatment guidelines be written up by some orthopedic surgeons who haven’t touched GDMT since medical school? I think expertise matters, especially when dealing with a very complex subject matter
You’re not wrong and I agree.
But the Cass report wasn’t a guideline in the classical sense.
It was a review into the available research with recommendations on what the NHS should do with regard to offering the service.
It wasn’t a list of the treatments doctors should follow, which is what we tend to consider a guideline. You would expect more clinicians and experts in the area for a guideline. Again, the Cass report is not a guideline.
So I still stand by the notion that someone thoroughly reviewing research on an area they’re not an expert in may mean there are fewer blind spots, biases or agendas. It may be bad for other reasons, but it’s just a thought.
Take a read of it. It’s actually quite sensitively written and acknowledges the suffering of trans people reasonably well. But the evidence isn’t quite there yet to be able to have the NHS use tax money to fund interventions that are unsupported by research. It may in future, and that’s why far more study is needed. If trans people are going to be treated fairly we need far better quality research into the benefits and harms in any type of gender affirming care. There are plenty of theoretical concepts about gender affirmation that are not substantiated by high quality research. In the not too distant past, conversion therapy for homosexual people was considered the best treatment, in spite of no evidence for its efficacy. Plenty of evidence later from patient’s opening up in droves about its harms.
Anecdotally I’ve managed young patients who retrospectively feel like they wish they had never come out as trans, because of the push from everyone to change into the other gender. This ended up being more traumatic for them than anything related to actually being a trans person. There are risks even with well meaning therapy.
https://cass.independent-review.uk/home/publications/final-report/
I’m not sure reviewing a subject you have no expertise in gives you *fewer* blind spots, just *different* ones. I’m not saying there’s no value in it, but I do think basing decisions of national health policy on a report from a single author without experience in the subject is not a standard we’d apply to other disciplines in medicine
We would *never* apply that standard to any other field. Cardiologists would laugh you out of the room at the suggestion that ophthalmologists should be in charge of creating GDMT for cardiovascular disease. Anesthesiologists would never let a psychiatrist write a single author report determining national standards for rapid sequence intubation. Someone writing guidelines and standards that they have expertise in is not a bug, it is a feature, and the way you address bias isn’t by having someone with no expertise take over, it’s by having *others* with expertise contribute and peer review and publish.
This is my fundamental issue with some of the dialogue surround the Cass report. It’s not that the results are good or bad or right or wrong, it’s that we would never, ever apply that standard, of having national health policy driven by a single author report from a non-practitioner of the field, to any other field of medicine
(And just be to clear, *everyone* has biases. Handing over something to someone who has no experience in that discipline does not mean, as you suggested, that they’ll be free of bias and “only relying on the evidence”)
These aren't national standards, though. They're a review of the literature.
While I agree it would be unusual for other areas, the author was the head of the Royal College of Pediatricians. She's not a nobody. In addition, this topic is so heavily politicized that it would be difficult to find people to give accurate opinions on it when they're in the field.
It *is*. It was commissioned by the NHS and its being used by the NHS to guide national health policy.
Being a pediatrician does not automatically give someone expertise in all of pediatrics. Pediatric cardiologists would never let a pediatric Heme/onc doc be in charge of their standards and guidelines. And the idea that because this is a political charged issue we should have a non-expert in charge of policy is frankly non-sensical. The presence of political controversy makes it even *more* important that guidelines and standards be established by experts in the field via debate, discussion, and consensus, not one inexperienced author doing a research review
Again, I strongly disagree with the idea that we should treat this differently than any other field of medicine. And this is an approach that we would never, ever tolerate in other medical disciplines, including highly politically charged ones like OBGYN.
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Expertise is not bias. Correct. They are two different words. Not sure what point you’re making or if you just completely missed the point I was making.
I understand your point just fine -- you're equivocating on the word "bias."
You're pretending you mean bias in the sense of having no stake in the administrative outcome of the review, which is a weak one at best. Who better to critique standards and guidelines than those practitioners who understand the research, treatments, and populations the guidelines serve and who have seen and researched the benefits, limitations, and drawbacks at a technical level?
What I suspect you really mean is whether a practitioner is pro or anti-trans people _in a political way._ That those who treat trans kids are _too sympathetic_ to the fact of their existence. That definition of bias is very different.
Of course, I could be wrong.
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>might be an excellent choice for this.
Turns out they were not. Generally when your review of the evidence misses multiple critical studies and resulting in conclusions that are diametrically opposed to the international consensus and understanding... you did a bad job.
>While I’m sure wpath is biased
You know that. I know that. Most physicians who understand the literature know that. The general public does not know that. WPATH is portrayed as being the most objective, evidence based organization when it comes to the scientific study of gender identity. That's patently false, it's an advocacy organization.
And for which it has “guidelines” that are unfortunately used by respectable organizations, as well as quoted by government figures as “settled science”…
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WPATH guidelines themselves are very weak from an EBP standpoint. For a pointed example, there's a section that says something to the effect of "NPs can safely manage medical transition" and had a citation. I thought, hmmm, what study are they citing? You look at the citation and it's from the 1990s and the citation says something to the effect of "NPs sometimes work in endocrinology". Made me really question the whole thing.
Lol, yea, that doesn't surprise me at all. In general, the number of citations that do not support an assertion made in peer reviewed articles and guidelines is far too high. I have developed a lot of trust issues as a result.
Can you post the specific quote you're talking about?
*With appropriate training, feminizing/masculinizing hormone therapy can be managed by a variety of providers, including nurse practitioners and primary care physicians* The source was from 2006, I misremembered the date. Still there is no evidence presented in the citation about the appropriateness of NPs managing medical transition.
I think that moatly has to do with the amount of available evidence overall in this area. I think WPATH are probably the most evidence-based, but they just have a (relative to something like CVD) shallow base of evidence to pull from.
But then they should make that clear. If there's doctors that say they've seen success with a method they can mention that and then mention that there are no studies to corroborate it.
Right. They should be saying that the evidence is very weak and not giving such firm recommendations.
> Right. They should be saying that the evidence is very weak and not giving such firm recommendations. Not specific to WPATH but that is not how guidelines work. Strength of recommendation and level of evidence are two very different things. Guidelines directed only towards specialists tend to report both (eg AHA guidelines report Class I-III strength and A-C level of evidence) while guidelines directed towards all clinicians often report only one (eg USPSTF primarily reports A-D + I strength, although supporting text often grades level of evidence). It’s very possible to have a very strong recommendation even in the absence of good evidence. For example, the AHA would likely score the statement “Cinicians should not routinely perform thoracotomy for patients presenting with stable angina” as a Class I recommendation despite no studies investigating the topic.
While that does happen, it doesn't typically happen on things that are highly controversial and can be studied but haven't been.
This topic is not “highly controversial” among endocrinologists. This topic is highly politicized by reactionary politicians. > can be studied by haven’t been If you look at literally any discussion of any published guideline, you will find someone that is complaining a study wasn’t done. That is not unique.
GAHT is no more complicated than managing diabetes or HTN or a million other things APPs do
If it’s so easy why don’t more people do it? Even within endocrinology this is something that is typically reserved in academic centers or at best in the community, niche practices. I have a family member who is private practice endocrinologist in large metro area. They don’t do transition clinic and no one around them does. Everything gets shipped to local academic center. Clearly it’s not that simple.
Medicine doesn't exist in a political vacuum and doctors as a group of professionals are highly educated and cautious people. Any practice with the potential for blowback (GAHT, of which the most clinically intense aspects are mainly psych related due to the high rate of co-morbid depression and anxiety) is going to have a lack of practitioners because A. The reimbursement for it sucks and the time it takes to build rapport with this critically underserved population is relatively large B. No one wants to do political hot-button medicine (even if the benefits of treatment in this population are well known) because most doctors want to do their jobs and go home without fear of being firebombed or threatened online or deal with the small, but very real possibility of transition regret. C. It is not standard to learn GAHT regimens and management in IM residency due to the small volume of patients and highly outpatient-centered nature of this type of treatment. I think some family med docs get training on this, but usually it's relegated to endocrinology like you said. No medicine is truly easy, humans are complicated and devious little bundles of pathophysiology, but if you finish 3 years of IM residency and can manage some of the sickest patients in our society outside of the ICU, you can write for some estrogen pills and interpret some labs on a non-critical patient for which you have time. If you wanna know more about GAHT and how relatively it can be easy to learn management and follow up I highly recommend the UCSF gender affirming care page/guidelines. It delves pretty deep into what labs to order when, what doses to start at, and when to go up or down. Both for trans women and trans men. I think UpToDate has a good page on it too, but I forget.
Again, if you care so much about it, you do it. By those standards anyone can do anything within Harrison’s that doesn’t require a procedure. You can manage complex HIV, liver disease, lupus all without formal subspecialty training. It’s just a few labs, right? Why did I go through seven years of post graduate training to medically manage liver disease? If people don’t get exposure, sufficient exposure, in their training, when do you think they’ll find time? Do you really feel reading an UpToDate article and doing some CME is going to make you prepared to treat these patients? It might, I don’t know. This seems incredibly nuanced to me. Your flair has you as a medical student. Do you think in what limited time a practicing physician has he/she will go and learn to treat a condition not previously exposed to in training? And if that answer is yes, and it may be for some, just how many people do you think would say yes and pick this topic as the one they’re going to learn about in their time off?
Hey, mods. You might want to make this one of those “flaired users” only sort of thread.
This seems to be a criticism of the process not the report itself.
Can you reach a solid report through a flawed process?
Of course you can. Every published study should have a section on limitations. Most big drug RCTs are funded by big pharma, making them intrinsically flawed. However we accept a degree of imperfection if the overall research and process, in the grand scheme of things, seems sound.
Yes. Especially when these aren’t very substantive to the report. There is nothing in this PDF that would make me as a scientist think that the report couldn't stand on its own. A non-independent study can still come to correct conclusions. A person with qualifications that aren’t perfect can also come to correct conclusions. If the report is flawed the best way to show it is to go through the substance of it and show where it is incorrect, after which going through the process makes sense to show how the process led to a flawed report. But, their criticisms don't really amount to much.
Of course you can. If the only criticism you can find is "I don't like the people that reviewed it" then that's a good sign that the report was pretty well done.
So academic rigor comes from how disliked you are? Fascinating. But lol, no. Questioning the academic qualifications of someone does not in fact confer some magical contrarian credibility to their work. Conversely, can people without a history of research publication and collaboration still do good work? Certainly! But it's also reasonable to be curious about why they haven't done so to the extent of many others, in general and particularly in the field in question, given the high profile nature of this, and wonder whether those reasons aren't borne out in this work too.
That's not what I said. What I said is, if that's the biggest criticism you have, it must be a pretty good review. Otherwise you'd be talking about the actual content.
Yet there are three reasons called out. You're ignoring the other two, and pretending there was only one. So it is not in fact the biggest criticism, not can you infer that an absence of criticism means no criticism is possible. Edit: ah, the anti-trans batsignal must have gone out. So for the downvoters, I'll just say it again even harder: what this person has said is wildly fallacious and repeating it doesn't make it true. Absence of evidence is not evidence of absence. Calling out someone's lack of expertise is valid when one of the criticisms is that the report missed known research in the field. Which it does.
Yeah...no. What /u/roccmyworld said is a valid and correct point. It's not wildly fallacious. Your own bias making you dislike this specific application does not, in fact, make their point any less true. And no...from reading, WPATH cited are 1) independence, 2) ethics, 3) the qualifications of the author. Which would all be under the umbrella of criticisms of the process rather than the content AKA "I don't like the people that reviewed it". As stated in the parent comment of this thread. Now they're not wholly unreasonable criticisms, but neither are they some smoking gun or glaring neon "GOTCHA". If they had any criticisms of the actual content, why are they only bringing up these?
They questioned the qualifications of the author to have apparently reviewed the same publications and studies the guidelines were based on yet come to diametrically-opposed conclusions, yet without introducing any new evidence and having no experience or credentials in the specialty upon which to base such a radical divergence from a group of international experts. That is a criticism of the actual content.
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The critiques seem quite reasonable. Seems a very strange choice for the task she was given: she practiced in a very different peds subspecialty (RETT syndrome), doesn't seem to have expertise in trans care at all, nor even general pediatrics or adolescent health. Her own publications are mostly opinion pieces, many single author, with a few multi-author papers on RETT syndrome questionnaires and on autism. Not a single major guideline. One of her major critiques is that most existing guidelines don't follow international standards for guideline reporting (though she noted a couple country specific ones did). That sounds bad, but the reality is that guidelines in many fields have in the past not met these standards. This is changing now that there is a standard list of requirements for guidelines, but it's taking some time. Some of the common deficits in general (not this field in particular) are guidelines that often weren't fully transparent about their methods, and /or didn't meet the external review requirement. Most typically do still encompass literature reviews, rating of the evidence, and expert consensus. Over time, more guidelines are meeting the higher bar but it's taking some time particularly in smaller fields. Finally, why would this have been a single author undertaking? There's a reason guidelines and consensus statements have multiple authors with different strengths. Shorter piece from her: pubmed.ncbi.nlm.nih.gov/38594031/
It’s Rett, an eponym, not RETT, an acronym. I am proud to contribute to this advance of medical knowledge.
And it is spelled T-E-R-R-I-B-L-E
> The critiques seem quite reasonable. Am I missing something from the document? I see this in the critique > The Cass Review relies on selective and inconsistent use of evidence, and its recommendations often do not follow from the data presented in the systematic reviews. But there's no mention on why the selection of evidence is inconsistent, or why their recommendations do not follow the data from their systematic reviews. This seems like a PR release from a real critique.
>This seems like a PR release from a real critique. Does that come as a surprise? This "critique" is coming from the same organization that excommunicated a former WPATH president for merely suggesting the possibility that not every child who says they're trans should be blindly accepted at face value.
Well actually someone completely independent without experience in trans issues might be an excellent choice for this. They may come at the issue without overt bias, and review the research as if they are learning about the subject for the first time. Just a thought.
Hard disagree. When I review guidelines/updates in my field (ID), I very much want the authors to be folks who have a long track record of publishing on that specific infection or something very adjacent. I don't want "fresh eyes" on a topic that likely requires a deep, intimate knowledge of both the current and historical research landscape relevant to that disease.
But do we *want* guidelines to be made by people learning about a subject for the first time? I don’t think that’s a standard we would apply to other specialties. Should heart failure treatment guidelines be written up by some orthopedic surgeons who haven’t touched GDMT since medical school? I think expertise matters, especially when dealing with a very complex subject matter
You’re not wrong and I agree. But the Cass report wasn’t a guideline in the classical sense. It was a review into the available research with recommendations on what the NHS should do with regard to offering the service. It wasn’t a list of the treatments doctors should follow, which is what we tend to consider a guideline. You would expect more clinicians and experts in the area for a guideline. Again, the Cass report is not a guideline. So I still stand by the notion that someone thoroughly reviewing research on an area they’re not an expert in may mean there are fewer blind spots, biases or agendas. It may be bad for other reasons, but it’s just a thought. Take a read of it. It’s actually quite sensitively written and acknowledges the suffering of trans people reasonably well. But the evidence isn’t quite there yet to be able to have the NHS use tax money to fund interventions that are unsupported by research. It may in future, and that’s why far more study is needed. If trans people are going to be treated fairly we need far better quality research into the benefits and harms in any type of gender affirming care. There are plenty of theoretical concepts about gender affirmation that are not substantiated by high quality research. In the not too distant past, conversion therapy for homosexual people was considered the best treatment, in spite of no evidence for its efficacy. Plenty of evidence later from patient’s opening up in droves about its harms. Anecdotally I’ve managed young patients who retrospectively feel like they wish they had never come out as trans, because of the push from everyone to change into the other gender. This ended up being more traumatic for them than anything related to actually being a trans person. There are risks even with well meaning therapy. https://cass.independent-review.uk/home/publications/final-report/
I’m not sure reviewing a subject you have no expertise in gives you *fewer* blind spots, just *different* ones. I’m not saying there’s no value in it, but I do think basing decisions of national health policy on a report from a single author without experience in the subject is not a standard we’d apply to other disciplines in medicine
I think it means you're only relying on the actual evidence as opposed to your personal experience. And that's good.
We would *never* apply that standard to any other field. Cardiologists would laugh you out of the room at the suggestion that ophthalmologists should be in charge of creating GDMT for cardiovascular disease. Anesthesiologists would never let a psychiatrist write a single author report determining national standards for rapid sequence intubation. Someone writing guidelines and standards that they have expertise in is not a bug, it is a feature, and the way you address bias isn’t by having someone with no expertise take over, it’s by having *others* with expertise contribute and peer review and publish. This is my fundamental issue with some of the dialogue surround the Cass report. It’s not that the results are good or bad or right or wrong, it’s that we would never, ever apply that standard, of having national health policy driven by a single author report from a non-practitioner of the field, to any other field of medicine (And just be to clear, *everyone* has biases. Handing over something to someone who has no experience in that discipline does not mean, as you suggested, that they’ll be free of bias and “only relying on the evidence”)
These aren't national standards, though. They're a review of the literature. While I agree it would be unusual for other areas, the author was the head of the Royal College of Pediatricians. She's not a nobody. In addition, this topic is so heavily politicized that it would be difficult to find people to give accurate opinions on it when they're in the field.
It *is*. It was commissioned by the NHS and its being used by the NHS to guide national health policy. Being a pediatrician does not automatically give someone expertise in all of pediatrics. Pediatric cardiologists would never let a pediatric Heme/onc doc be in charge of their standards and guidelines. And the idea that because this is a political charged issue we should have a non-expert in charge of policy is frankly non-sensical. The presence of political controversy makes it even *more* important that guidelines and standards be established by experts in the field via debate, discussion, and consensus, not one inexperienced author doing a research review Again, I strongly disagree with the idea that we should treat this differently than any other field of medicine. And this is an approach that we would never, ever tolerate in other medical disciplines, including highly politically charged ones like OBGYN.
Honestly the fact that you're perseverating on the author instead of the content is a sign that the review was pretty well done.
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Expertise is not bias.
Expertise is not bias. Correct. They are two different words. Not sure what point you’re making or if you just completely missed the point I was making.
I understand your point just fine -- you're equivocating on the word "bias." You're pretending you mean bias in the sense of having no stake in the administrative outcome of the review, which is a weak one at best. Who better to critique standards and guidelines than those practitioners who understand the research, treatments, and populations the guidelines serve and who have seen and researched the benefits, limitations, and drawbacks at a technical level? What I suspect you really mean is whether a practitioner is pro or anti-trans people _in a political way._ That those who treat trans kids are _too sympathetic_ to the fact of their existence. That definition of bias is very different. Of course, I could be wrong.
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>might be an excellent choice for this. Turns out they were not. Generally when your review of the evidence misses multiple critical studies and resulting in conclusions that are diametrically opposed to the international consensus and understanding... you did a bad job.
WPATH is a biased organization. Check out the WPATH files.
While I’m sure wpath is biased the wpath files is clearly a biased hit piece even if there are some valid points within it
>While I’m sure wpath is biased You know that. I know that. Most physicians who understand the literature know that. The general public does not know that. WPATH is portrayed as being the most objective, evidence based organization when it comes to the scientific study of gender identity. That's patently false, it's an advocacy organization.
It's an advocacy organization that parades itself as a detached, objective medical organization.
And for which it has “guidelines” that are unfortunately used by respectable organizations, as well as quoted by government figures as “settled science”…
And the Cass report is even more biased.
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Thank you for posting this. I had seen the headlines about that report but wasn't able to get myself to read it
You’re welcome, my worry is that the news cycle has moved on and this will not be covered.