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PaperclipPerfector  7mo ago (text post)   25441 thread views

Culture War Roundup for the week of April 8, 2024

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The critics point out that randomized control studies just aren't possible in some areas of medicine.

And the critics are wrong. If you give a treatment to one group, and not give it to another to another, that's still an RCT. Or you can offer an alternative treatment to the control group. It's a plus when you can blind a patient to what they're getting, but it's not a strict necessity. In this case it's probably just as important to blind the researchers when they're assessing results as to blind the patients themselves.

In a better version of the Cass Review, I would have liked to see a few paragraphs justifying the use of GRADE, and explaining why they used this standard and not some other standard.

That demand seems arbitrary to me, and "that's what we use for everything" is a perfectly fine justification.

It's a bit circular to arbitrarily use a standard that will say, "there are basically no high quality studies in this medical field" no matter what, and then to conclude in your recommendations to the government.

Where did you get the idea that the decision was arbitrary? That studies with a control group are better than studies without one, or that random samples are better than self-selected surveys, isn't something that Cass ceme up with on the spot. The critics are more than happy to use the same strict standards when dismissing studies they don't like (see: ROGD).

This is all without going into the juicy details about some of these studies, some of which are hilariously bad. The "Dutch study" that kicked off the whole puberty blockers thing would most likely get the same result, even if you replaced blockers with farting in the patient's face, for example.

My opinion is that trans activists and researchers wildly oversold the scientific basis for the interventions they were promoting, and sometimes they were outright lying ("puberty blockers are reversible"). They could have just not done that, and tried to gradually accumulate stronger evidence. But the way things are, gender medicine should have never seen such widespread adoption, and people who allowed it should probably be punished.

Addressing the other parts of your post:

That demand seems arbitrary to me, and "that's what we use for everything" is a perfectly fine justification.

I agree it's "fine" from a CYOA point of view, as in, no one will be able to blame you for using a standard tool used across the industry. But from the perspective of trying to perform a Bayesian update based on the final report, I'm not sure I agree.

A lot of the scientific method in general is a heuristic crystallization of Bayesian approaches, and so I have no doubt that a lot of what is present in GRADE is justifiable across a wide swath of evidence, and comes to largely the same answer as a Bayesian approach would. But I think that if GRADE systematically downgrades some kinds of evidence from being "high quality", which in a proper Bayesian approach wouldn't require any serious adjustment, that can lead to certain evidence being ignored or de-emphasized compared to where it should.

My opinion is that trans activists and researchers wildly oversold the scientific basis for the interventions they were promoting, and sometimes they were outright lying ("puberty blockers are reversible"). They could have just not done that, and tried to gradually accumulate stronger evidence. But the way things are, gender medicine should have never seen such widespread adoption, and people who allowed it should probably be punished.

I think absent any other evidence, just the existence of the Replication Crisis is enough to call a lot of medicine into doubt, and I see no reason why this wouldn't apply to trans healthcare. That the evidence is weaker than often claimed, is almost certainly true. (I'm not sure that that isn't the case for a wide variety of healthcare fields as well though - is trans healthcare uniquely bad, or is it just as bad as medicine as a whole, and do we need to adopt a whole swath of reforms to deal with things like p-hacking, the file drawer effect, small sample sizes, etc.)

I agree with Cass' conclusion, even if I question her methodologies, because I want to see higher quality medical evidence around trans issues, and especially trans kids. I want the medical research to be beyond reproach, whatever conclusions it comes to.

The basic problem with medicine, across the board, is that we're routinely doing barbaric things to be people, and the only justification we can have is that the evidence shows it will have a better outcome for the patient. Chemotherapy involves poisoning a patient with the hope that the poison will kill the cancer faster than it kills the patient. Amputating a limb might be a tough decision sometimes, but it is most justified if a patient would likely die if you didn't do it.

I want the evidence we use in all instances, especially trans healthcare to be airtight so that no one can say we're poisoning people or removing functional limbs or organs for no reason. It'll still be "barbaric", but if it can be justified as much as chemotherapy, then I think trans healthcare will be in a good place.

I agree it's "fine" from a CYOA point of view, as in, no one will be able to blame you for using a standard tool used across the industry. But from the perspective of trying to perform a Bayesian update based on the final report, I'm not sure I agree.

Well then I have 4 words for you: isolated demand for rigor. If you want to throw out all the published studies, and force the authors to do them right, I'm game. If we're supposed to apply the highest standards to Cass, and ignore the gaping holes in the literature published to date, I don't think you'll get a lot of people signing up for that.

if GRADE systematically downgrades some kinds of evidence from being "high quality"

As per my other comment, I've seen no indication that it does. The whole argument smells like a scramble to get some talking points out ASAP so the report doesn't get to circulate uncontested, even for just a few days.

The basic problem with medicine, across the board, is that we're routinely doing barbaric things to be people, and the only justification we can have is that the evidence shows it will have a better outcome for the patient. Chemotherapy involves poisoning a patient with the hope that the poison will kill the cancer faster than it kills the patient. Amputating a limb might be a tough decision sometimes, but it is most justified if a patient would likely die if you didn't do it.

There's a few major differences between cancer/chemotherapy and dyshporia/GAC. For one, the risks of cancer are pretty well measured. A doctor can tell you "you have an X% chance of living Y months/years" and be mostly right. By contrast a GAC doctor saying "would you rather have a happy daughter or dead son" is stoking fears that aren't justified by data at all. We are also open about the mechanism and effects of chemotherapy, every doctor will tell you it's basically poison, but the hope is it will kill your cancer before it kills you. By contrast puberty blockers are declared to be a magical pause button, safe, and fully reversible. That's just an outright lie. We also have good data about the chances of chemotherapy working, but not for puberty blockers improving outcomes for dysphoria. Finally, even if the decision to undergo treatment is the right one based on available data, we only do it with informed consent, which we tend to not have in case of GAC, by gender clinicians' own admission (see: WPATH Files).

You're right that there are issues in all of medicine, but we ensured there are some guardrails around it to minimize the barbarity. The guardrails were happily abolished for GAC at the insistence of trans activists, and the result is that "gender affirming care" is a lot more barbaric than other forms of medicine practiced today.

And the critics are wrong. If you give a treatment to one group, and not give it to another to another, that's still an RCT. Or you can offer an alternative treatment to the control group. It's a plus when you can blind a patient to what they're getting, but it's not a strict necessity. In this case it's probably just as important to blind the researchers when they're assessing results as to blind the patients themselves.

You're right of course. I think the concerns are more nuanced in some areas of medicine.

I doubt it applies to trans medicine, but I have heard of cases where medicine has such obvious positive effects for the sample group early on, that it then becomes unconscionable to not provide it to the control group (mostly in cases involving terminal diseases with quick turn arounds.) This would be one instance where a study initially meant to be a RCT trial for a terminal disease, might turn into an observational study instead.

And I was clearly thinking of double-blinded RCTs being nearly impossible in some cases, which I believe is true in some areas of medicine, but I can admit that GRADE only requires RCTs period for evidence to be considered high quality. That said, reading through the actual GRADE hand book it does seem like Lack of Blinding is considered a risk for study bias, which can drop a piece of evidence one level:

Example 3: High Risk of Bias due to lack of blinding (Downgraded by One Level)

RCTs of the effects of Intervention A on acute spinal injury measured both all-cause mortality and, based on a detailed physical examination, motor function. The outcome assessors were not blinded for any outcomes. Blinding of outcome assessors is less important for the assessment of all-cause mortality, but crucial for motor function. The quality of the evidence for the mortality outcome may not be downgraded. However, the quality may be downgraded for the motor function outcome.

I'm going to edit my original post to reflect this information, but I'll make clear what I'm adding. Basically, it appears to be the case that non-double-blinded RCTs cannot easily be high quality evidence according to GRADE.

Where did you get the idea that the decision was arbitrary?

I tried to search through the report, and they just used GRADE without really explaining why. I suppose "arbitrary" isn't quite the right word, but "unjustified within the report" is probably defensible.

And I was clearly thinking of double-blinded RCTs being nearly impossible in some cases

Ok, but what does that have to do with the Cass Review then?

I haven't even started reading the report yet, but I looked up the excerpt you quoted about only one study on puberty blockers being high quality. If you check the report, the excerpt references "Taylor et al: Puberty suppression", CTRL+Fing for that takes you to table 1 on page 53. The full title of the systematic review is Interventions to suppress puberty in adolescents experiencing gender dysphoria or incongruence: a systematic review, and the "one study" is Psychological Functioning in Transgender Adolescents Before and After Gender-Affirmative Care Compared With Cisgender General Population Peers. The "methods" section from the abstract says:

Methods: In this cross-sectional study, emotional and behavioral problems were assessed by the Youth Self-Report in a sample of 272 adolescents referred to a specialized gender identity clinic who did not yet receive any affirmative medical treatment and compared with 178 transgender adolescents receiving affirmative care consisting of puberty suppression and compared with 651 Dutch high school cisgender adolescents from the general population.

You can even look up the break down of it's score in the supplemental material of the systematic review (it's the last entry in the table - "van der Miesen"), it only got dinged for "controls for co-interventions" and "assessment of outcome", and still got a final grade of "high quality".

So where is this idea that Cass was autistically demanding a double-blinded study, where it was not applicable, coming from?

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