The BMA Council Shames Itself

Another salvo in the war on the Cass Review

On July 31st, The BMA’s UK Council voted to publicly critique the Cass Review. This is a decision that has been roundly criticised by its membership and even some members of the council, seeing as this sort of action goes well beyond their remit. That a tiny number of seeming ideologues in positions of authority can issue such proclamations on behalf of the BMA with no democratic oversight does seem extraordinary.

However, while the dissent has been widely covered, what has not really received sufficient attention is the evidence they based this decision on.

In the statement, they make two citations:

• A preprint paper titled “Critically appraising the Cass Review“

• A white paper from the self-styled “Yale Integrity Project” titled “An evidence based critique of the Cass Review”

This is the entire basis on which 21 members of the BMA’s council voted to publicly critique the Cass Review, and bring the entire BMA into disrepute.

Neither of these is a peer-reviewed publication and both are extraordinarily bad in a number of ways, none of which inspires much confidence in the objectivity and reasonableness of those who used them to push this decision onto the BMA.

Both are also a continuation of the process of deeply interconnected source laundering I have already documented here, all produced in service of attacking and discrediting any and all evidence that does not support the so-called “affirmative model”. These are simply the next iteration of an existing echo chamber of interconnected activists all repeating each others’ talking points in a variety of venues, giving the illusion of breadth and independence. That the BMA council has now lent these arguments credence is an embarrassment to the organisation.

An Evidence Based Critique of the Cass Review

The first document offered in evidence is from the Yale Integrity Project. This is a small group set up as part of the Yale School of Law with the express purpose of opposing bans on youth medical transition in the US. It starts from the position that such bans are the result of the spread of “disinformation”, which it seeks to counter. It has given evidence in legal cases in the US in favour of the “gender-affirming” model and published reports attacking the reputation and credibility of clinicians and academics with a different point of view, and downplaying uncertainty.

In 2022, the principal authors (Meredithe McNamara and Anne Allstott, founders of the Yale Integrity Project) released a similar white paper criticising the Society for Evidence-Based Gender Medicine and cherry-picking positive evidence to downplay potential desistance, regret and social contagion among adolescent transitioners, and an unprecedented rise in teenage girls adopting a trans identity.

To give an idea of how all this scholarship is being used, a June 2024 paper was authored by Meredithe McNamara, Anne Allsott and Quinnehtukqut McLamore titled “A thematic analysis of disinformation in gender-affirming healthcare bans in the United States”. This builds on and cites this earlier document, repeating many of these lines, as well as citing six papers authored or co-authored by Florence Ashley, all intended to cast doubt on themes of desistance and social contagion, and to claim the unethicality of attempting to gather better evidence for treatment efficacy. The paper brands claims like the following as disinformation:

• “Many of the children who undergo these procedures have other psychological problems, like attention deficit hyperactivity disorder and autism.”

• “The manifestation of gender dysphoria in adolescents is a relatively new phenomenon. […] Those presenting as adolescents are ‘predominately biologically female.”

• “While you refer to these procedures as ‘sex changes,’ it is important to note that it remains medically impossible to truly change the sex of an individual”

• “systematic reviews from multiple European nations – where similar interventions have been studied – have shocked those nations’ medical professionals and led to greater restrictions on the medical interventions”

And so on. Unfortunately, the Cass Review drives a coach and horses through this, as it substantiates the position that all of the above are completely true, based on the most comprehensive systematic reviews of the peer-reviewed evidence to date. In order to further the project’s stated goals, the Cass Review has to be discredited.

This new Yale Integrity Project document has to be seen in that light. This is not an impartial, non-partisan assessment, but a highly motivated one from a group of activists with a view on helping defend against legal bans on youth medical transition in the US, which so far have been waged with skewed and selective presentation of the evidence and branding contrary positions as “disinformation” and those who point to them “hate groups”.

Other citations of this Yale white paper include:

• Cal Horton’s “The Cass Review: Cis-supremacy in the UK’s approach to healthcare for trans children” (which I discussed previously, and I'll note again here gave thanks to Quinnehtukqut McLamore for input)

• A paper published in WPATH’s own journal titled “Biological and psychosocial evidence in the Cass Review: a critical commentary” by D. M. Grijseels, which also thanks Quinnehtukqut McLamore for input, and also cites Cal Horton’s paper, above.

As for substantive criticisms of this white paper, there are almost too many to mention. Jesse Singal has produced two long and forensic critiques of this white paper, and is still only halfway through it.

There are too many issues to go into detail here, but one example to illustrate the level of problems. The Yale team make much of the fact that the York systematic reviews employed a “modified” version of the Newcastle-Ottowa Scale (NOS) for evaluating studies:

Furthermore, the York SR team did not implement the NOS as it is presented by its authors. They modified the scale in an arbitrary way that permitted the exclusion of studies from further consideration, for reasons irrelevant to clinical care. For instance, in the York SR on social transition, the modified NOS asked if study samples were “truly representative of the average child or adolescent with gender dysphoria.” There is no such thing as the “average child or adolescent with gender dysphoria” —this is an inexpertly devised and meaningless concept that is neither defined by the authors nor used in clinical research. And yet it was grounds for excluding several important studies from consideration.

However, this is an utterly specious claim. The modification simply clarified the criteria for this specific case, which is absolutely standard when using the NOS (as can be seen in plenty of other instances). So where NOS Q1 says:

• 1) Representativeness of the exposed cohort

  • a) Truly representative (one star)

The York researchers expanded this to define "truly representative" in this instance:

• 1) Representativeness of the paediatric gender dysphoric group Score 1 if:

  • a) truly representative of the average child or adolescent with gender dysphoria / incongruence, e.g., nationally representative community sample, population-based medical database, national gender service, multiple gender services covering different localities

So the Yale team complain both that NOS was "modified", and that "average" is undefined, but the modification the York team made here was a common one and explicitly defines what "average" means in this context. It is just a test that means that the sample was drawn from a broad enough base (national, or geographically distributed) that it is representative of the population as a whole, on average. So studies which don't meet that standard - eg. single clinics, self-selected samples - just had a lower quality score. The authors try to imply this is some sort of novel or arbitrary concept used to wrongly exclude important studies, but these objections are all just sophistry and obfuscation.

The whole document is full of this sort of thing, claims that are so wrong or tendentious that my most charitable assumption is that the members of the BMA council who were swayed by it hadn’t read the Cass Review.

Critically Appraising the Cass Review

The second citation used by the BMA is again not published in a peer-reviewed journal, but a preprint with 21 authors, some of whom will be familiar from my previous piece on source laundering by highly partisan activists. Specifically Florence Ashley (whose dozens of self-referencing academic essays are the source of claims that exploratory therapy is conversion) and - again - Quinnehtukqut McLamore (who has contributed to and co-authored many papers and partisan publications disseminating this same perspective, including the Southern Poverty Law Centre’s CAPTAIN report).

It was also co-authored by D.M. Grijeels, whose own critique of the Cass Review that I highlighted above as being cited by the Yale team is also cited in this preprint, and on top of that the Yale white paper cites this preprint as well. So we actually have three interconnected critiques of the Cass Review by the same handful of activists citing each other.

This preprint is, bluntly, badly written, full of meandering circuitous statements, handwaving and nonsense that makes it very hard to pick out any quotes because very little actually makes any sort of sense in isolation. It also, infuriatingly, refers to the Cass Review as the Cass Report throughout.

The most substantive claim made is that the preprint authors employed the ROBIS (Risk Of Bias In Systematic reviews) tool to assess the “risk of bias” in the York systematic reviews, and determined that they have a “high” risk of bias. ROBIS however is not a straightforwardly objective tool, but one intended to assist experienced systematic reviewers to navigate some subjective assessments in a consistent way, and in that light some of the grading in this preprint is arguably questionable. Comparing some of the scoring to the ROBIS guidance documentation here, it is hard to see how the assessors arrived at some of these conclusions.

For example, The York team searched five standard databases, and there is absolutely no reason to think that is inappropriate, yet were bafflingly marked down for not searching an appropriate range of databases. The preprint authors take major issue with the fact that the search was conducted in English and excluding “grey literature” (ie, white papers, unpublished results, conference papers etc), but there isn’t a compelling reason to do otherwise. Including grey literature or not is not necessarily indicative of bias under ROBIS, and grey literature can be included in a search to assess whether published work exaggerates the effectiveness of a treatment, since poor results in clinical trials sometimes languish unpublished. As for the English language selection, paediatric transition is an overwhelmingly Western phenomenon, and it is, shall we say, unlikely there is a significant piece of published research that isn’t available in English that was excluded from the search, especially since none are presented here. Far too much weight is given to the language restriction when research shows this is rarely a significant source of bias:

To lessen this possible source of bias, efforts are occasionally made to find and include non-English-language literature in systematic reviews. Nonetheless, there is some evidence that, at least in the field of conventional medicine, only incorporating English-language papers does not bias meta-analyses

Multiple reviews are marked down on this scale for not formally assessing methodological quality using appropriate criteria - but the reviews in question did in fact do so, and this all just seems to have been incorrectly scored, because the authors also devote a page to attacking the York team’s use of the Newcastle-Ottawa Scale at all, describing it as not the recommended tool for the job:

the NOS is considered a quality appraisal scale, but within systematic reviews exploring the effectiveness of interventions (which this review claims to be doing) it is recommended that a domain-based risk of bias assessment tool should be used instead of a quality appraisal tool.

This seems to completely mis-cite the Cochrane handbook. The relevant section (Chapter 8) says:

The Collaboration’s recommended tool for assessing risk of bias is neither a scale nor a checklist. It is a domain-based evaluation, in which critical assessments are made separately for different domains, described in Section 8.5

(Cochrane Handbook pp191)

Fine so far - but section 8.5 is for reviewing the very randomised studies the preprint authors claim are unethical and impossible:

Chapter 8 (Section 8.5) describes the ‘Risk of bias’ tool that review authors are expected to use for assessing risk of bias in randomized trials.

(Cochrane Handbook pp417)

For non-randomised and cohort studies of the sort that the York team were reviewing, the Cochrane Handbook says a different tool must be used:

Many instruments for assessing methodological quality of non-randomized studies of interventions have been created, and were reviewed systematically by Deeks et al. (Deeks 2003). In their review they located 182 tools, which they reduced to a shortlist of 14, and identified six as potentially useful for systematic reviews

[…]

The two most useful tools identified in this review are the Downs and Black instrument and the Newcastle-Ottawa Scale

(Cochrane Handbook pp417)

The ROBIS scores seem to be based on criticisms that are completely wrong on their face.

In addition to the overblown “risk of bias” claims are a laundry list of other complaints, none of which are any better when scrutinised. The section titled “Unsupported Claims” contains examples such as the following:

The authors also claimed that ”the switch from birth-registered males to birth-registered females” is ”unlike trans presentations in any prior historical period” (p. 26), without evidence for this change occurring, and without considering studies that contradict this claim.

First, the “evidence for this change occurring” is all in this systematic review, encompassing dozens of papers globally. Here is a series of charts showing the shift in sex ratio from male to female over time:

Second, the citation for “without considering studies that contradict this claim” is this paper, which was considered. It is part of that graph above, right here:

Not only that, but it doesn’t contradict this claim either. What this paper actually did was look at the sex ratio in 2012 and 2015 and find it did not change significantly between those two dates - but by that point the sex ratio had already changed to favour female referrals, by around 2:1, a significant change to ratios in prior decades.

---

On top of the attempts to poke holes in the methodology, the preprint devotes a good chunk to smearing the Cass Review as part of the “political context”, offering up claims of rising hate crime and attempts to ban youth medical transition in some US states, before concluding:

By making this point, we make no assessment or claim of political bias on the part of the authors of the Cass Report and associated systematic reviews. Rather, we suggest that it is not possible for these authors to separate their research from this social and political context

This is all empty handwaving about completely unrelated things and insinuating some sort of association to the Cass Review before backing innocently away from the pile of steaming bullshit the authors have left at the door of the review.

It attempts to imply this is somehow related to the review because of thematic connections between what the Cass Review found and what it regards as “disinformation” in US legal challenges to paediatric transition:

The specific themes of misrepresentation and disinformation in both Arkansas and other states throughout the U.S. include insinuations that being trans is, in and of itself, evidence of mental illness and can be ”cured” through talk therapy, outdated and misleading claims about the process of gender-affirming care in the U.S., misrepresenting the evidence regarding ”desistance” in transgender youth, and rejection of scientific and medical authority.

But the citation once again brings us full circle, as it is based on the previously mentioned paper on “disinformation” by McNamara, Allsott and McLamore. This is itself all based on the same opinionated essays by Florence Ashley on desistance, ROGD, social contagion and ethicality of paediatric transition as all the other publications - and then re-cited by the authors of these works with the pretence of independence.

There’s a difference between good scholarship that builds upon prior work and this sort of self-referential echo chamber that exists only to amplify its own worldview and rubbish anything that disagrees in the strongest possible terms.

Once again, the same handful of interconnected activists are churning out authoritative-seeming efforts to discredit the Cass Review, building on the earlier chain of laundered sources. None of these are independent works, and the criticisms range from weak to questionable to flat-out wrong. All in service of creating the impression that the Cass Review is “widely criticised” by “scholars”, when in reality it is so much obfuscation by a small number of ideologues. This is all a highly motivated crusade to discredit any medical evidence that does not support their preferred “affirmative model”.

Taking partisan material like this and using it as the sole basis to place the BMA’s reputation on the line by going against the Cass Review is really quite startlingly irresponsible.

I hope one day the BMA leadership comes to its senses and realises how badly they’ve been had.