Yesterday I wrote a short article about the repeated statements made to me by Barry Purcell and his colleagues, claiming that The Cass Report has been “trashed” by the medical research community. I provided evidence to the contrary, which included support for the conclusions of Dr Cass from all of the other gold standard systemic reviews of gender-affirming medicine that have been completed to date. I also described how Dr Cass and her team conducted their systemic reviews, by transparently applying best practice measures to evaluate how useful or otherwise all of the existing relevant research papers have been. Dr Cass concluded that this existing evidence for the efficacy of puberty blockers and cross-sex hormones is “remarkably weak”.
Since Dr Cass required her team to openly publish all of their work and the criteria used to arrive at their determinations, I suggested that Barry Purcell might in turn show his work. I proposed that he should provide some of the “robust data” that he insisted exists to support the prescription of powerful hormones to gender-dysphoric children. In fairness to him, Barry Purcell has now followed up and done just that.
The link provided by Barry Purcell is to one of his own blog posts, titled “Trans Healthcare is Healthcare”. This blog post includes statements such as “biological sex is not binary”, and links to a series of research papers. As it happens, since the clinical researchers that were commissioned by Dr Cass have transparently published all of their work, it is easy to see how they have evaluated the specific studies that have been cited by Barry Purcell. For example, we can start with the first research paper linked to in the Barry Purcell blog post, and compare it with the associated commentary from the clinical research team commissioned by Dr Cass. This can help us evaluate whether the research cited by Barry Purcell provides sufficiently convincing evidence to support the treatment of dysphoric young children with very consequential drugs.
The first research paper linked to by Barry Purcell is about “gender-affirming hormone therapy”, and it describes a study conducted by Green et al in 2022. The methodology of the study targeted youths from the age of 13 with an online advertising campaign using platforms like Snapchat. Those who clicked on Snapchat ads relating to the survey, were asked to complete an online questionnaire. The first issue with this study that is highlighted within The Cass Report, is that this is a “self-selecting survey”. That is, whereas youths who have a positive view of gender-affirming care may be keen to respond when they see an ad on this topic, those who have had a negative experience may be less likely to participate. In principle, this kind of self-selecting sample often recruits cohorts that are heavily skewed and unrepresentative of the target population as a whole. Such self-selection is likely to provide us only with the views of those keen to engage with the topic, while excluding by design those who have already experienced difficulties with the treatment that they are less keen to revisit.
Some examples of the questions posed to youths from the age of 13 are included in the paper, such as the extract illustrated below.
The Cass Report also notes in relation to the “ascertainment of treatment exposure” for this study, that this represents a self-reporting approach to determining what drugs were taken by each patient. That is, the study does not include any medical records created by clinicians to describe which dosages of which specific pharmaceuticals were prescribed on which dates. Rather, youths from the age of 13 participating in an online questionnaire after clicking on a Snapchat ad, were asked to self-report on their own hormone medication.
Any parent of a 13 year old may already be wondering if they would trust their child to self-report on whether they had taken paracetamol or ibuprofen, let alone self-report about much more consequential medical treatments. In fact, all of the data relating to the entire study was collected through the self-reporting of participating youths. It is not even the case that a 13 year-old participant was expected to have adult help or supervision to complete the questionnaire. This is obvious from another question that was posed to participating youths:
“Do you have at least one parent who is supportive of your gender identity?” with answers of (1) “No,” (2) “Yes,” and (3) “I am not ‘out’ about my gender to any of my parents.”
Quote from Green et al, 2022
Parents of 13 year-olds may at this point be worrying not only about the reliability of responses, but also about whether or not the participating youths even fully understood the questions they were being asked. The Cass Report provides some further context that could create additional cause for skepticism in this regard. Of the 11,914 participating youths that indicated they were transgender, a quarter did not provide any answer to the gender-affirming hormones question in the extract illustrated above. If such a high proportion of youths who self-reported as being transgender were not willing or able to even answer this question, how much confidence can we have in the reliability of the responses to this question that were actually given? These 11,914 participants were typically youths with a smart phone, completing an online survey between Snapchats with their friends. They agreed to answer a questionnaire about gender-affirming hormone treatments, but fully one quarter of them didn’t provide any answer at all to the core question about gender-affirming hormones. It is reasonable to wonder then how much attention these youth study participants were paying to the process.
This kind of context for the data that was reported by Green et al, has implications about how much care and consideration was involved when the participating youths were actually providing the relevant data. It is not necessary to be a highly qualified clinical researcher commissioned by Dr Cass, to point out that there may be limited “underlying value” in asking a 13 year-old with a smart phone to self-report on a complex hormone therapy in between Snapchats with their friends.
Since I did ask Barry Purcell to show his work though, I am certainly grateful that he has followed up with links to the data sets that I requested. However, there is nothing in the data he has linked to that would cause me to question the conclusion of Dr Cass, that the evidence supporting the prescription of these drugs to vulnerable children is “remarkably weak”. Barry Purcell has cited this Snapchat research as providing the “robust data” that justifies prescribing powerful hormones to vulnerable youths. Anyone who shares the concerns of Dr Cass about the quality of this evidence, is then described by Barry Purcell as a “transphobe” who can only be motivated by bigotry against trans people. This is not an adult way to approach a very serious issue. If he wishes to move beyond directing unjustified insults at eminent clinicians and instead deal with the merits of the issues he has raised, then Barry Purcell still has all of his work ahead of him.
The efforts to change the gender of youths suffering from dysphoria by using life-altering drugs and other medical interventions, represents an enormous medical scandal that has caused appalling harms to very many vulnerable children. The reasons why this scandal has persisted for so long include an environment that was created by far-left activists, who were more interested in shouting postmodernist slogans and personal abuse than objectively considering the interests of children suffering from gender dysphoria. The contribution of Barry Purcell has consisted only of such self-preening sloganeering, rather than the gown-up behaviour that vulnerable youths should expect of actual adults.