Care pathways of children and adolescents referred to specialist gender services: a systematic review
Jo Taylor,
Ruth Hall,
Trilby Langton
et al.
Abstract:BackgroundIncreasing numbers of children and adolescents experiencing gender dysphoria/incongruence are being referred to specialist gender services. However, little is currently known about the proportions accessing different types of care and treatment following referral.AimThis systematic review examines the range of care pathways of children/adolescents (under 18) referred to specialist gender or endocrinology services.MethodsDatabase searches were performed (April 2022), with results assessed independentl… Show more
“…Seven systematic reviews were commissioned by the Cass Report and published in the BMJ Archives of Disease in Childhood [2][3][4][5][6][7][8] with a single systematic review protocol registered in PROSPERO for all seven reviews 9 . To evaluate their risk of bias we applied the ROBIS tool 10 as recommended by Cochrane 11,12 .…”
The Cass Report aimed to provide recommendations for how services for gender diverse children and young people should be delivered in England. Our critical appraisal reveals significant methodological and conceptual flaws within the report and the research commissioned to inform the report, which included seven systematic reviews and both quantitative and qualitative primary research. Using the ROBIS tool, we identified a high risk of bias in each of the systematic reviews driven by unexplained protocol deviations, ambiguous eligibility criteria, inadequate study identification, and the failure to integrate consideration of these limitations into the conclusions derived from the evidence syntheses. We also identified potential sources of bias and unsubstantiated claims in the primary research that suggest a double standard in the quality of evidence produced for the Cass Report compared to quality appraisal in the systematic reviews. We discuss these issues in relation to how evidence regarding gender affirming care is framed, the wider political context, and the future for gender affirming care. To uphold evidence-based medicine, future gender-affirming care research must generate robust observational data, involve transgender communities, and prioritise patient-centred outcomes, ensuring validity, generalisability, and cultural relevance. The Cass Report’s recommendations, given its methodological flaws and misrepresentation of evidence, warrant critical scrutiny to ensure ethical and effective support for gender-diverse youth.
“…Seven systematic reviews were commissioned by the Cass Report and published in the BMJ Archives of Disease in Childhood [2][3][4][5][6][7][8] with a single systematic review protocol registered in PROSPERO for all seven reviews 9 . To evaluate their risk of bias we applied the ROBIS tool 10 as recommended by Cochrane 11,12 .…”
The Cass Report aimed to provide recommendations for how services for gender diverse children and young people should be delivered in England. Our critical appraisal reveals significant methodological and conceptual flaws within the report and the research commissioned to inform the report, which included seven systematic reviews and both quantitative and qualitative primary research. Using the ROBIS tool, we identified a high risk of bias in each of the systematic reviews driven by unexplained protocol deviations, ambiguous eligibility criteria, inadequate study identification, and the failure to integrate consideration of these limitations into the conclusions derived from the evidence syntheses. We also identified potential sources of bias and unsubstantiated claims in the primary research that suggest a double standard in the quality of evidence produced for the Cass Report compared to quality appraisal in the systematic reviews. We discuss these issues in relation to how evidence regarding gender affirming care is framed, the wider political context, and the future for gender affirming care. To uphold evidence-based medicine, future gender-affirming care research must generate robust observational data, involve transgender communities, and prioritise patient-centred outcomes, ensuring validity, generalisability, and cultural relevance. The Cass Report’s recommendations, given its methodological flaws and misrepresentation of evidence, warrant critical scrutiny to ensure ethical and effective support for gender-diverse youth.
Improving the evidence base for young people is an essential next step, writes Hilary Cass, as her independent review into gender identity services for children and young people is published
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