Has anyone read the Cass report yet?

are you connecting different things or have they literally said an double blind RCT on puberty blockers?

I'm talking about their summarisation of the evidence base, where they expressly downgraded studies due to a lack of blinding

That's as per the hierachy of evidence in medical science, no?

No. Typically where double blinded studies can't be done, researchers acknowledge that and don't try to apply it - in fact the vast majority of modern medicine doesn't have double blind rcts backing it up. Sometimes because it's grossly unethical (no one has ever said "this group will recieve the placebo heart transplant") and sometimes because it's not practical (there are no double blind trials on amputations for very obvious reasons). But, the cass review wasn't performed by honest researchers, it was a hit job which started with a conclusion and then fixed the evidence to fit that. Hence why one of the studies they promoted was the truly laughable Ruuska et al (2024) in which the researchers concluded there wasn't evidence of suicide rates being higher in gender clinic referred patients than in the general public by misapplying confounding factors (there was evidence, the disparity disappeared if you factored in referral to specialist level mental health treatment, but that's not a confounding factor, its a mediating one).

Is this reply in good faith or is your mind made up? There are some false analogies here, most medicine is not heart transplants or amputations. The hierarchy of scientific research remains what it is, not being able to be applied to certain things, even naturally, such as hormones, will also weaken the objective evidence, as much as you can get objective evidence. I'm arguing this point outside of the emotion involved, the hierarchy of evidence remains the same. But Id agree stating no research can be done/trusted is equally flawed.
I'm not entirely sure of your point with regard to specialist mental health intervention reducing suicidality in those referred to a gender clinic (who no longer require MH approval) reducing levels to those of the general population. This reads to me, but again please help my comprehension. That there may be a specialist mental health intervention required in the population studied and when given this reduces the overall suicidality to that of the general population. Co-morbidity or inherent MH difficulties?
There are many questions about the Ruuska study, not least the range of years studied which makes it look like a direct longitudinal study which is wasn't, it was registry and the follow up ranges were small. Many social aspects have changed since 1996, not least the access to specialist mental health intervention. I've seen studies quoted about suicidality that have been relied on survey data from within group data and including consideration of which would be a misrepresentation of the study. Using a likert scale and only excluding "not at all" would be quite misleading.
What did you make of the Biggs study?
Confounding and mediating variables are largely down to the direction you see them in and certainly subject to such biases especially if you want an outcome as you say. I'm not even sure that's how it was represented (Ruuska) to be honest, maybe should have conclude "alone":
"The study found that suicide among young people <23 ("youth") seeking gender services in Finland is an unusual event (0.3%, or 0.51 per 1,000 person-years). Further, in comparing gender-referred youth to a cohort of matched controls (n=16,643), the study found no convincing evidence that gender-referred youth have statistically significantly higher suicide rates as compared to the general population, after controlling for psychiatric needs.
The study also did not detect a statistically significant association between gender reassignment and the risk of suicide. The study did, however, find a statistically significant relationship between a high rate of co-occurring mental health difficulties and increased suicide.
The authors concluded that "it is of utmost importance to identify and appropriately treat mental disorders in adolescents experiencing GD [gender dysphoria] to prevent suicide, while also noting that "the risk of suicide-related to transgender identity and/or GD per se may have been overestimated."
"...the researchers found that among <23-year-olds referred to the gender clinic between 1996 and 2019, 0.3% died by suicide, corresponding to 0.51 per 1,000 person-years. While this rate was about 4 times higher than the rate observed in the population of non-gender-dysphoric peers (0.12 per 1,000 person-years), the researchers found that once specialty psychiatric visits were controlled for, the difference between suicide rates in gender-referred adolescents and the general population was no longer statistically significant."
The SEGM do refer to this too, I've no idea how the SEGM are perceived:
"Imperfect control for co-occurring mental illness. To assess the level of co-occurring psychiatric conditions, the researchers relied on the count of psychiatric visits to tertiary care. However, this approach does suffer from limitations.
While the frequency of psychiatric visits is an indicator of severe psychiatric disease (the authors explain that in Finland, only severe psychiatric illness is treated at a tertiary level), it is an imprecise measure of psychiatric morbidity. For example, 1 psychiatric hospitalization, 1 outpatient consult for severe and persistent mental illness such as schizophrenia, and 1 visit related to depression would all count as "1 visit" but would signal different levels of psychiatric needs.
At the same time, disorders such as anxiety may not be captured at all, if such less severe conditions are addressed at a lower level of care in the Finnish healthcare system. Further, while the researchers controlled for birth year, it does not appear that the number of psychiatric visits was annualized; instead, it was summed across the entire timespan. This risks underestimating the burden of psychiatric illness for most recently referred youth, who are presenting with large numbers in recent years with significant mental health comorbidities, but who have shorter psychiatric histories (fewer total visits)."
Lots of people view research with inherent biases and do not stay consistent if a pre-existing idea exists. Scrutiny is much higher for contradicting statements than agreeing. Logical consistency is quite a missing interpretation variable the more online we have become.
As I asked in the beginning, I'm not sure you wanted a dialogue, I did, I wanted a conversation, not someone's concluded opinions lens, if that makes sense?

I'm not interested in a dialogue on it, because you can't debate junk science (which the cass review is) into being good science.
The hierarchy of evidence is not always applicable! I gave you two examples, and perhaps they shouldn't have both been surgical ones, of how the "gold standard" double blind RCT is not always practical or ethical. An over instance on them is the sort of thing that would see you fail undergrad level introductions to methodology courses. But, lets go through another couple of medical examples, this time focusing on medical prescriptions. There are basically no medications prescribed to paediatric populations which have had double blinded placebo controlled RCTs done on the patient base because it's grossly unethical to perform medical studies on children, instead the drugs are studied in adult populations and prescribed off-label, with cohort studies performed instead on the population and that is perfectly legitimate. Cancer medications are rarely placebo controlled again because of the ethics, instead they're controlled against the current standard of care. A standard of care exists for gender dysphoria, blinding is not possible (the populations will become very quickly unblinded) and doing it against placebos is unethical when a standard of care exists. That's not to say you can't do RCTs on gender affirming care, they do exist but they are open-label and have the control group recieve the appropriate standard of care (e.g. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10485726/).
Controlling for psych visits is entirely improper and seeks to hide the causal pathway by pretending that it's psych visits themselves which cause suicidality in populations with mental health conditions like PTSD and Depression, and by dismissing the probability that when those who are feeling suicidal turn for help, they go to psych institutions they're already patients of. You cannot properly control for a variable that's so closely associated with your explanatory variable, that only seeks to hide the effects you're studying.
SEGM are an anti-LGBTQ+ psuedoscience network, much along the lines of the ACP. They are very much not a suitable source due to severe bias issues: https://www.splcenter.org/captain/defining-pseudoscience-network

Yes, it's an abysmal piece of scholarship that would be laughed out of any undergrad class, given it's insistence on blinded RCTs when literally any researcher knows they're not always possible or ethical, and in the case of puberty blockers/hrt are 100% impossible (the groups will become unblinded very quickly when puberty continues to progress)...
Like, when your methodology can be lampooned by an XKCD comic, you know it's bad:

It's not just the overwhelming rejection of evidence either, it's that she then makes conclusions on the basis of that lack of evidence. For the sake of argument, let's assume Cass is right that the vast majority of existing evidence is too thin and unreliable to be included. If this is the case, she should struggle to make any reliable recommendations at all. But obviously, that's not what happened. Instead, she largely substitutes biased assumptions instead.
For instance, let's take the section on social transitioning. She characterises the dispute around this accordingly:
"There are different views on the benefits versus the harms of early social transition. Some consider that it may improve mental health and social and educational participation for children experiencing gender-related distress. Others consider that a child who might have desisted at puberty is more likely to have an altered trajectory, culminating in medical intervention which will have life-long implications." (Section 12.3)
The problem here is that, while she initially talks of benefits vs harms, if you have a neutral view of transition then she hasn't actually presented any views of harms here. She's presented one line of argument that social transition is beneficial, and contrasted it against a line of argument that it is unnecessary. But unnecessary is not the same as harmful. This framing only really makes sense if you assume a view of transition as a prima facie harm.
To implicitly justify her bias against social transition, Cass argues for classifying it as an "intervention":
"Social transition may not be thought of as an intervention or treatment, because it is not something that happens in a healthcare setting and it is within the agency of an adolescent to do for themselves. However, in an NHS setting it is important to view it as an active intervention because it may have significant effects on the child or young person in terms of their psychological functioning and longer-term outcomes." (Section 12.5)
This is begging the question - Cass is basing an argument on a point that she herself acknowledges is in dispute.
But for the sake of argument, let's take her word for it and assume it is an intervention. The bigger problem is what she contrasts it against, namely implicitly describing prevention of social transition as "no intervention" (Sections 3.5 and 3.8).
It's really rather absurd to argue that parents allowing a child to dress and refer to themselves how they choose constitutes "active intervention" but psychologists actively coercively preventing them from doing this, against the child's will, constitutes "no intervention". The most generous interpretation of Cass here is that she's ignorant of what this kind of "non-intervention" treatment actually looks like in practice. For instance, let's take her main source for the argument that most gender-dysphoric children desist over the course of puberty: Kenneth Zucker (see Section 12.32). Zucker's goal was rather explicitly to prevent children from becoming trans, and his prescription was for extreme levels of parental control and prohibition of their kids - taking and disposing of their toys, controlling what kinds and even what colour of clothes they could wear, preventing them from socialising with or seeing friends. Quite frankly, Zucker's "treatment" was simply abuse.

The Observer has been a voice of reason throughout the gender wars. Here is its columnist's take on the Cass report -
https://www.theguardian.com/commentisfree/2024/apr/14/hilary-cass-review-gender-trans-young-people-children-nhs-evidence

I wasn’t expecting this from Sonia Sodha

What is your point? Sonia Sodha is a respected journalist who stands up for ethical medicine.

Is this reply in good faith or is your mind made up? There are some false analogies here, most medicine is not heart transplants or amputations. The hierarchy of scientific research remains what it is, not being able to be applied to certain things, even naturally, such as hormones, will also weaken the objective evidence, as much as you can get objective evidence. I'm arguing this point outside of the emotion involved, the hierarchy of evidence remains the same. But Id agree stating no research can be done/trusted is equally flawed.
I'm not entirely sure of your point with regard to specialist mental health intervention reducing suicidality in those referred to a gender clinic (who no longer require MH approval) reducing levels to those of the general population. This reads to me, but again please help my comprehension. That there may be a specialist mental health intervention required in the population studied and when given this reduces the overall suicidality to that of the general population. Co-morbidity or inherent MH difficulties?
There are many questions about the Ruuska study, not least the range of years studied which makes it look like a direct longitudinal study which is wasn't, it was registry and the follow up ranges were small. Many social aspects have changed since 1996, not least the access to specialist mental health intervention. I've seen studies quoted about suicidality that have been relied on survey data from within group data and including consideration of which would be a misrepresentation of the study. Using a likert scale and only excluding "not at all" would be quite misleading.
What did you make of the Biggs study?
Confounding and mediating variables are largely down to the direction you see them in and certainly subject to such biases especially if you want an outcome as you say. I'm not even sure that's how it was represented (Ruuska) to be honest, maybe should have conclude "alone":
"The study found that suicide among young people <23 ("youth") seeking gender services in Finland is an unusual event (0.3%, or 0.51 per 1,000 person-years). Further, in comparing gender-referred youth to a cohort of matched controls (n=16,643), the study found no convincing evidence that gender-referred youth have statistically significantly higher suicide rates as compared to the general population, after controlling for psychiatric needs.
The study also did not detect a statistically significant association between gender reassignment and the risk of suicide. The study did, however, find a statistically significant relationship between a high rate of co-occurring mental health difficulties and increased suicide.
The authors concluded that "it is of utmost importance to identify and appropriately treat mental disorders in adolescents experiencing GD [gender dysphoria] to prevent suicide, while also noting that "the risk of suicide-related to transgender identity and/or GD per se may have been overestimated."
"...the researchers found that among <23-year-olds referred to the gender clinic between 1996 and 2019, 0.3% died by suicide, corresponding to 0.51 per 1,000 person-years. While this rate was about 4 times higher than the rate observed in the population of non-gender-dysphoric peers (0.12 per 1,000 person-years), the researchers found that once specialty psychiatric visits were controlled for, the difference between suicide rates in gender-referred adolescents and the general population was no longer statistically significant."
The SEGM do refer to this too, I've no idea how the SEGM are perceived:
"Imperfect control for co-occurring mental illness. To assess the level of co-occurring psychiatric conditions, the researchers relied on the count of psychiatric visits to tertiary care. However, this approach does suffer from limitations.
While the frequency of psychiatric visits is an indicator of severe psychiatric disease (the authors explain that in Finland, only severe psychiatric illness is treated at a tertiary level), it is an imprecise measure of psychiatric morbidity. For example, 1 psychiatric hospitalization, 1 outpatient consult for severe and persistent mental illness such as schizophrenia, and 1 visit related to depression would all count as "1 visit" but would signal different levels of psychiatric needs.
At the same time, disorders such as anxiety may not be captured at all, if such less severe conditions are addressed at a lower level of care in the Finnish healthcare system. Further, while the researchers controlled for birth year, it does not appear that the number of psychiatric visits was annualized; instead, it was summed across the entire timespan. This risks underestimating the burden of psychiatric illness for most recently referred youth, who are presenting with large numbers in recent years with significant mental health comorbidities, but who have shorter psychiatric histories (fewer total visits)."
Lots of people view research with inherent biases and do not stay consistent if a pre-existing idea exists. Scrutiny is much higher for contradicting statements than agreeing. Logical consistency is quite a missing interpretation variable the more online we have become.
As I asked in the beginning, I'm not sure you wanted a dialogue, I did, I wanted a conversation, not someone's concluded opinions lens, if that makes sense?

I wasn’t expecting this from Sonia Sodha