2025
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Mar
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False Positive: Transphobic Regimes, Ableist Abandonment, and Evidence-Based Practice

In Brief

This paper explores the relationship between EBP as a system of knowledge governance, its implementation in library work, and the means by which librarians’ value-neutral commitments to EBP consequently serve the interests of oppressive regimes. I expand on this contention by first exploring the origination and early adoption of EBP first in medical research domains and then in policy-based decision making — not because EBP is especially constitutive of quality knowledge production, but rather because EBP is reflective of a hegemonic commitment to an ideologically positivist presumption that empirical evidence grounded in neutral, unbiased research will lead to beneficial outcomes. To the contrary, these commitments create conditions wherein EBP can be wielded by capitalist and state violence workers as a means of controlling and subjugating at-risk groups. To solidify this claim, I present two case studies. First, I focus on the use of EBP as a force for centering the “needs” of capital — especially over the needs of people with disabilities — during the COVID pandemic. Second, I analyze the means by which the Cass Review makes use of EBP in order to drive transphobic policy goals. I conclude with a call for library workers to reject the notion of neutrality entailed in EBP while instead aiming for a more robust perspective on librarianship through the lens of class liberation and solidarity.

MALONE. Me father died of starvation in Ireland in the black 47. Maybe you’ve heard of it.

VIOLET. The Famine?

MALONE. No, the starvation. When a country is full of food, and exporting it, there can be no famine.

— George Bernard Shaw, Man and Superman

Justice is always an attempt to change reality.”

— Andrea Long Chu, Freedom of Sex

Evidence-based Practice (a Short History)

For decades, librarians have relied on evidence-based practice (EBP) as a means to frame information search, retrieval, and application (Marshall, 2014; Pappas, 2008; Tsafrir & Grinberg, 1998). David Sackett established the common definition of “evidence based medicine” in 1996, being “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients” (Sackett, 1996). Sackett, William Rosenberg, Tracy Greenhalgh, Gordon Guyatt, and other early adopters framed EBM through the lens of literature review, and especially through the concept of the systematic review. For that reason, EBM was not constitutive of decision-making based on individual expertise; rather, it was built around the idea that scientific research is cumulative and therefore ought to be taken into consideration in clinical practice (Zimerman, 2013). Further, the EBM project relied on a conceptualization of evidence as that which can be separated into distinct, hierarchical categories to establish value in given medical situations (Tonelli, 1998). 

While it is beyond the scope of this paper to provide a thorough historical analysis of EBM, it is important for readers to understand that EBM did not appear from out of nowhere or even from a single person’s head. To the contrary, the process of bringing EBM to the fore was carefully constructed. As pointed out by Zimerman (2013), in order to establish EBM as an authoritative framework, Guyatt and Drummond Remmie worked together to publish a series of articles on EBM in the Journal of the American Medical Association (JAMA), the first of which would be “written by a new anonymous Evidence-Based Medicine Working Group, giving it the authority of a consensus paper” (p. 74). This JAMA collaboration and the subsequent popularization of EBM elided a vital element of EBM; there was little evidence that it worked to improve patient care, and as Norman (1999) pointed out in an examination of the assumptions inherent in EBM, the participants in the McMaster’s EBM Working Group (in which Guyatt and Sackett played a role) recognized that there was no evidence to support the idea that EBM improved care. That is not to contend that there is no evidence supporting EBM in 2025; rather, it is to point out that EBM was constructed, not because researchers determined that it was viable through scientific research, but because a group of researchers believed EBM could be viable based on inherent assumptions that they held concerning the value of research literature — especially randomized controlled trials (RCTs) and systematic reviews of RCTs (Gupta, 2003). 

At its most basic, EBP remains part of a wider healthcare infrastructure, though it has been expanded to include knowledge production across a range of disciplines. This is not because EBP is “naturally” constitutive of quality decision-making. Rather, it is due to a wider commitment to EBP, which derives from an ideologically positivist presumption that empirical evidence grounded in neutral, unbiased research will lead to beneficial outcomes. In the health sciences and informatics landscapes, this commitment is both supported and reinforced through multi-billion dollar research and literature apparatuses which have a vested, economic interest in ensuring that the EBP project withstands critique. And yet, EBP is value laden. It is deployed to maximize profit in the interests of capital through increasingly extractive means. In the following sections, I expand on this critique, opening EPB up as a site of oppression and contestation within librarianship and the greater sphere of knowledge production. For library workers, this entails a reappraisal of EBP as unbiased or neutral and a rejection of positivist assumptions that EBP (or scholarly research in general) “occurs” absent political and economic intervention.

Challenging EBP

Opening this section, it is worth noting that EBP has its uses but for librarians and other knowledge workers who must make value judgments concerning the quality of evidence, EBP cannot serve as a sole (or even primary) method for framing information search and delivery, selection and deselection, information literacy instruction, or any other form of library praxis. Moving forward, I lay out this argument by focusing on the process of “policy-based evidence-making” as constituted in the COVID-19 pandemic and the recent publication of a transphobic medical report which closely adheres to an EBP framing and which uses EBP as a means of rationalizing state violence against transgender people in the UK. Taken together, these two cases exemplify the means by which so-called evidence is produced, not to advance scientific understanding, but to empower oppressive regimes while further enabling the flow of capital within their ranks.

The COVID Pandemic (Wherein We Have Learned Nothing)

The COVID-19 pandemic has generated concerns among some policy experts as to the reliability of EBP when dealing with emergent crises (Greenhalgh et al., 2022; Murad & Saadi, 2022). As Paul et al. (2024) points out, epidemiological responses to the COVID pandemic perpetuated a simplistic overreliance on EBP and a “follow the science” mentality to public health messaging. For instance, U.S. state apparatuses consistently failed to establish or enforce mask mandates. A lack of randomized controlled trials (RCTs) led spokespersons from the CDC to discourage the use of medical-grade face masks, ignoring mechanistic evidence supporting masking as a preventative measure (Greenhalgh et al., 2022). Likewise, rhetoric couched in the EBP framework has been consistently deployed to shift COVID protections away from large-scale interventions such as federal mandates that require workplaces to compensate workers for imposed self-isolation. Instead, individual approaches reliant on accessing vaccines and “protecting one’s own health” rapidly coalesced into a so-called post-COVID environment in the U.S. that has seen: 

  • a dramatic weakening in federal guidelines to prevent COVID transmission,
  • insurance companies and federal institutions scrapping free vaccines, testing sites, and at-home tests for uninsured people, 
  • emerging bills that seek to outlaw masking in public spaces,
  • laws that prevent or mitigate the executive ability to declare public health emergencies (Karlis, 2024; Pitzl, 2022; Planas, 2024; Santhanam, 2024).

These measures are constitutive of a process which Boden and Epstein have termed “policy-based evidence-making,” in which policy directives dictate what and which evidence is considered as well as the rhetorical moves that deploy “evidence-based” language in order to rationalize the production of said policy (2006). Such moves in evidence-making are constitutive of a necropolitics that justifies debilitation and subjugation of people at-risk of COVID-based job loss, poverty, homelessness, and mortality (Núñez-Parra et al., 2021). As pointed out by Baer, these moves have implications for librarians, which are at least alienating and at worst, violent and ableist (2023). 

Baer makes the argument that critical information literacy provides a framework for assessing dominant COVID ideologies (2023). Combining her critique with a Marxist analysis of material conditions related to the “post”-COVID political landscape, we can ascertain the remarkable speed at which economic factors have overridden the necessities of public health. In fact, we quickly realize that economic forces governed every aspect of pandemic health, even from the beginning. For instance, within just four days of Texas governor Greg Abbott’s order to “shut-down” most indoor economic activity in 2020, Texas Lieutenant Governor Dan Patrick made the argument on Fox News that “grandparents” like himself ought to be willing to sacrifice their own health and well-being for the sake of the economy (Livingston, 2020). While Patrick’s words may stand out for their blunt cynicism, they are reflective of the ultimate direction taken across the US to protect economic interests over the lives of at-risk people. In fact, Patrick’s argument that the elderly and disabled1 fall on the sword of COVID expresses the internal logic of COVID hegemony and by extension, “extractive abandonment.”

Abandonment

Borrowing from the framework developed by disability rights activists, Adler-Bolton and Vierkant (2022), I deploy the term “extractive abandonment” to indicate the rationale provided within capitalism to produce able-bodied workers while: a) sidelining as “surplus” those debilitated or disabled bodies who can no longer work (or, due to bureaucratic constraints, are not allowed to work), and b) by extracting profit from disabled or medicalized bodies, thereby profiting from their “very flesh and blood” (np, 2021). Pandemics constitute both crises and opportunities for capital to assert itself through extractive abandonment. On the one hand, a pandemic creates newly disabled bodies primed for reification and resource extraction. Additionally, it coaxes the fear of disability and abnormality2 among nondisabled, bourgeois classes to the extent that members of said classes are reconstituted into consumers who can spend capital on products that stave off or mitigate fears of disability and mortality (i.e.: everything from homeopathic therapies to work-from-home offices to easy access to Paxlovid, in the case of COVID). Meanwhile, the disabled and the debilitated are forcefully emptied of resource value and as a result, primed for abandonment by state apparatuses. In the end, experiences of debilitation are minimized or treated as outliers for the purpose of returning social and economic structures to business-as-usual. 

These extractive processes are crystalized in Lt. Governor Patrick’s suggestion that the elderly and the disabled sacrifice themselves for the economy. Again, Patrick was not alone in this sentiment. Ultimately, his directive became the universal clarion call of American neoliberal order. And while COVID remains a deadly health crisis, one might argue that most (privileged, nondisabled) people no longer express widespread fear about the disabling potential of COVID. To the contrary, what they now fear to a far greater extent is the loss of normalcy which COVID entails. To once again echo Adler-Bolton, “the sociological production of the end of the pandemic” has required the displacement of fear, not in such a way as to protect disabled and debilitated people, but instead to protect neoliberal economic order and to preserve the illusion that everything is back to normal (Adler-Bolton & Vierkant, 2023). 

EBP has played an integral role in the sociological realignment of society under the COVID pandemic. Most evidently, the rhetoric of EBP was reified for the purpose of enhancing capitalist order both during and “after” the pandemic. Whereas critical analysis might lead us to presume that EBP offers a way out of the processes leading to abandonment, the hegemonic administrative state embodied by public entities like the NIH and CDC working alongside private industrial giants like Pfizer and Kaiser Permanente and consent manufacturers (or, propagandists) in mainstream media, served to establish the grounds by which pandemic-era EBP could even be understood (Herman & Chomsky, 2010). 

Through the looking glass of the COVID pandemic, we begin to ascertain how EBP is used, not only in overly simplistic terms like “follow the science” but also as a system which provides a rationale for given decisions, supported by evidence or not. Research from Stanford-based epidemiologist John Ioannidis provides a useful example. At the onset of the COVID pandemic, Ioannidis was critical of “extreme” lockdown measures, which he called a “nuclear option” akin to “a drug with dangerous side effects” (Saurabh, 2020). Ioannidis further argued that COVID-based fatality rates were over-inflated, with COVID killing a “mere” 0.5 – 0.9% of people infected (Saurabh, 2020).3 That would equate to 1,000,000 – 5,000,000 deaths in the US alone, a number that Ionnidis presumably believed to be worth sacrificing for the sake of a return to “normalcy.” At the time, Ioannidis was lauded by rightwing media for his perspective (Saurabh, 2020). In 2022, Ioannidis helped construct the widely held notion that COVID’s “endemicity” (its consistent presence in human populations) was an inevitability (Ioannidis, 2022). In the same paper, Ioannidis notes that the risk of being harmed by COVID was “very small by the end of 2021” and “grossly overestimated” by members of the general public (Ioannidis, 2022). Ioannidis rationalized this perspective elsewhere by constructing a binary between elderly/disabled people (already primed for extraction and abandonment) and so-called healthy members of society (who, being debilitated by COVID, serve as new resources for extraction) (Pezzullo et al., 2023). Ioaniddis’ claims may have been perceived as outliers by policy makers at one time. However, as time has passed, his research on COVID as well as his theory-crafting around COVID measures have been adopted in neoliberal responses to “ending” the pandemic.

Under the logic of American neoliberalism, frameworks like EBP were only ever going to be deployed to the extent that a crisis of capital could be prevented or mitigated (Hill, 2022; Li, 2023). Looking beyond COVID, there is no arguable incentive (under capitalist order) to use EBP-focused preventative measures to prepare for a future pandemic as “there’s no profit in preventing a future catastrophe” (Li, 2023, p. 99). To the contrary, there is the possibility of immense profit arising in the moment of crisis itself, as evidenced by Pfizer Inc.’s share prices reaching record highs upon the release of the initial Pfizer-BioNTech vaccine (Krauskopf & Carew, 2021). Even still, some might ask whether we have not learned anything, and if so, maybe the next time will be better? To answer this question, we need only look 40-odd years into the past. As Adler-Bolton and Vierkant point out, “while it may be tempting to say that we have ‘learned from the pandemic,’ it is clear that none of its lessons were previously unknown, and we are unconvinced that any such learning has taken place. Just ask anyone who lived through the dawn of the ongoing AIDS crisis [emphasis added]” (2022, p. xv).

In light of the economic consensus that developed around COVID, we can ascertain that EBP does not (always) serve the function of finding out “truth” or “fact;” instead, it becomes a naturalizing force for hegemonic displays of acceptable truth, what Foucault calls a “truth regime” (2012). In this context, EBP takes on the shape of a weapon, one which can be explicitly and implicitly wielded to assert dominance over oppressed classes. For critical librarians, it is vital that we reorient ourselves to this framing of EBP, not only because it is worth understanding how truth regimes are constructed, but also because the positivist overreliance on EBP prevents us from considering other epistemic possibilities which bear the potential to disrupt oppressive regimes. 

In the remainder of this essay, I focus on one such case, the Cass Review, in which EBP is weaponized for the purpose of subjugating transgender and nonbinary (from here on, trans) people. By analyzing the Cass Review, we develop a more cohesive understanding of EBP as a site of contestation which is capable of reproducing the violence in oppressive truth regimes. In doing so, we also hone our capacity for declaring which epistemic forms we consider to be authoritative in the context of health science librarianship and librarianship in general.

The Cass Review (Or, Violence-Based Evidence Making)

Prior to outlining the Cass Review, I want to emphasize that it is an explicitly political project (while keeping in mind that mine is an explicitly political project as well). The politics of the Cass Review are not made immediately evident, yet they are core to understanding how the author, Dr. Hilary Cass, makes use of EBP to wedge transphobic propaganda into scholarly literature as an exercise in “evidence-making,” and as a result, wraps transphobic values into health policy and practice guidelines. 

It is also important to note that the UK (home of the Cass Review) has an extended and violent history oppressing trans people. Historian Jules Gill-Peterson has traced transphobic policy in the British empire as far back as 1852, when colonizers in India established “trans panic” as a legible rationale for the subjugation and elimination of people deemed to be trans (2024). In more recent history, the UK has restricted transgender pediatric care to a single NHS funded program (Horton, 2024). Founded in 1989, Gender Identity Development Service (GIDS) was the sole public provider of gender affirming healthcare for British youth and adolescents; however, starting with a 2020 legal case, the NHS barred dissemination of puberty blockers by GIDS and commissioned Dr. Hilary Cass to undertake a systematic review of gender affirming healthcare, with the goal of guiding NHS policy. In the years since, Britain has increasingly developed into a breeding ground and focal point for transphobic ideology, much of which is directed at trans children (Horton, 2024). As reported by Woods and Haug (2024), a 2022 “Interim Report” by Hilary Cass was used as a rationale by the NHS to shut down GIDS in 2023. Prior to the GIDS closure, NHS indicated that GIDS was overwhelmed by demand, and to help relieve pressure, it was ending services and instead would open satellite clinics across the UK (Hunte, 2023). 

From a critical perspective, it is worth asking how exactly closing a clinic would help to decrease demand. However, in 2023, Vice reporter Ben Hunte received whistleblower documents from GIDS personnel who feared that opening new clinics in time would be functionally impossible. At the same time, an open letter was published by GIDS staff indicating that NHS statements about GIDS expansion were “misleading” (Ali, 2023). Ultimately, GIDS was shuttered in Spring 2023, and no NHS-funded alternative was made immediately available to trans people (some of whom had been waiting upwards of seven years for access to gender affirming care) (Bullock, 2023). 

One year later, in April 2024, Hilary Cass released “The Final Report” alongside the complete Cass Review. The resulting fallout has been absolutely devastating to trans people in Britain and has repercussions for trans liberation on a global scale, serving as a blueprint for policy-based evidence-making elsewhere. In short, Cass:

  • concludes that clinicians over rely on puberty blockers (p. 31), 
  • makes the genuinely baffling claim that because children who take puberty blockers tend to eventually undergo hormone replacement (suggesting that they persistently insist on their being trans), puberty blockers should therefore be administered with caution on the basis that they “may change the trajectory of psychosexual and gender identity development” (p. 32),
  • contributes to spurious arguments that gender incongruence has a causative relationship with autism (p. 29), 
  • hints at withholding medical transition-related care in favor of nebulous “psychological interventions” (even as the report also indicates there is no evidence that “psychological interventions” relieve dysphoria) (p. 30),
  • recommends that hormone replacement therapy be withheld from transgender youth prior to the age of 18 (p. 34),
  • calls attention to and recommends against the use of “private provision” of gender affirming healthcare within and outside the UK (p. 43).

It is tempting to provide the trite argument that these recommendations and findings are in direct contradiction with evidence-based guidelines published by organizations like the World Professional Association for Transgender Health (WPATH), the U.S. Professional Association for Transgender Health (USPATH), the American Academy of Pediatrics (AAP), and The Endocrine Society, all of which have released statements either rebutting or rejecting the recommendations made by the Cass Review (Endocrine Society, 2024; Hoffman, 2024; WPATH & USPATH, 2024). However, I will argue that a retreat to “EBP” serves to sustain the illusion that documents like the Cass Review are “part” of a scientific process of discovery leading to “truth.” On the other hand, the Cass Review is itself a vital reminder that EBP should be understood as a tool which gets deployed to lend credibility to oppressive policy-making endeavors in the service of extractive abandonment. It is nothing short of the chisel with which a violently anti-trans truth and profit regime is being sculpted.

And to be clear, the Cass Review is making “truth” in order to both make oppressive policy and construct a means for the reification and capitalist extraction of trans bodies within medical apparatuses. Upon publication of “The Final Report,” anti-trans groups immediately lauded Cass’s work, with accolades coming from the Alliance Defending Freedom, Genspect, and the Society for Evidence-Based Gender Medicine (SEGM) (Alliance Defending Freedom, 2024; Genspect, 2024; SEGM, 2024). That groups such as these, which openly advocate anti-trans policies, would immediately support findings in the Cass Review indicates (at the very least) that the Cass Review provides an evidentiary rationale for their own political goals (SPLC, 2023). Similar connections have been drawn to the supposedly neutral and objective reporting of the New York Times, which is consistently cited by politicians seeking to enact transphobic legislation (Walker et al., 2023). This in mind, it is notable that following publication of the Cass Review, the NYT published an interview with Dr. Cass in which she was given permission to perpetuate myths about trans neurodivergence, a lack of “quality” research concerning trans healthcare, panics around detransition, and conspiratorial beliefs that the AAP is being pressured to promote gender affirming care under “political duress” (Ghorayshi, 2024). The AAP’s response to Cass’ accusations was limited to the bottom of the NYT “Letter to the Editor” page, and no correction was made to indicate that such a response had been received (Reed, 2024).

It is unsurprising that the NYT would platform Dr. Cass and the Cass Review. The NYT has been widely accused of transphobic journalism and editorial practice (Factora, 2023; McMenamin, 2022; Reed, 2024; Romano, 2023; Walker et al., 2023). However, this is also because the NYT is one part of a greater media apparatus that has engaged in a near-totalizing exercise to sociologically produce a consensus around the Cass Review, uncritically treating it as the product of exemplary research. Unsurprisingly, UK and UK-adjacent media including the BBC, The Guardian, and The Telegraph have applauded the Cass Review (Cumming, 2024; Gregory et al., 2024; Parry & Pym, 2024). Meanwhile, in the US, The Washington Post has platformed Paul Garcia-Ryan of Therapy First to gush over the Cass Review. Therapy First rejects gender affirming care in favor of an undefined “psychotherapeutic” approach that veers suspiciously close to aspects of conversion therapy (Garcia-Ryan, 2024). 

In a NPR interview with Meghna Chakrabarti, Cass again perpetuated the moral panic over social contagion while also suggesting that trans “happiness” should be assessed based on job retention and “getting out of the house” (Chakrabarti, 2024; Reed, 2024). Chakrabarti did not push back on Cass’s claims. Finally, writing for The Atlantic, Helen Lewis made the argument that American medical groups like the AAP are being left behind by rejecting the findings of the Cass Review (Lewis, 2024). Lewis contends that “the intense polarization of the past few years around gender appears to be receding in Britain,” unlike in the US. This statement is a sublime example of evidence-making, as it is not indicative of scientific consensus; rather, it may very well be due to the fact that transphobic ideology is now constitutive of acceptable knowledge production in the UK (Horton, 2024). Assumedly, such hegemonic dominance is pleasing to Lewis, who has been accused of pushing for trans-eliminationist policies since at least 2019 (Wang, 2019). 

Aside from mainstream media, the Cass Review is being piped into scholarly publishing as well. Less than a week after Cass published her report, the British Medical Journal (BMJ) included the following articles in Volume 385, Issue 8424:

  • “The Cass review: an opportunity to unite behind evidence informed care in gender medicine;”
  • “Guidelines on gender related treatment flouted standards and overlooked poor evidence, finds Cass review;”
  • “Gender medicine for children and young people is built on shaky foundations. Here is how we strengthen services;”
  • “‘Medication is binary, but gender expressions are often not’–The Hilary Cass interview.”

In addition to the above articles, BMJ also published an internally funded feature article (labeled a BMJ Investigation) written by an embedded reporter with anti-trans group Genspect (James, 2023), accusing the American Psychological Association, the American Psychiatric Association, and the American College of Obstetricians and Gynecologists of capitulating to the “affirmative model” (Block, 2024). Ironically, Block accuses American news media of being “hesitant” to engage with (and assumedly validate) the Cass Review. Her source for this supposed hesitance is Jesse Singal, who is widely considered to have created the blueprint for anti-trans activism today (Jesse Singal, 2023).

Of all the aforementioned attempts at evidence-making, Block’s BMJ article goes the furthest in leveraging EBP to make authoritative claims. She contends that trans activists are engaging in a mass silencing campaign that ignores a “growing list of systematic reviews” which challenge gender-affirming care. Block does not clarify that these reviews were all six commissioned for the Cass Review. Further, Block suggests that legitimate critiques of the Cass Review’s research methods from trans journalist Erin Reed are “misinformation.” In an interview with BBC Channel 4, Cass also expressed that said criticism was misinformed (Mackintosh, 2024).

However, a careful review of the material shows that Reed was correct: above all else, the Cass teams disregarded evidence supporting trans care. They did so by starting their research from the position that trans care is a problem which must be solved in the first place. That is, the questions asked by the Cass Review teams were the wrong questions4, and the decision to perform benefit/risk analysis was the wrong decision. They started from the logic of a pandemic, expressed in the fear of  a “social contagion” capable of upending cisgender supremacy, and in so doing, they created the conditions to make evidence that would assert a position of cis-supremacy (Horton, 2024).

Cis- normativity and supremacy (a systematic review)

There are six Cass-commissioned systematic reviews which partially inform the conclusions and recommendations in the Cass Review. 

TitleResearch question (summarized)Presumptions
Characteristics of children and adolescents referred to specialist gender services: A systematic review. Archives of Disease in Childhood.Understand the etiology of trans identities, with focus on children and adolescents presenting for gender affirming health services.– etiological questions about trans identity reduce transness into something which “happens” to a person;
– operates from a perspective of “social contagion,” a phenomenon which is unsubstantiated and without scientific merit.
Impact of social transition in relation to gender for children and adolescents: A systematic review. Archives of Disease in Childhood.How does social transition impact or alter development and perspectives of gender identity in children and adolescents?– transgender children experience the social components of their gender identity in a way that is somehow different from cisgender peers, and in a way that is explicitly connected to medicalization;
– assumes that questions about social transition belong in a series of reviews focused on medical aspects of transgender health;
– assumes clinical authority should express power over aspects of social transition.
Psychosocial support interventions for children and adolescents experiencing gender dysphoria or incongruence: A systematic review. Archives of Disease in Childhood. What psychological supports are provided to children / adolescents experiencing gender dysphoria?– relies on a rigid EBP framework that denigrates included studies as low quality and therefore inconclusive.
– hints at (but does not explicitly state) the possibility that gender-affirming interventions might not be the “most suitable” option.
Interventions to suppress puberty in adolescents experiencing gender dysphoria or incongruence: A systematic review. Archives of Disease in Childhood.Understand the quality of studies focusing on pubertal suppression (puberty blockers).– over-reliance on strict criteria for determining quality (see McNamara et al, 2024);
– makes conclusions about risks but refuses to assert conclusions concerning benefits of care.
Masculinising and feminising hormone interventions for adolescents experiencing gender dysphoria or incongruence: A systematic review. Archives of Disease in Childhood.Assess the outcomes of hormone replacement therapies for transgender adolescents.– relies on a rigid EBP framework that denigrates included studies as low quality and therefore inconclusive;
– describes positive health outcomes based on “moderate-quality” evidence but writes it off as inconclusive;
– relies on a framing of harm/risk that does not incorporate the harms or risks of being denied care.
Care pathways of children and adolescents referred to specialist gender services: A systematic review. Archives of Disease in Childhood. Understand how children and adolescents continue or opt out of transition-related care over time.– positions “detransition” as a widespread medical problem without supporting evidence;- transgender people should be bound to clinical systems into adulthood in order to continue receiving care;
– presumes that young people choosing to opt out of care is indicative of detransition;
– presumes that detransition occurs because one stops identifying as trans rather than occurring for other reasons, primarily social stigma or lack of access to care (see Turban et al, 2021).

Reject the truth (regime)

Once more, recall Foucault’s “truth regime,” and recognize that “regime” is the necessary word to describe the Cass Review. Putting it bluntly, Cass, alongside cisnormative media and research apparatuses, is in the process of producing a regime which controls the bounds of “trans truth.” As evidenced by the findings of her systematic review teams and the recommendations in her “final report,” transness5 is reduced to the domain of the medical. To be trans is to be pathologized and to be irrevocably linked to a medical industrial complex that profits from trans needs and desire and which locks the means of trans abolition behind a process of gatekeeping overseen by clinicians, therapists, insurance providers, public health administrators, and (increasingly) legislators. Cass is at the forefront of a project that (at its most benign) seeks to return us to a historical context in which the trans capacity to live and thrive was placed under the punitive and disciplinary gaze of the clinic. In this future, “trans truth” is limited to the logic of the economy, such that the “very flesh and blood” of trans bodies is increasingly commodified in the service of extractive abandonment. Barring that, at its most terrifying, this is a project that would seek to eliminate us entirely.

Elimination is not an impossibility. 

One month after the Cass Review’s publication, the UK Conservative Secretary of State for Health and Social Care, Victoria Mary Atkins, outlawed the use of puberty blockers by trans children in the UK (Reed, 2024). At the same time, families with trans kids were sent notices that procuring puberty blockers through international or private means might constitute grounds for “safeguarding referrals” (Wareham, 2024). The Cass Review was directly mentioned in the rationale for criminalization (Reed, 2024). This is the reality of policy-based evidence-making.

While it is tempting to retreat to EBP, debunk the Cass Review for what it gets wrong, and argue that one only needs to “follow the science” to validate the lived realities of trans people, this constitutes a misunderstanding. This is not to say that scientific inquiry is invalid. Rather, the grounds for rejecting the appeals in documents like the Cass Review need not be made in the language of EBP. If trans people must always provide a medical and scientific rationale for trans existence, then trans existence will always function as a medical and scientific question to be answered, not by trans people, but by those who seek to outline the parameters of gender and sex variance in order to further subjugate those who they deem to be variant. 

EBP protects and uplifts “evidence neutrality,” but as with “journalist neutrality,” and as with “library neutrality,” the retreat to what is neutral will inevitably re/produce class dominance among the normative and the naturalized. Likewise, within a political and economic context that exists to serve capitalist interests, EBP eventually succumbs to the logic of capital. As it is with those who experience disability, poverty, and debility in relation to COVID, so it is with the “social contagion” that is transness. The fear therein, which facilitates a desire to eradicate the so-called disease enfeebling the body-economic: that is the condition of illness that we face. And these are the stakes for library workers who would create new pedagogies, policies, and potential for mediating “health” and “care” against the grain of EBP and how it gets used in the inevitable, sociological production of harm.

Acknowledgements

The author extends her gratitude to her external reviewer, Sam Popowich, for his insight and attention to a holistic critique of the subject matter. The author also wishes to thank the internal reviewers and editorial team at In The Library With The Lead Pipe, whose assistance throughout this process has been invaluable as well as deeply insightful: Jessica Schomberg, Brea McQueen, and Jaena Rae Cabrera.

Works Cited

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Adler-Bolton, B. (2024). Policy-Based Evidence Making w/ Jane Thomason (3/14/24). https://www.deathpanel.net/transcripts/nnu-hicpac-3

Adler-Bolton, B., & Vierkant, A. (2022). Health communism: A surplus manifesto. Verso.

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Endnotes

  1. In this essay, I use pathologizing terminology (ie: “disabled,” “medicalized,” “pathologized,” “debilitated”). As somebody who has experienced both temporary and permanent disability, this is not a commentary on people who live with disabilities or debilitation; rather, it is meant to signify the means by which capitalism produces the conditions for debilitation to occur, actively “disables” those who are forced to work under capitalist hegemony, and profits from the commodification of disability. In short, we are not defined by disability, but it is capital which disables us. ↩︎
  2. By “abnormal,” I do not mean abnormality in people. Instead, I am calling attention to the “abnormal conditions” which arise in moments of crisis. Systems of capital produce the rationale for abnormality to return to “normalcy.” ↩︎
  3. As of March 2023, Johns Hopkins Coronavirus Resource Center predicted that the US infection fatality was 1.1% (Mortality Analyses, n.d.). Ironically, Johns Hopkins decision to stop collecting and publishing fatality data in March 2023 is indicative of the universalizing, economic disinterest towards continuing to investigate and mitigate COVID in the wider population. ↩︎
  4. What are the “right questions”? Ideally, the right questions center the intersecting plights of all trans people by establishing directives for research that hones in on issues such as: 
    – what are barriers to trans-affirming healthcare for children and adults?
    – how do practices of medical, psychological, and legal gatekeeping impact the health and wellbeing of trans children and adults?
    – how do social conditions give rise to expressions of desistance and detransition over time?
    – how do social disparities related to determinants such as housing, joblessness, legal documentation, policing, and education contribute to the overall health and wellbeing of trans children and adults? ↩︎
  5. I do not use the term “transness” to imply that there is any “essential” characteristic of being trans. To the contrary, “transness” indicates the multiplicity of political, social, rhetorical, and performative projects undertaken by all trans and nonbinary people. ↩︎
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