Falsification, the Cass Review, and the Postmodernisation of Science

A lesson in subverting scientific integrity to social causes.

No doubt it is a reflection of the writers and issues that I follow and pay attention to, but my inbox has been inundated with various thought pieces on the publication of the recent Cass Review in the UK, which bears the name of the paediatrician, Dr Hilary Cass, who chaired the review. Officially entitled the Independent Review of Gender Identity Services for Children and Young People, the review is the most comprehensive synthesis of the evidence, or more appropriately the lack thereof, for gender-related medical practices that fall broadly under the model of “affirmative care”. This model is characterised by the early medicalisation of children and adolescents presenting with self-reported gender dysphoria, ranging from iatrogenic puberty blockade drugs and high-dose cross-sex hormones to surgical sex-trait modification.

The drugs utilised for these ends have been repurposed off-label to their medically approved use, and are thus entirely experimental in this context, lacking any hypothesis-driven randomised controlled trials (RCTs) upon which to ground an evidence-base for their use in paediatric gender-related medical care. Irrespective of where someone stands on the social issue to which this relates, the evidential issue should have always been, even to a rudimentary first-year medical or biosciences student, obviously deficient in every way. The ultimate conclusion of the Cass Review is thus entirely unsurprising to anyone who has looked at the substandard evidence in this area, which was characterised as “remarkably weak” by the review. That is a charitable understatement; there is little long-term follow-up of patients, shoddy outcome data, little to no controlled trials, and “attempts to improve the evidence base have been thwarted by a lack of cooperation from the adult gender services.”

The propagation of the highly medicalised “affirmative care” model also has distinctly American characteristics. Even before the publication of the Cass Review, multiple European countries (Finland, Sweden, Norway, France, the UK, and the Netherlands) had, from around 2020 onwards, already conducted independent systematic reviews and concluded the evidence was insufficient to justify the model. These are all countries with varying degrees of public healthcare, and a greater duty of public care, in their medical models. America is the outlier, reflecting a combination of for-profit healthcare and the toxic polarisation of any socio-cultural topic, including gender-related issues. As a result, the overwhelming Left/liberal bias in academic institutions and media combined with opportunistic medical capitalism to create a narrative that the “affirmative care” model was “scientifically proven” and “settled science”. The lie was repeated enough until it became a post-truth. No independent systematic review of the evidence has yet been conducted in the U.S.

Most pieces I’ve read have followed a similar arc: the evidence was never there; anyone who tried to draw attention to this or raise concerns roused the fury of activists and was de-platformed, cancelled, and personally and professionally attacked; it is a travesty of the medical profession, a gross failure of the fundamental principle of “first do no harm”; a failing of ethical standards with the lack of informed consent; a failure of standards of evidence and duty of care by both institutions and individual healthcare professionals working in this area; and deeply homophobic assessments of gender-related distress, based largely on crass gendered stereotypes. All of this is spot on. Andrew Sullivan provided perhaps the most eloquent rendition of these themes. For a different, interesting perspective on some cultural drivers and the role of social media and Very Online lives, you might enjoy this piece from Alexander Beiner.

And yet something has been missing in this commentary, at least for me, as a more fundamental question: how did unproven theories and unfalsifiable assumptions derived from pseudo-academic (“something studies”) disciplines become the basis of a model of treatment within medicine? Isn’t medicine supposed to be grounded in the “evidence-based medicine” model? And isn't the very concept of “evidence-based” itself grounded in the scientific method, as a particular ontological and epistemic model of inquiry into the nature of natural phenomena and reality?

In stepping back to these first principles, we can see that the rot within gender medicine did not exist in a vacuum; it is merely the most prominent and controversial example of the postmodernisation of science.

Modern Science, Falsifiability and Transparency

An exhaustive deep dive into epistemology would be beyond the scope of this essay, so please accept the simplified cliff-notes version for the sake of a more cohesive flow. The word “science” often requires that we revisit and clarify precisely what we mean. “Science” can refer to the method of producing knowledge, grounded in a specific ontology and epistemology. It may also refer to the body of knowledge itself, i.e., published research. And it may refer to the institutions and ancillary apparatus responsible for the production and dissemination of that knowledge, e.g., universities, research institutes, and journals. For present purposes, we are primarily concerned with the method of producing knowledge, what we term “the scientific method”.

The scientific method is grounded in the ontology of realism or positivism: that there is an objective reality. The term “objective” here gets people wrapped in a philosophical knot that is as unnecessary as it is unhelpful. What “objective” means in this context is that we can verify that reality through testing, which is where the epistemology of the method enters the equation. The epistemology of the scientific method is empiricism, which holds that we can come to know the truth of reality through observation and testing. Thus, evidence is developed as knowable facts through direct observation (empiricism) and experimentation (hypothesis testing).

Combined, the ontology of positivism and the epistemology of empiricism give us the scientific method. (Note: there are two other important elements here, axiology and methodology, but we'll leave them aside for today’s central point). The scientific method is the best method we, as human beings, have developed for elucidating the truth, or proximity to truth, of a matter or question. It is not perfect, and it is not suggested to be: limitations from publication bias to industry funding or influence, to lack of adequate peer-review, to predatory journals and publishing practices, are acknowledged and widely discussed issues within science.

Recognised limitations aside, however, it is inarguably the most robust method for proposing, testing, questioning, and ultimately explaining phenomena of our existence and the wider world. The true scientific method is characterised by process: of positing a theory, forming testable predictions - a hypothesis - about that theory, experimentally testing the theory, and deriving results by which the theory may be rejected, affirmed, or modified. We then move forward with those results, updating our mental models to incorporate those findings into current knowledge, shaping new questions, and then testing them anew.

In this respect, the true scientific method is a forward-moving, iterative evolution of knowledge that brings us closer to an approximate truth. A crucial characteristic of what separates knowledge acquired through this method is that the truth of that knowledge, of the findings in a given field, is not conditional on irrelevant criteria, e.g., the sex, ethnicity, or political persuasion of the researchers. Knowledge derived from the scientific method is knowledge independent of such criteria. The Stark Effect, for example, describes the splitting of atomic spectral lines when subjected to an external electric field; Johannes Stark, the German physicist who discovered this effect in 1913, was a prominent Nazi scientist, a strong adherent to Nazi eugenics and rabid anti-Semite. Yet the Stark Effect remains because it is true independent of Stark’s reprehensible character. To use another glib truism, gravity is true whether one believes it or not; “other ways of knowing” do not change the fact of gravity.

There are three crucial characteristics of the scientific method that are often overlooked in such discussions: falsifiability, standards of proof, and transparency. Falsifiability, a concept originating with Austrian philosopher Karl Popper, holds that we must be able to disprove any theory or hypothesis. The defining feature of falsifiability is that the hypothesis or theory must be testable. The proposers of a theory or hypothesis must present predictions about their theory or model, and these predictions are what make the theory testable and, therefore, falsifiable. Falsifiability provides a minimum threshold to distinguish scientific claims, which are testable, from pseudo-scientific claims, which are either faith-based and/or untestable, and therefore unfalsifiable. A common example here would be the theory of evolution, which is a fact established through numerous lines of reproducible scientific inquiry, from creationism, which is an unfalsifiable, and therefore pseudo-scientific, faith-based premise about reality.

A testable theory or hypothesis is always open to subsequent falsification, while evidence may gather in favour of the theory/hypothesis. What evidence may be sufficient to deem a theory/hypothesis proven, or at least to obtain a degree of persuasiveness for action, is not a static concept; this is why standards of proof are important. The standard of proof denotes the evaluation of evidence relative to the “degree of necessary persuasion”¹ required to be satisfied that there is a sufficiency of evidence to support a given conclusion. All standards of proof contain a margin of uncertainty inherent in the standard being met. It is the very fact that decision-making in the real world inherently contains margins of uncertainty that give rise to the need for standards of proof in the first place. As the standard of proof increases, the probity of evidence required to meet that standard of proof increases, and the acceptable margin of uncertainty narrows. Where there are safety and ethical concerns to any given question, that uncertainty margin becomes even tighter.

Because “scientific proof” is not absolute (falsifiability), the scientific method for health and medical sciences operates within an evidential framework for establishing standards of proof. This framework, otherwise known as the “hierarchy of evidence”, provides a base point of departure from which to evaluate, synthesise, and extrapolate multiple lines of evidence. In reality, the hierarchy is not a static evaluative process, but a guiding tool to consider the persuasive power of a body of knowledge, and to consider the strength of available evidence in informing a given conclusion. Crucially, it allows for evidential blindspots to be identified. It acknowledges that every evidence base has limitations and that acting on imperfect knowledge requires that conclusions be arrived at that are sensible, safe, and have a greater likelihood of benefit than harm.

Finally, there is transparency. Transparency underpins the integrity of the entire scientific method because it provides accountability. Transparency in the methods used, in reported results, in the open scrutiny of a paper by peer reviewers, and indeed post-publication when papers are often subjected to far more scrutiny than during the peer-review process. The reason transparency is crucial is because science serves a social function; we apply scientific findings and developments in our daily lives, from technology to drugs. This reality also entails ethical implications.

From a health sciences perspective, at the core of this concept of transparency is the need to establish the safety, efficacy, and effectiveness of interventions and treatments. Establishing safety, efficacy, and effectiveness, is a quantified process: determining the independence of effects of an intervention compared to no-treatment or placebo, calculating the magnitude of the effect size for that intervention, calculating the precision of that effect estimate, i.e., the margin of error, and determining the risk of adverse effects/events. These data should be clear and transparent precisely so these criteria can be properly scrutinised.

Of course, this process is not perfect. It could never be perfect: it is a human endeavour. However, almost all criticisms of “science” are not a critique of the scientific method itself; the issues that arise almost all relate to the ancillary uses of that term, from individual scientists to institutional issues, to the mess that is the is publishing world and “publish or perish” cultures within research, to the weaponisation of science for politicised purposes, to undue influence of commercial interests. But the method itself is robust and, when adhered to, it works to improve the human condition. When adhered to, it engenders a unifying axiom of intellectual honesty and epistemic humility that binds the scientific method with the framework of evidential assessment for making sense of the knowledge derived from research.

In health and medical sciences, the social function the scientific method has served is arguably unrivalled in improving the human condition, from the eradication of many communicable diseases to eradicating diseases of nutritional deficiency to advancing our ability to treat, mitigate risk, and in some cases reverse, chronic diseases such as cardiovascular disease, type-2 diabetes, and cancers. There is almost no sound, non-ideological reason to assume, based on the success of the method, that it would not deepen our understanding of youth gender dysphoria, identify antecedents and modifiers, and yield an actionable evidence-base grounded in safety, efficacy, and effectiveness, of hypothesis-driven, tested approaches to managing and treating this vulnerable population subgroup.

So, why did that not happen?

Postmodern Science and Ideological Subversion

To grasp the postmodernisation of science, we need to understand the distinction between the ontological and epistemic basis of the scientific method with that of postmodernism. Again, for the sake of this essay this will be a cliff-notes version of postmodernism (see this previous 3am Thoughts essay for a more expansive critique). I’ve also previously written about the scourge of postmodern influence on history as an academic field. Postmodernism is a school of philosophy grounded in an entirely different ontological and epistemic universe. The ontological basis of postmodernism is idealism or subjectivism, which holds that objective reality does not exist, and reality is instead a construct of perception. The epistemology of postmodernism extends this ontology; if truth or reality is not constructed through perception and interpretation, then there is no truth or reality to be discovered. Thus, postmodernism is characterised by hyper-subjectivity in its ontology, and hyper-relativism in its epistemology.

Within postmodernism, how reality is “constructed” is crucial, and language is considered the fundamental mechanism. Any perceived reality is that created by language, which gives language a hierarchical power imposed over society as a tool of “hegemony”. “Reality”, the existence of which is denied, is merely a construction of language; there is no non-linguistic reality. Rather than focus on the discovery of truth or reality, it takes the world as we find it and instead “deconstructs” what it finds. As a result, language, both in text and in our vernacular speech, becomes the target of investigation and interpretation of the social world, but this interrogation of language never has to correspond with any reality; language only relates to other language. Hence, fields that adopt this tautological epistemic framework are reduced to language games, largely stripped of intellectual seriousness and rigour.

In the postmodern language-based mode of critique, where everything can be anything and anything can be nothing, stability in the meaning of words is lost. In the postmodernisation of science, relativity and subjectivity have been superimposed over the conduct, publication, and interpretation, of evidence. By applying relativism to evidence, postmodern science is defined by a landscape where evidence can be anything and nothing. Stability in the meaning of standards of proof and ancillary heuristics, such as the hierarchy of evidence, are lost. Unfalsifiable, faith-based premises are championed predicated on the identity-based social cause to which they relate, and transparency is flouted for a culture defined by the intellectual arrogance of “knowing”. Language supplants evidence, and “evidence” becomes whatever interpretation can be self-justified by framing the evidence around the desired ends, rather than by any rigorous examination of the standards of that evidence. And because of the primacy of hyper-subjectivity, the validity of interpretations becomes dependent on the individual’s “positionality”, rather than independent of irrelevant identity-based criteria.

The writing was on the wall in 2020 following the death of George Floyd. The issues had been present before this juncture but were largely latent, a slowly developing condition that the social convulsions that gripped America from June 2020 turned into an overt pathology. The very question of the deaths of Black men by police was one that research should have been left to answer. Data on police shootings and fatalities in the U.S. is shockingly inadequate, and a national statistics database only started being compiled in 2016 (before which the Washington Post compiled statistics from police department records). With an area of poor quality data, the analytical methods chosen by researchers, and what they chose to adjust for in a statistical model (e.g., regional differences, area population density, urban vs. rural, etc.), will influence the results. This is normal and not controversial; a culture of open science, unfettered by political constraints, would move forward in its iterative process, reconciling and resolving any methodological issues and/or discrepancies over time.

That didn’t quite happen. American liberals had formed the narrative that the unlawful deaths of Black men by police were an “epidemic”. Scientific findings were subjugated to that narrative, to the social cause to which the findings related. A paper published in 2019² serves as a good example. The study used a more refined statistical approach to predicting whether, given the race of an individual fatally shot and the race of the police officer, there was evidence of racial disparities in police shootings. The analysis found no evidence of racial disparity between Black fatalities and White police officers; rather, with increasing percentages of Black and Hispanic officers involved in a fatal shooting incident, the fatally shot individual was more likely to correspond to the race of the shooting officer.

The paper contained no methodological or statistical errors, nor was it based on fabricated data, which would warrant a retraction. The primary “error” related to their choice of language in the significance statement that accompanied the paper. The reason for retraction, made clear by the journal’s reasons for retraction, had “to do with the misinterpretation and partisan political use of a scientific article after its publication.”³ In other words, the findings were subjugated to the social cause to which the study related, and could not stand because they ran counter to the public narrative of heavy racial disparities in fatal police shootings.

Another clear indication of this culture came with a 2022 editorial published in one of the prestigious Nature family of journals, which argued that it was no longer sufficient to evaluate scientific research based on its methodology and merits.⁴ Rather, vague criteria such as “indirect harm” were invoked in favour of refusing publication of research or even rejecting a research project in the first place. To quote:

“Although the pursuit of knowledge is a fundamental public good, considerations of harm can occasionally supersede the goal of seeking or sharing new knowledge, and a decision not to undertake or not to publish a project may be warranted.”

“Harm” was given its usual nebulous scope, and because the paper made it clear that “harm” related to specific identity groups, there was little doubt as to the implication: science and the pursuit of knowledge were to be subverted an opaque but highly politicised agenda. The paper made clear that the remedy to any findings not according to a Left/liberal worldview should be censored by declining to publish, or retraction and/or amendment of already published papers. One need only imagine the reaction if a Christian conservative published an editorial calling for scientific research to be judged according to whether they caused “harm” to Christians by publishing findings in favour of safe access to legal abortions.

It would not be unreasonable to assume that an editorial, inconsequential as they are to the overall process of scientific evaluation, would have little effect. Except, the Nature Human Behaviour editorial was merely articulating a culture that had already taken hold, as the example of race and police shootings served to illustrate. However, nowhere was this culture of subjugating science to politicised ideology more apparent than in relation to gender medicine. Shaky research in favour of “affirmative care” was published in prestigious journals like The New England Journal of Medicine, while papers challenging the model, and the individual researchers behind any such research, were attacked, retracted, and vilified.

A 2021 paper⁵ by the Russian chemistry professor, Anna Krylov, highlighted the slippery slope of subjecting science to ideology, based on her experiences as a young scientist under the Soviet regime. The paper contained some examples of the postmodern language-game enveloping the pursuit of knowledge:

A comment in Nature calls for replacing the accepted technical term “quantum supremacy” by (sic) “quantum advantage”. The authors regard the English word “supremacy” as “violent” and equate its usage with promoting racism and colonialism… Remarkably, this Soviet-style ghost-chasing gains traction. In partnership with their Diversity, Equity, and Inclusion taskforce, the Information and Technology Services Department of the University of Michigan set out to purge the language within the university and without (by imposing restrictions on university vendors) from such hurtful and racist terms as “picnic”, “brown bag lunch”, “black-and-white thinking”, “master password”, “dummy variable”, “disabled system”, “grandfathered account”, “strawman argument”, and “long time no see”.

At the University of Minnesota, medical students - future doctors - adapted their graduation Hippocratic Oath ceremony to include a “pledge to honor all Indigenous ways of healing that have been historically marginalized by Western medicine.” To confirm, this is a medical school, not some random naturopathy college. Confused with the very basis of their training, the students seem to forget that if “ways of healing” were effective they would be part of “Western” medicine. Such truthy-sounding language soup may be inconsequential when confined to the pseudo-academic disciplines from which it emanates; when it is adopted as mainstream thinking within science and medicine, alarm bells should be sounding.

Those alarm bells should have sounded for paediatric gender medicine a long time before the Cass Review.

Gender Medicine as the Epitome of Postmodern Science

And so we come to the fundamental issue: how did contestable theories and unfalsifiable assumptions derived from half-baked ideas generated from fields like “gender studies” become the basis of a model of care in medicine? It is difficult to think of any other example of such disciplinary hijacking. The most immediate answer is obvious: strong advocacy from activists created an illusion of consensus in ideologically motivated organisations, such as the World Professional Association for Transgender Health (WPATH) or the Stonewall charity in the UK, aided and abetted by activist-clinicians who implemented a model of care based on ideology rather than evidence.

An article by a psychiatry student who attended a WPATH conference illustrates the frightening incuriousness and arrogance of gender clinicians and the dangers of the “affirmative care” model:

“During the Denver conference, presenters role-played how to secure informed consent for a hysterectomy and phalloplasty in the case of a schizophrenic, borderline autistic, intellectually disabled “demiboy” with a recent psychiatric hospitalisation. At no point do the role-players encounter any real barriers. Instead, they persevere. At first, the patient struggled to understand why a phalloplasty might require multiple surgeries, but then the clinicians “explained everything” and the patient understood. This is called “lean[ing] into the nuance of capacity”. The moral of this story is clear: failure to achieve informed consent is a failure on the part of the clinician, a failure of imagination and flexibility, not a recognition that some patients — whether because of age or mental illness or intellectual disability — will simply not be able to consent.”

The core theory at the heart of the “affirmative care” model is that of “innate gender identity”, knowable to the person as an inner experience and immutable in its expression. As an immutable and innate expression of gender identity, the model held that “kids know who they are”, which justified immediate affirmation and intervention. And yet this very concept of “innate gender identity” is a philosophical debate, not any hypothesis-driven model for care. It is a philosophical argument that is highly contestable, as philosophers like Kathleen Stock have addressed. More particularly for science-based medicine, it is a largely unfalsifiable faith-based premise about the nature of reality, one which only postmodern science would entertain. Even given the relatively unfalsifiable nature of the claim, there was still immediately disconfirming evidence in a paediatric context given that a vast majority of gender dysphoric youth eventually come out as same-sex attracted, thus falsifying the “innate” component of “knowing” by indicating transience in the experience.

The model was distinctly postmodern in that paediatric gender activist-clinicians deployed language (“kids know who they are” ... “innate identity” ... “science is settled”) to supplant research and invent a model of medical care based on non-existent evidence. Evidence for the use of puberty blockade drugs was replaced with a claim that such interventions were “pressing the pause button”. The treatments were “life-saving”, weaponising the threat of suicide which was simply absent from the available published research specifically addressing that outcome. Postmodern paediatric gender medicine moved to language-based modes of “constructing” its own evidential reality while “deconstructing”, usually by kicking and screaming, any disconfirming evidence. This is a field that operated, as the Cass Review makes clear, with little to no transparency, and no regard for standards of proof and evidence, no regard for consequences.

In postmodern gender medicine, language never had to correspond to evidence, only to other ends that justify the means. The entire construction of evidence was circular; the WPATH referenced the Endocrine Society and vice versa, but neither based their recommendations on actual evidence. In this regard, there was no evidential standard. With no standard, the evidential goalposts could constantly be set, moved, or taken down entirely. This is why, although this may be unintended, postmodernism engenders the opposite axiom to the scientific method; if the latter is grounded in epistemic humility and intellectual honesty, postmodernism engenders a culture of epistemic arrogance and intellectual dishonesty. In the postmodernisation of science and medicine, this manifests as a culture of incuriousness, certitude, and hubris. The Cass Review is another testament to the prevalence of these characteristics in paediatric gender medicine practitioners.

The science was never “settled”; it wasn’t even there. And evidence-based medicine was steamrolled by a cabal of moral narcissists and cavalier activist-clinicians to pursue a model of care with reckless disregard for safety, efficacy, and effectiveness of unproven, experimental treatments on a population subgroup with a disproportionate prevalence of mental health co-morbidities and, in many cases, a transient experience on the road to acceptance of same-sex attraction. At its core, it represents a regrettable example of the consequences of allowing contestable ideologies and unfalsifiable “theories” from pseudo-academic fields to be given credence within science and medicine.

One would like to think that it will serve as a warning of the perils of the postmodernisation of science, but alas, this is the cultural Zeitgeist, academia is overwhelmingly politically biased, and these “theories” will be difficult to uproot given the institutional capture by relativist and subjectivist ideologies.

1. Clermont KM, Sherwin E. A Comparative View of Standards of Proof. Am J Comp Law. 2002;50(2):243–75.

2. Johnson DJ, Tress T, Burkel N, Taylor C, Cesario J. Officer characteristics and racial disparities in fatal officer-involved shootings. Proc Natl Acad Sci U S A. 2019 Aug 6;116(32):15877-15882. Retraction in: Proc Natl Acad Sci U S A. 2020 Jul 28;117(30):18130.

3. Massey DS, Waters MC. Scientific versus public debates: A PNAS case study. Proc Natl Acad Sci U S A. 2020 Aug 4;117(31):18135-18136.

4. Science must respect the dignity and rights of all humans. Nat Hum Behav. 2022 Aug;6(8):1029-1031.

5. Krylov AI. The Peril of Politicizing Science. J Phys Chem Lett. 2021 Jun 10;12(22):5371-5376.