Netherlands Puberty Blocker Review Comes to Opposite Conclusion, Dismisses Cass Review

Thank you. I appreciate the respectful engagement as well :).

We may disagree about the evidence, the risks and the best way forward, but I think it is important to recognise that disagreement does not necessarily come from bad intentions.
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I'm glad you watched it. Despite our viewpoints being at odds on the fundamental question about PBs (with or without CSH) vs only psychological support, I do appreciate you engaging with information being shared.

Yes, the studies were on animals. But a large amount being explained in that video is about human brain development and the critical windows within which key milestones need to happen.... or they never can.

However, there is a very important distinction between “this is an area requiring further research” and “this intervention is known to cause brain damage”.

At no point did I say that"this intervention is known to cause brain damage". I said it was likely to cause brain damage. Frankly, I'm amazed that anyone who watches that video could conclude otherwise.

The latter requires a level of evidence that currently has not been establised.

Agreed. And we're now right back at the point that we'll never agree on: whether or not it's ethical to experiment on children to gather this evidence.

Got to say watching this from the sidelines, there's a very definite set of double standards at play. And also a lot of quite detailed knowledge about the incumbent ideas of "trans" children from someone who initially didn't seem.to know much about it. Hmmmm.

It's also very noticeable how the conversation has been kept incredibly trammelled into the subjective experience of these so called "trans" children.

They "might" feel a certain way so we must treat them as if this is a known fact.

Whether what they feel has anything to do with the actual lived reality of the opposite sex is irrelevant but nevertheless we must treat them as if we believe it does and therefore the appropriate treatment is medical intervention to disrupt the natural development of their actual sex body, leading almost inevitably to further medicalisation in an attempt to visually mimic the opposite sex.

Whether what they feel has anything to do with the actual lived reality of the opposite sex is irrelevant and need not be examined but nevertheless the depth of their distress requires that we must treat them as if we believe it does and therefore the inclusion of people of one sex in the social category of the other must be acceptable as a necessary provision to relieve their subjective distress.

While the objective reality that they are not of that sex and that whatever they feel has in reality no especial commonality with the opposite sex is being paid lip service to, the impact of society appearing to condone the belief that what makes one a man or a woman is what is in ones head rather than ones body, and of the impact on women of opening up supposedly woman-only resources or legal identities to the opppsite sex is firmly out of bounds for discussion.

The experiences and statistics about detransitioners are out of date so should be ignored, but we must nevertheless proceed with damaging treatments based on anecdotal evidence that those who want them believe they will reduce distress.

What does it all add up to? While focusing on anything other than the distress of the trans person "isn't what we are talking about", the case is nevertheless being built for doing things that have far wider impacts than just the trans person. Women who try to engage are finding their focus tramelled into only one small area, and this creates the impression that this small focus is the core, most significant or only relevant concern of those women rather than being the only area in which they believe their points have any hope of being heard. So they keep trying to frame the bigger picture within the very small area of allowed topics, and as a result even their own expression of the bigger picture gets smaller and smaller, and the real spread of consequences is accidentally edited out in the hope o getting any recognition of bigger consequences at all.

It's fascinating to watch. I wonder if it's being done consciously or simply the consequence of having an incredibly narrow minded, individual focus view of trans issues rather than a societal or feminist one.

As I said in an earlier post on this thread, it's not that I haven't thought about the whys and whats and hows of trans identities' cause and development, it's that after homestly engaging with this type of thread many times trying to get a poster to place their passionate support of trans people in the wider social context and consider its impact on others as well, I realised it was really just a distraction technique.

Because whatever the reason a trans person feels as they do, the answer to supporting their distress is never to accept, or even pretend to accept, bending everyone else's sense of self and how one relates to ones own sex and the sex of others tp accomodate a distorted body image or projected ideas of what feelings belong in what body.

This is simply wrong on the biology and medicine.

Puberty is just the physical changes — bone growth, the growth spurt, secondary sex characteristics, brain maturation — that estrogen or testosterone cause in a developing body. It doesn't matter where the hormone comes from. A body given estrogen builds bone density, stops growing, and develops secondary sex characteristics through the exact same pathways it would if that estrogen came from ovaries instead of a pill. The hormone doesn't check chromosomes or birth certificate before it binds :) :) :).

Your claim that it's "impossible to go through the puberty of the opposite sex" is doing political work, not describing biology. Take the case of people with CAIS, born with XY chromosomes and testes who have them removed before puberty (once routine, due to cancer risk) and are then given estrogen externally. They go through a normal female puberty as a result — breast development, fat redistribution, bone changes, the full range of typical female pubertal hormonal effects. Of course there are still differences - they never menstruate, since CAIS also means no uterus, but otherwise it's real puberty by any physiological measure.

No one claims these women are stuck in a permanent pre-pubescent state, failed to mature into adulthood, or suffered brain damage from having their puberty driven by external rather than gonadal hormones.

That is why these decisions require individualised clinical judgement rather than assuming that one approach is inherently compassionate or harmful in every case.

I find it difficult to believe that the application of individualised clinical judgments just happens to result in the same outcome in 98% of cases tbh.

the potential need to initiate them earlier for physiological and other reasons

There is never a "need" to give opposite sex hormones to a child.

you appear to believe it's cruel not to do this. I believe it's cruel to do it. I agree that it's a good idea to leave it there, as neither of us looks likely to concede to the other's viewpoint.

Agreed. Just to quickly clarify my position - it's not that I think it's cruel to do it or not to do it. I don’t think there are simple absolutes in terms of what is or is not “cruel” in these situations.

Whether a particular pathway is preferable depends on the individual child, their circumstances, the evidence available, and a careful assessment of the potential risks and benefits of different options. That is why these decisions require individualised clinical judgement rather than assuming that one approach is inherently compassionate or harmful in every case.

Thanks for sharing the youtube clip, its really interesting.
I think there are some important points to note:

• this evidence comes from 11 animal studies. Of these, 8 were done in the same single flock of sheep . 2 were in monkeys and one was in mice
• Only one of the studies - on sheep - had any length of follow up (around 40-55 weeks follow up). The rest looked at immediate outcomes with no follow up at all. I don't think anyone has any doubt that suspending puberty has strong physiological effects while on the drug, the question is do these effects reverse after ceasing or are there long term effects.
• The presenter concludes herself - particularly given that there isn't any evidence of follow up - that the point is that we simply don't know, rather than long term cognitive impairment has been proven.

Finally, it's important to recognise that this is one expert's interpretation of a complex and contested area of medicine. It is entirely reasonable to discuss possible long term risks of puberty suppression, including questions about neurodevelopment. However, there is a very important distinction between “this is an area requiring further research” and “this intervention is known to cause brain damage”. The latter requires a level of evidence that currently has not been establised.

Ok have to get back to the day job :)

A relief or quiet joy when you are perceived, addressed, or treated as the gender you experience yourself to be. People often describe this as the clearest signal.

This is bollocks though. I loved it when people mistook me for a boy. If you're distressed about developing as a girl for all sorts of reasons of course you'll be happy if people don't notice that in you. Particularly if you for whatever reason have hung the label 'because I'm really a boy' on your distress.

No one has suggested keeping children permanently in a pre-pubescent state — I’m not sure where that idea has come from.

You did @Sunnibee

I appreciate you may not be aware that that's what you're suggesting. But that doesn't stop it being factually true that this is the outcome of PB "treatment", with or without cross-sex hormones taken subsequently. Unless PBs are stopped before puberty should naturally become starting (e.g. from the age of 8/9), there is no other outcome.

It is impossible to go through the puberty of the opposite sex. There is either puberty or no puberty.

Edited for clarity.

Talk about deliberately missing the point. In a family with two mothers, no one pretends that the "other" mum who didn't give birth literally gave birth. Everyone is open about who gave birth and who didn't. That's completely different from demanding that everyone pretends to see you as the opposite sex.

Your other false comparison of people adjusting behaviour to mental health and disability interventions is also completely different from requiring the whole of society to view trans-identified people as the opposite sex. Autism and mental health adjustments are done on a case-by-case basis among a small group around the individual. We are being asked not only to pretend that men are women, but to have men compete in women's sports, men enter women's toilets and changing rooms, lesbians being pressured to be open to dating men, etc.

At least you acknowledge that identifying as trans is a mental health issue and that men can't actually become women.

Those who progress onto cross sex hormones are still held in a prepubescent state - just with the addition of side effects from exogenous hormones. They never go through puberty. Puberty blockers have been repeatedly shown to lock children into a pathway to cross sex hormones.

Why do you think sterilising children is a good thing?

If the purpose is to pause in order for decisions to be made on whether to continue endogenous puberty, why do you believe only 2% of patients continue with that puberty? What reflection and exploration do you think takes place?

Yes, you have misunderstood. No one has suggested keeping children permanently in a pre-pubescent state — I’m not sure where that idea has come from.

The purpose of PBs is to temporarily pause the irreversible effects of endogenous puberty, giving the child and clinicians more time for reflection and exploration before a decision is made about whether to allow endogenous puberty to proceed or to consider the use of cross-sex hormones. PBs are intended as a temporary intervention and should be used for the shortest period appropriate.

The question then becomes how to balance the young person’s capacity to consent to cross-sex hormones against the potential need to initiate them earlier for physiological and other reasons.

That's certainly my understanding.

@Sunnibee You appear to believe it's cruel not to do this. I believe it's cruel to do it. I agree that it's a good idea to leave it there, as neither of us looks likely to concede to the other's viewpoint.

However, this point is worth following up:

You are also continuing to make assertions that are not evidence based - like children "will likely have brain damage due to impact of PBs" and presenting them as self evident facts.

This is a great video where Sallie Baxendale explains the impact on brain development if puberty blockers are used beyond the age at which puberty should be starting i.e. outside their purpose for treating precocious puberty:

No, she's saying that puberty is a perfectly natural, normal and healthy developmental path in human beings that occurs because its appearance and timing are hard-wired into our genetic and chromosomal blue print. It is not an additional add on; it is integral to our development as mature adults.

Suddenly thinking about the judgment of Solomon. No idea why
https://en.wikipedia.org/wiki/Judgement_of_Solomon

Posted this on the PB thread, but it might be of interest here too.

SEGM have a report on a recent Acta Paediatrica article (by a Swedish gender psychologist) which basically points out that "gender identity" and "gender incongruence" are undefined terms that shouldn't be used as a basis for medical intervention:

https://nitter.net/segm_ebm/status/2082853108648997110

https://segm.org/gender-identity-conceptual-clarity

https://onlinelibrary.wiley.com/doi/10.1111/apa.70686

Are you really saying that you think doctors keeping a child in a permanently immature state, because the pre-pubescent child thinks that is what they want, is an acceptable thing for medical professionals to do?

Once again, I really hope I have misunderstood what you're saying.

I think we have reached the point where we are repeating the same points of disagreement. Your position is that puberty is an inherent good that must be experienced; my position is that clinical decisions should be based on an assessment of evidence, benefits, risks and individual circumstances. That assessment also needs to take children’s own experiences, distress and developing capacity to participate in decisions seriously, rather than relying on a predetermined ideological position. You are also continuing to make assertions that are not evidence based - like children "will likely have brain damage due to impact of PBs" and presenting them as self evident facts.

I don’t think continuing to repeat the same points is productive, so I’ll leave it there.

Saying that every child “deserves” to go through puberty implies that experiencing those changes is inherently preferable, even when they are causing significant distress. I’m not sure how that conclusion is justified.

Yes, experiencing the result of those changes is inherently preferable. Even if getting there is distressing. Any child experiencing distress associated with going through puberty deserves therapeutic support to navigate their feelings and alleviate their distress.

I chose the word "deserve" deliberately re going through puberty because the opposite (not going through puberty) is abhorrent. Puberty blockers + cross-sex hormones does not equal puberty. It equals no puberty and a few physical facsimiles of the secondary sex characteristics of the opposite sex. It means people will look a bit like the opposite sex, will have a lifetime of medical complications to maintain this and will likely have brain damage due to impact of PBs.

Children deserve to grow up into adulthood with physically healthy brains and physically healthy bodies. The only way to achieve this is to go through puberty.

Edited for clarity.

It is preferable because it is a normal and healthy path of human development - not a pathology. The pathology is the distressed feelings.

Yes but review teams typically include both - you need subject matter expertise and methods expertise, you can't just substitute one for the other.

People can feel dysphoric about all sorts of things and also feel deeply uncomfortable with their bodies - that is what anorexia is - a form of bodily dysphoria which tends to have its roots in deeper psychological issues.

'Gender' dysphoria only exists if you are using or applying a model of 'gender' to assess why somone is feeeling distressed or dysphoric. If a very small child is firmly suggesting that they are really of the opposite sex that can only have come from people in their environment imposing or exposing them to heavily sex based stereotypes, roles, expectations or personal longings for a child of the opposite sex to the child that they have ( See 'La Petite Fille' - french documentary about a boy who thinks he's a girl - very much aided and abbetted by his mother)

This was certainly the case for the child of Susie Green - whose dysphoric feelings arose when he had his preferred 'girl toys' removed from him because his father didn't like that he wanted to play with them and not 'boys toys'.

Lots of nascently gay children tend to have preferences for cross sex 'gendered' items or for associating or identifying more with the opposite sex or for feeling alientaed from the social expectations of their own sex. And lots of other children do too.This is normal and part of the process of coming to realise what you and don't like in life.

That many young people referred to gender services have autism, depression or other co-occurring difficulties is well recognised. But comorbidity is not the same as causation. It doesn't establish that gender dysphoria is simply a manifestation of those conditions, or that treating them will resolve it.

Puberty related stress may be caused by many underlying issues, and unpacking that is the purpose of assessment. Two different children may experience this distress while the nature, focus, and underlying mechanisms of that distress differ. The fact that both are distressed doesn’t mean they are experiencing the same phenomenon or that the same intervention is appropriate. Clinical assessment isn’t just about recognising that distress exists; it’s about understanding its nature, context, and likely causes before deciding how best to respond.

I just wanted to also respond to this -

Yes. It's called puberty. Every child deserves to go through it, even if it's really difficult to get used to those changes.

That is a strange way to frame it. Saying that every child “deserves” to go through puberty implies that experiencing those changes is inherently preferable, even when they are causing significant distress. I’m not sure how that conclusion is justified. We don’t usually argue that children should endure a biological process regardless of the impact it has on their wellbeing simply because it is natural. The relevant question is not whether puberty is “deserved”, but how we respond when a child is experiencing severe distress associated with it.

Not RTFT but a point earlier in the thread about needing to be experts to carry out review ignores the fact that carrying high quality systematic reviews of evidence IS a specialism. Knowing how to assess trial quality, the impact of various biases, doing effective searches, understanding statistics and potential issues with techniques used etc etc is a specialism of its own. Clinicians often have incredibly poor understanding of all this and also lack independence and have vested interest in their own way of working. The researchers who carried out the reviews in the Cass report were highly trained specialist teams.