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

Psychological support is important and should be available. The difficulty is that we don't currently have a psychological or cognitive therapy that has been shown to reliably resolve gender dysphoria itself.

We do if we look beyond the dysphoria.

Similar to Dr House (Hugh Laurie's grumpy character) the simplest route to do this is to look at the symptoms and wider context, then identify and treat the most likely diagnosis. A differential diagnosis approach. House got it wrong sometimes and then moved on to the next most obvious root cause for the symptoms. Where it was unclear which was the most likely, he tried the least risky treatment first (but most of the time the show needed drama, so most of the time he was already sure his first approach was right - we can ignore that as we don't need TV drama here).

Let's take a 13 year old girl with autism, who has been bullied for being different.

Symptoms and presenting facts:

• feel upset about breasts growing. Hates how it feels having them there.
• hate periods.
• feels she doesn't have friends and doesn't fit in. Talks about feeling lonely
• doesn't feel like the rest of the girls. Not into make-up or boys
• has always hated long hair and fussy clothes because they feel uncomfortable
• has autism

First diagnosis:

Autism-related puberty distress.

Treatment:

• sports bras to hold down breasts
• mini-pill to stop periods from happening
• talking therapy to unpick feelings of loneliness, what it means to feel you don't fit in and potential trauma of being bullied
• careful listening to understand what she means by not feeling like the other girls. Careful exploration about all the different things that girls can do, including having short hair and wearing whatever clothes they feel comfortable in
• cognitive language assessment and skills building to understand perception of stereotypes and what it means to "be" a girl. Many/most autistic children have Speech and Language Therapy to support how they process information, so this fits into that standard approach

And then..... see if the dysphoria eases over time. It's not going to be a quick fix but it's a way to meet a very distressed child exactly where they are, recognise and validate the distress and take careful steps to address it. All without thinking about gender identity at all.

Note also that the proportions of these children who are over 16. Other things children can do at 16:

• consent to their own medical treatment if they meet Gillick-Fraser competence (including surgery, sexual health services, abortion, medication and others)
• Get married in Scotland (and in England and Wales before 2023)
• leave school and enter employment
• consent to adoption-related decisions;
• join the armed forces;
• open financial accounts and enter legal agreements.

the 80% is an outdated and widely challenged statistic

Do you have a source for this?

So even if your statistic was correct - 20% persist - we are not offering medical interventions to this 20%, let alone the proposed 80% who desist.

How do we know which ones will desist and which ones won't? Do you have a crystal ball?

50 years ago, transsexual children were unheard of. Given that the majority of children diagnosed with gender dysphoria are now female, where are the thousands of late-transitioning women who would have transitioned 30, 40 or 50 years ago, but didn't have the opportunity?

@Sunnibee

What makes the condition gender dysphoria is whether the distress derives from feeling like one is in the wrong sex category.

So someone can hate the shape of their genitals for many reasons - that doesn’t mean they have gender dysphoria.

Well, yes, but I was speaking from within the gender dysphoria context already.

We don't have the evidence to say what proportion of children who have gender dysphoria desist post puberty - the 80% is an outdated and widely challenged statistic. We simply don't have robust evidence from contemporary cohorts to estimate a reliable desistance rate.

We also don't have the evidence to say how many children presenting to gender clinics receive interventions. The numbers of children referred for puberty blockers even before the legal restrictions introduced in 2024 in the UK were absolutely tiny. The majority of these children were being referred to endocrinology relatively late in puberty, meaning many had already experienced a substantial proportion of pubertal development by the time puberty blockers were being considered.
Here is some data from Tavistock and Bell for GIDS.

161 children referred for puberty blockers in 2019/20:

• 10–11 years: 3
• 12 years: 13
• 13 years: 10
• 14 years: 24
• 15 years: 45
• 16 years: 51
• 17–18 years: 15

2,728 children were referred into the service the same year.

A recent GIDS/ endocrine audit found that over a 13 year period (2008-21), 1151 children were referred for cross sex hormones, that's roughly 89 per year. 166 were close to but under 16 at referral and 701 were 16 years or older.

So even if your statistic was correct - 20% persist - we are not offering medical interventions to this 20%, let alone the proposed 80% who desist.

so they no longer exist

it seems much harder to imagine a society in which being male or female carries no social meaning whatsoever

I've not seen anyone naive enough to suggest this.

Thinking aloud here, but perhaps a more helpful way of visualising this issue, which is currently being envisioned as two extremes (yours above, and references to problematic stereotypes) - may be a spectrum?

Yes, male and female bodies lead to different social roles. So at one end of the spectrum is the necessary but not sufficient (only women can give birth, but not all women give birth). Amd at the other is the imposition of oppressive and extreme stereotypes.

Where one shades into the other along a complex spectrum that we still don't fully understand - nature and nature etc. - and in any case can only ever be generalised - individuals v. society etc.) will often be subject to debate. This whole discussion is about matters of degree.

And my argument is that there is, currently, an extraordinary and destructive imbalance in this respect, in the societal construction and perception of gender dysphoria and so-called gender identity (indeed, in the very existence of the latter, posters here may argue - most of us are like, Huh? What even is that?!) That imbalance has encouraged reductive stereotyping - I think that's actually hard to argue against (ref. my Barbie > GI Joe post as one example of thousands).

So I think it's understandable that there's real focus on and concern about that in this thread, and to deny its relevance entirely, or to reduce concerns about shades of grey (I point out that even Mrs/Miss/Ms has a problematic history with associated stereotypes - they're often inextricable from your "gendered roles") to the bold above, is perhaps to simplify a more complex issue.

have you ever stopped to reflect on whether your own interpretation of these issues may be confused?

Absolutely all the time :)

About 80% of children who have gender dysphoria desist post puberty if left alone. And you think we need a more interventionist approach to, I presume, medicate more of these children who would desist if left alone?

Please tell me I've misunderstood your post.

You have a strong opinion on this subject which you are presenting as factual. You insist that trans people are confused. My question was and is - have you ever stopped to reflect on whether your own interpretation of these issues may be confused?

You have a strong opinion on this subject which you are presenting as factual. My question was and is - have you ever stopped to reflect on whether your own interpretation of these issues may be confused?

She's is no more qualified to speak especially authoratively on this than on paediatric oncology, or neurosurgery or any other specialist area of care.are prep

You on the other hand although totally unqualified are prepared to contradict the findings of her report. I know which opinion carries more weight (hint - it's not yours).

That is entirely your prerogative of course . I shan't presume or indeed try to persuade you otherwise 😅

I don't find Cass's arguments compelling and I don't think she has the relevant expertise or experience to serious engage on this issue.

I don't find your arguments compelling and I don't think you have the relevant expertise or experience to seriously engage on this issue. You are not a clinician of any sort let alone a past-president of the Royal College of Paediatrics.

I think we agree to be honest, although I think you are worried about something I'm not - which is widespread mis/ over diagnosis of gender dysphoria and an overly interventionist approach. In terms of the latter point, I think the current balance is way in the other direction.

Yes you are right, my language was really clumsy here. it was late at night and I was starting to ramble 😅.

I've tried to clarify what I've meant more precisely since.

I think the problem is that people understand 'gender'/ social gender categories/ roles as being reducible in a simple way to 'stereotypes'.
The reasoning then becomes: if someone experiences a gender that does not align with their sex, that must be because they have internalised mistaken stereotypes about what it means to be male or female. From that perspective, the solution is to challenge those stereotypes and change society so they no longer exist.

I wanted to acknowledge that there is a certain logic to the idea that, if we lived in a world without socially meaningful categories of male and female, then the experience of being in the "wrong" one might also disappear.

The difficulty is that this strikes me as utopian. We can and should challenge harmful stereotypes and reduce the extent to which people are constrained by gendered expectations. But I don't think we can eliminate the social significance of the categories themselves. They are not only collections of stereotypes; they are rooted in real biological differences that have social consequences. We can reject the idea that women should do the cooking, for example, but it seems much harder to imagine a society in which being male or female carries no social meaning whatsoever.

Indeed, if anything, current developments appear to be moving in the opposite direction. The EHRC guidance, for example, places renewed emphasis on recognising sex-based categories and organising some aspects of society around them.

Categories of male and female therefore remain socially meaningful. So too does the experience, for a minority of people, of profound distress at being somehow in the 'wrong' one - physically and socially. That is the phenomenon referred to as gender dysphoria.

As with my earlier posts, you draw some surprisingly absolutist conclusions from what I hope are rather more cautious arguments.

I'm not saying any of the below in bold (my underlining), and I do think this is clear, or at least, I hope, implied, in my posts.

This means you don't engage quite fully with the issues actually being raised.

But they don't demonstrate that gender dysphoria is simply ordinary pubertal anxiety, or that everyone presenting with it has been misdiagnosed.

Self-evidently. I acknowledge this. What I'm questioning is the societal biases meaning ordinary anxiety can be misdiagnosed, and cited evidence (Schrier) that it is being.

it does not automatically lead to medical intervention.

Self-evidently.

rather than assuming they all belong in the same category.

Exactly! I talk of subtle distinctions - cultural idiosyncrasies and the associated potential for quite genuine pathologies to be in part socially constructed, with the consequent potential for there to be some kind of symbiosis between (formal or informal) diagnosis and presentation.

I think this is so important.

The medicalisation cannot deliver the relief suggested.

Perhaps, perhaps accomodating the medicalised person as if we truly believe they are the opposite sex in all things would ... but then we run up against that annoying question of how far are we prepared to utilise women and to ignore the reasons places are single sex in the first place to support sad men?

The only reason that the "distress" of gender dysphoria is treated different to the distress of, oh let's say losing a loved one and believing you hear their voice every day, is that a still often very sexist society falsely believes that a man with surgery "might as well be" a woman, and the medical establishment has falsely believed it was good enough, or actually not quite good enough but defintely just about to make the discovery that would make it good enough, to change someone's sex.

And all this based on a "maybe" belief that there "might" be a "complex psychological" cause for gender dysphoria yet to be discovered, while happily ignoring the totally obvious point that this still doesn't actually make that person in reality any more like the opposite sex than anyone else.

And while we are counting how many complex psychological causes might be able to dance on the head of a pin and wringing our hands over whether we might somehow be being unfair to a gender dysphoric person for reasons we will only later learn, we are apparently 100% a-ok to continue to impose known harms and cause known distess to women to mitigate that "maybe" risk of regret.

It really is quite disgusting how little even women seem to value women sometimes, when their attention is being diverted to someone who really really needs that extra help.

UK society has already more-or-less decided how to accomodate trans-identified people.

Names: chose anything sensible

Pronouns: Some people may use them out of 'kindness' or to avoid confrontation, but compelled speech is not acceptable in a democracy. There may be some workplaces which will try to enforce them, but it will proabaly end in tears and cannot possibly be mandated in everyday unregulated interactions.

Toilets etc: gender neutral options and transpeople-specific options are being offered where possible. Everything set aside for women as a sex-class will mean observed-at-birth women. Woman will continue to mean adult, human female and man, adult human male. Some people may be willing to accommodate the terms transwoman and transman.

'Passing', if ever truly possible, will mean living a life where every meaningful encounter will involve wondering if you are being 'clocked' and where every sexual interaction will involve revealing one's transgender status. Many, many people will never accept that 'passing' should allow you to access facilities meant for the opposite sex, whether you went through the puberty meant for your sex or not.

Anyone who proposes to 'transition' in any way needs to be told by clinicians that this is the reality of the world in which they will be living, and to take that into account when making their decisions.

All this needs to be weighed in any consideration of the benefits and harms of a medical as opposed to a psychological treatment pathway.

I think the same may be said of the opposite approach, in the current context of affirmation (and including social affirmation as a form of clinical intervention,as Cass suggests):

administering treatment may contribute to the very issues cited as a reason not to provide it

Ultimately, if the treatment is to affirm, to the extent that's now commonly accepted (trans women ARE* *women), as a way to alleviate significant clinical distress, the outcome of the treatment can only ever be uncertain: except in the vanishingly few cases of someone passing perfectly, it will always rely on uncontrollable external factors - how others respond to the trans person.

Hence the oppressive, authoritarian pressure on society to affirm at all costs - including substantial costs to other groups.

My understanding is that a condition of medical transitioning in the past was accepting that sex-change isn't possible to mitigate this, as well as greater clinical oversight.

In losing these precautions, it feels as though we're risking creating or compounding dysphoria and associated clinical levels of distress.

If your concern is that some young people experiencing fairly typical pubertal anxiety or other psychological difficulties are being misidentified as having gender dysphoria, then I agree that is a legitimate concern. Careful assessment is essential precisely because misdiagnosis can occur.

I also accept that some people later regret treatment or conclude that transition was not right for them. Those experiences matter and should inform clinical practice. But they don't demonstrate that gender dysphoria is simply ordinary pubertal anxiety, or that everyone presenting with it has been misdiagnosed.

I don't personally share the view that gender dysphoria is routinely being diagnosed inappropriately on a large scale. I do think there has been a cultural shift, with more young people questioning and exploring their gender in diverse ways. But questioning one's gender is not the same thing as having persistent gender dysphoria, and it does not automatically lead to medical intervention.

The challenge is distinguishing as accurately as possible between young people whose distress reflects broader developmental or psychological difficulties and those with persistent gender dysphoria, rather than assuming they all belong in the same category.

In terms of not answer my question, it doesn't especially matter but it was just that when I looked at your list, the 'benefit' - "likes their body a little better - maybe" seemed so trivial compared to the harms you listed (even just those applying to adults). Even if you goals for treatment are personally realistic and achievable, these same harms remain, so I was thinking that surely there must have been something that wasn't coming across in the 'benefits' pile, that goes beyond 'likes body a little better, maybe'?

In terms of expectations, I think you're right that some trans people may have unrealistic expectations of what medical interventions can achieve. However, I think there's a tension in your argument.

On the one hand, you argue that expectations of being able to "pass" are often unrealistic. But that is, at least in part, a consequence of having undergone endogenous puberty - especially those going through male puberty who wish to pass as female. One of the principal arguments for offering puberty blockers or other early interventions is precisely that they may reduce the development of secondary sex characteristics that can later make those goals much harder to achieve.

So if the argument is that treatment should be denied because the outcomes are unlikely to meet patients' expectations, it's worth recognising that those poorer outcomes may themselves result from delaying treatment until after puberty. That creates a circular line of reasoning: delaying treatment contributes to the very limitations then cited as a reason not to provide it.

The issue with choosing medical transition as a solution is that it will be an exercise in futility for most.

No matter how well a transwoman passes they still won't be allowed to compete in women's sports, they won't be eligible for women only jobs, they still won't be able to get pregnant.

The distress will continue. Especially if expectations have not been managed.

A one fits all treatment is not appropriate.

Have you considered there may be more approaches that can be trialed and researched? Such as therapy. Would you be in favour of that?

The point isn’t that one approach is easier.

That’s precisely what you said “But changing the cognitive and psychological aspects of the mind is actually much harder and more complex than administering hormonal therapies, for example.”.

You’ve also persistently, presumably deliberately, conflated the treatment of adults and the treatment of children. You haven’t shown any objective way of determining which children have a form of gender dysphoria that would benefit from the use of puberty blockers, that would be comparable to the way their appropriateness is determined for children without dysphoria.

You’ve also ignored the fact, recorded in a previous review, that some of those children placed on the pathway you keep defending, have no diagnosis of GD.

I don't think anyone has suggested removing sex categories (unless you did).

Sunnibee did suggest something akin to removing gendered roles in response to one of my posts, appearing to think that I, or GC feminists, describing a "less gendered" world as an impossible "utopian" ideal (paraphrased). In my following post, I questioned the conflation of "less" and "utopian" - it did seem to imply total removal - and explained what I'd meant. I posted this response again just now, and am currently catching up with most of the thread so I'm on top by the time I get to any reply from Sunnibee.

I've already outlined the approach I think a thoughtful therapist should take when dealing with someone who reports 'gender distress'. It shouldn't begin with an unquestioning acceptance of that framework; it should involve a more holistic approach which allows the distress to be both acknowledged and contained and then worked with, and then hopefully resolved to a greater or lesser extent in the long run. You cannot heal 'gender distress' by confining it within gender.

Hey @Sunnibee , I see that you have not been brave enough to answer this post. @FlirtsWithRhinos is one of the most respected posters on FWR and is asking some of the most fundamental questions that you need to grapple with, if you want to be taken seriously.