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

There's an obvious Catch-22 in using medics who prescribe PBs to run a review.

Suppose for the sake of argument there is insufficient evidence of benefit for such a serious intervention. Medics who are neutral and have made some attempt to look at the evidence are not going to be prescribing. By construction, anyone who is prescribing is not neutral and therefore not suitable to run the review.

On the other hand if you only use medics who work with gender confused kids and refuse to prescribe PBs, you will be accused of bias in the other direction by applying exactly the same argument in reverse. (Can you imagine?)

And if you include both, which might be appropriate for a less polarising treatment, on this particular topic you'll have a bunfight not a review.

So by far the best course is to use a team with expertise in general paediatrics and in running reviews.

I think the reason people are so opposed to these types of therapies is that they don’t seem to work and can be really distressing for the person if they’re being told they need to change when they can’t. But if there were some sort of therapy that genuinely alleviated the distress of gender dysphoria without coercion or harm, that would be a wonderful thing. Not because there’s anything inherently wrong with being trans, but because it would give people another option for reducing distress without the need for more invasive approaches.

I think the reason people are so opposed to these types of therapies is that they don’t seem to work and can be really distressing for the person if they’re being told they need to change when they can’t. But if there were some sort of therapy that genuinely alleviated the distress of gender dysphoria without coercion or harm, that would be a wonderful thing. Not because there’s anything inherently wrong with being trans, but because it would give people another option for reducing distress without the need for more invasive approaches.

(Sorry, got distracted.)

Thank you for answering! I asked because I wanted to have an idea of where you stand on the matter of treatments for gender dysphoria, if you're the hardline type who accepts only medical transition, or if you're open to other possibilities.

I'll confess I'm quite surprised by your answer, though. I wasn't expecting it, since proposing any kind of talking therapy to reconcile trans people to their bodies is considered "conversion therapy" by many TRAs. Even just suggesting that kids be pushed to investigate their gender dysphoria before being put on a hormonal prescription, is decried as abusive and harmful. So, yeah, surprised, I'll admit.

yes absolutely. But only on the basis of informed patient consent of course. Why wouldn't I? Having gender dysphoria can be so distressing and painful; if there were a way to "cure" gender dysphoria without the need for invasive medical interventions I'm sure that would be transformative for many people.

yes absolutely. But only on the basis of informed patient consent of course. Why wouldn't I? Having gender dysphoria can be so distressing and painful; if there were a way to "cure" gender dysphoria without the need for invasive medical interventions I'm sure that would be transformative for many people.

In any other area of medicine we’d expect those leading a major evidence review to have deep knowledge of the field they’re evaluating, while managing conflicts of interest transparently. Excluding specialists from leadership because they have relevant experience risks losing the contextual understanding needed to interpret the evidence accurately and meaningfully. And that was exactly the problem with the Cass review which makes it so poor. A review cannot adequately assess a complex specialist field without leaders who understand that field in depth.

I wonder, @Sunnibee : if a talking therapy appeared, which managed to reconcile trans people with their body in their birth sex in a matter of months, without any need for hormones or surgeries, would you support it? Why or why not?

They consulted experts in an advisory capacity, but that is not the same as having people with subject-matter knowledge and expertise embedded within the review team and involved in the evidence synthesis and interpretation itself.

The people conducting the review did not have substantive expertise in the specific clinical field under review, which was a massive problem for quality. Subject-matter expertise is not just about providing background information, it is essential for framing the right questions, making methodological decisions, interpreting evidence and understanding the clinical context and limitations of the available literature.

Can you be more specific about where you believe subject matter expertise was lacking in the Cass review systematic reviews?

For example, I've just looked at the first of the reviews 'Characteristics of children and adolescents referred to specialist gender services: a systematic review' where they state that "With reference to the literature and input from expert advisors, key demographics, gender, mental health, neurodevelopmental conditions and psychosocial characteristics were extracted."

My criticism here is that (I can't find) who these expert advisors were. They probably didn't have enough input to get co-authorship so it would have been useful if they were acknowledged. But this does suggest they had clinical expert input.

https://adc.bmj.com/content/early/2024/09/26/archdischild-2023-326681.info?versioned=true

But that is all about feelings, where are the measurable and observable signs and symptoms? Powerful drugs can't be prescribed without clear and observable abnormalities which require remedy. Follow up includes reassessing that the drugs have improved the situation or not.

Methodological neutrality is important, but subject-matter expertise isn't a source of bias to be eliminated. It's essential for framing the right questions, interpreting heterogeneous evidence, understanding the clinical context and recognising the limitations of the literature. You need both methods expertise and subject matter knowledge and understanding to conduct a high quality evidence review. The latter was lacking in the Cass team.

This page gives a really helpful summary for you https://theprivatetherapyclinic.co.uk/blog/how-to-be-certain-you-have-gender-dysphoria/

A persistent unease with your sexed body
A specific, ongoing discomfort with the primary or secondary sex characteristics of your body. Breasts, voice, body hair, genitals, body shape, height. This often intensifies during or after puberty, when those features develop more fully. The distress is not vague body dissatisfaction. It is specifically about the features that mark you as the gender you were assigned at birth.
A felt sense that the gender role does not fit
An ongoing experience that the social role you are living in as a man or a woman does not match who you actually are. This can show up as a quiet, persistent wrongness in everyday situations. Being addressed by your name or pronouns, getting dressed, being seen by others. It is the gendered nature of these moments that creates the friction, not the moments themselves.
Gender euphoria when treated as another gender
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. The contrast between the everyday low-level distress and the sudden relief of being seen correctly can be one of the most diagnostic experiences. Some people only realise the dysphoria was there once they feel it lift.
Preoccupying thoughts about a different gender
Recurring, sustained thoughts about what it would be like to live as a different gender. Not as fleeting curiosity, but as an ongoing pull. People often describe years of intrusive imagining before they let themselves say it out loud.
Questions worth asking yourself
When people in my clinic are trying to work out whether what they are feeling is gender dysphoria or something else, these are the questions I ask them. They are worth sitting with on your own as well.

• When did the feelings start? Did they begin before puberty, during it, or later? What else was happening in your life at the time?
• Do the feelings stay roughly constant, or do they fluctuate with depression, anxiety, or what is going on around you?
• Is your distress about specific gendered features of your body, or about your appearance more generally?
• Is it about how others perceive you, how you feel internally, or both?
• Have you ever felt a clear relief or rightness when treated as a different gender, even briefly?
• If you imagine your body without the features that distress you, does that imagining bring relief, or does a different distress move into its place?

Gender dysphoria vs gender nonconformity
This is a distinction people often get tangled in. Gender nonconformity is a way of presenting or behaving that does not match the conventional expectations attached to someone’s gender. A man wearing a dress, a woman with a shaved head, a child who refuses to play with the toys associated with their assigned sex. These are choices about how to live in the world.
Gender dysphoria is something different. It is not about whether someone wants to wear dresses or trousers. It is about whether they experience themselves as fundamentally a different gender from the one they were assigned at birth, and whether that experience is causing sustained distress. You can be gender nonconforming without dysphoria, and you can have dysphoria while presenting in conventionally gendered ways.

What gender dysphoria actually feels like
People in my clinic rarely describe gender dysphoria in clinical language. They describe it in physical terms. A cold wave that washes over them when they catch their reflection. A sense of looking in the mirror and seeing the wrong face. The feeling of performing in a play that never ends, where the role does not match who they are. One person described it to me as a kind of chronic pain that gnaws at them without any clear physical cause.
That embodied quality is one of the things that distinguishes it. Gender dysphoria is not just a thought about gender. It is a felt sense of incongruence between the gender someone experiences themselves to be and the body or social role they are living in.

I don't see that as a persuasive criticism at all. Clinical expertise is an essential component of high-quality evidence review and would this would be uncontroversial recognised in every other area of medicine. Clinicians play a critical role in contributing to guideline development and evidence reviews across medicine, including in oncology, cardiology and psychiatry, despite treating patients in those fields. Their expertise is considered essential.

More fundamentally, this criticism seems to assume that involvement in a field necessarily creates bias in one direction. That doesn't follow at all. There are clinicians who are sceptical of puberty blockers and who generally advocate against their use. Should they be excluded on the same grounds?

That is not how evidence review is normally conducted. The objective is not to eliminate subject-matter expertise, but to ensure that potential conflicts are declared, managed transparently, and balanced by robust methodology and a multidisciplinary panel.

If there is evidence that conflicts were not declared, that members influenced conclusions inappropriately, or that the review departed from accepted methodological standards, those would be legitimate criticisms. But simply pointing out that clinicians who prescribe puberty blockers are involved in reviewing the evidence is not, on its own, sufficient to demonstrate a conflict of interest or undermine credibility.

It is absolutely fundamental to a trans identity

It's really not. What everyone else feels is completely irrelevant to whether or not someone is trans.

Some people are high on their own righteousness

Indeed they are.

Some people just hate to hear the word no. Some people are high on their own righteousness. And some people have allowed, even fought for, medical treatment based on a child's ideas of what boys and girls are supposed to feel like.

The first two make me angry. The last makes me angry but also breaks my heart.

So you have no idea how trans kids know they are trans. Why are you here, arguing so passionately about this, when it seems you know nothing about it?

You seem to be avoiding the specific criticism of the Dutch review linked in the OP. The board conducting the review has 12 members. Of those, 6 are either directly or indirectly involved with the prescribing of puberty blockers. While 2 of those don't have voting rights they will still influence the review. So we have a board, half of which's members have some involvement with prescribing puberty blockers, reviewing the evidence on the prescribing of puberty blockers within the context of care for children claiming a trans identity. And you don't see that as an issue?

Indeed the problem with this is particularly pronounced as it is a small field within the Netherlands. The small number of clinicians involved means that those involved in the review are essentially reviewing their own work, and the work of close colleagues.

.

This page gives a really helpful summary for you https://theprivatetherapyclinic.co.uk/blog/how-to-be-certain-you-have-gender-dysphoria/

A persistent unease with your sexed body
A specific, ongoing discomfort with the primary or secondary sex characteristics of your body. Breasts, voice, body hair, genitals, body shape, height. This often intensifies during or after puberty, when those features develop more fully. The distress is not vague body dissatisfaction. It is specifically about the features that mark you as the gender you were assigned at birth.
A felt sense that the gender role does not fit
An ongoing experience that the social role you are living in as a man or a woman does not match who you actually are. This can show up as a quiet, persistent wrongness in everyday situations. Being addressed by your name or pronouns, getting dressed, being seen by others. It is the gendered nature of these moments that creates the friction, not the moments themselves.
Gender euphoria when treated as another gender
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. The contrast between the everyday low-level distress and the sudden relief of being seen correctly can be one of the most diagnostic experiences. Some people only realise the dysphoria was there once they feel it lift.
Preoccupying thoughts about a different gender
Recurring, sustained thoughts about what it would be like to live as a different gender. Not as fleeting curiosity, but as an ongoing pull. People often describe years of intrusive imagining before they let themselves say it out loud.
Questions worth asking yourself
When people in my clinic are trying to work out whether what they are feeling is gender dysphoria or something else, these are the questions I ask them. They are worth sitting with on your own as well.

• When did the feelings start? Did they begin before puberty, during it, or later? What else was happening in your life at the time?
• Do the feelings stay roughly constant, or do they fluctuate with depression, anxiety, or what is going on around you?
• Is your distress about specific gendered features of your body, or about your appearance more generally?
• Is it about how others perceive you, how you feel internally, or both?
• Have you ever felt a clear relief or rightness when treated as a different gender, even briefly?
• If you imagine your body without the features that distress you, does that imagining bring relief, or does a different distress move into its place?

Gender dysphoria vs gender nonconformity
This is a distinction people often get tangled in. Gender nonconformity is a way of presenting or behaving that does not match the conventional expectations attached to someone’s gender. A man wearing a dress, a woman with a shaved head, a child who refuses to play with the toys associated with their assigned sex. These are choices about how to live in the world.
Gender dysphoria is something different. It is not about whether someone wants to wear dresses or trousers. It is about whether they experience themselves as fundamentally a different gender from the one they were assigned at birth, and whether that experience is causing sustained distress. You can be gender nonconforming without dysphoria, and you can have dysphoria while presenting in conventionally gendered ways.

What gender dysphoria actually feels like
People in my clinic rarely describe gender dysphoria in clinical language. They describe it in physical terms. A cold wave that washes over them when they catch their reflection. A sense of looking in the mirror and seeing the wrong face. The feeling of performing in a play that never ends, where the role does not match who they are. One person described it to me as a kind of chronic pain that gnaws at them without any clear physical cause.
That embodied quality is one of the things that distinguishes it. Gender dysphoria is not just a thought about gender. It is a felt sense of incongruence between the gender someone experiences themselves to be and the body or social role they are living in.

Methodological neutrality is important, but subject-matter expertise isn't a source of bias to be eliminated. It's essential for framing the right questions, interpreting heterogeneous evidence, understanding the clinical context and recognising the limitations of the literature. You need both methods expertise and subject matter knowledge and understanding to conduct a high quality evidence review. The latter was lacking in the Cass team.

So you have no idea how trans kids know they are trans. Why are you here, arguing so passionately about this, when it seems you know nothing about it?