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

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.

(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.

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.

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 don’t think it’s the Catch-22 you’re describing.

It assumes that having previously prescribed puberty blockers demonstrates bias, but that doesn’t necessarily follow. A clinician may prescribe to a particular patient in a particular clinical context because, based on the circumstances before them, the evidence available at the time and the existing clinical guidelines, they judge that the balance of benefits and risks favours treatment in that individual case. That doesn’t mean they are incapable of later reviewing the totality of the evidence objectively and fairly.

If it did, we’d have to conclude that no clinician could ever objectively evaluate interventions they use in practice. But that’s clearly not how medicine works. We don’t say that cardiologists shouldn’t lead reviews of cardiac interventions because they perform them, or that oncologists shouldn’t evaluate chemotherapy because they prescribe it. Instead, we manage potential conflicts through declarations of interest, balanced panels and rigorous review methods. Why should a different standard apply here?

The suggestion that including clinicians with different perspectives would inevitably produce a “bunfight” is also overstated. Expert guideline panels routinely include people who disagree strongly, and structured evidence-review processes exist precisely to ensure disagreements are resolved through transparent and consistent methods.

I also think there’s a more fundamental problem here - your perspectives assumes that the absence of an existing view is the same as "neutrality". but the reality is nobody approaches a controversial topic like this as a blank slate. The goal is not to find people with no opinions- that is unrealistic and misleading -, but to minimise bias through transparent and structured methods, declarations of interest, etc.

Finally, while expertise in general paediatrics is undoubtedly valuable, it is not, on its own, sufficient subject-matter expertise for reviewing a rare and highly specialised area of healthcare. We wouldn’t normally ask a general paediatrician to lead a review of paediatric neurosurgery or paediatric oncology or paediatric neurodevelopmental disorders simply because all of those fall under the broad umbrella of paediatrics. We’d expect the review to involve clinicians with recognised expertise in the specific field

Exactly as they are for children with gender dysphoria.

The issue is really that gender dysphoria in children really isn't like the other conditions you mention in your post.

You were asked about the symptoms of this condition (in children) which the puberty blockers are supposed to be treating, but you seem to have been unable to answer this simple question. You posted a link to a webpage about gender dysphoria in adults, which doesn't help anyone to understand what the symptoms are in children.

I have read many different descriptions elsewhere of what gender dysphoria is in children, and it is almost exclusively about stereotypes. For the children themselves this is all it is about, for their parents there's sometimes homophobia as well - the fear that their child may grow up to be gay. Anyone who thinks that medicating these children with harmful drugs which stop their natural development is a sensible course of action shouldn't be trusted to run any sort of review of the 'treatment'.

Not exactly. Prescribing them to children with gender dysphoria is an off-label use. These drugs were developed and approved specifically for use in children with precocious puberty - not gender dysphoria. so all the studies/safety protocols/design of label/education of prescribers was done for children with precocious puberty. none of that was done for children with gender dysphoria.

It was a blog post written to provide advice to adults who think they might have gender dysphoria. The symptoms in children are the same. Why would they be different? It's the same condition regardless of age. I posted that info as I had a quick dig around and it was the best description I found. Gender dysphoria has nothing to do with stereotypes as that advice explains.

The Pathways trial uses the ICD-11 definition of childhood gender dysphoria. I have copied this from the trial protocol:

'Inclusion criteria: 1. Diagnosis of gender incongruence according to ICD-11, which includes:
a. Strong desire to be a different gender than the birth-registered sex.
b. Strong dislike of sexual anatomy or anticipated secondary sex characteristics. c. Gender Incongruence persisted for a minimum of 2 years.
d. Strong desire to ‘transition’ and live as the experienced gender.'

Except ICD-11 actually says (my bold):

'Gender incongruence of childhood is characterised by a marked incongruence between an individual’s experienced/expressed gender and the assigned sex in pre-pubertal children.
It includes a strong desire to be a different gender than the assigned sex;
a strong dislike on the child’s part of his or her sexual anatomy or anticipated secondary sex characteristics and/or a strong desire for the primary and/or anticipated secondary sex characteristics that match the experienced gender;
and make-believe or fantasy play, toys, games, or activities and playmates that are typical of the experienced gender rather than the assigned sex.
The incongruence must have persisted for about 2 years.
Gender variant behaviour and preferences alone are not a basis for assigning the diagnosis.'

Why is the part in bold not in the trial protocol? Is there a good reason? Or is it because it is gender stereotype bollocks and they are aware of how ridiculous it looks?

@Sunnibee The description I shared from that online blog, which includes questions about experiences during puberty is much more useful in explaining the symptoms and experience of gender dysphoria

More useful than ICD-11? You had better let WHO know.

The ICD- 11 is more of a basic checklist / list of diagnostic criteria for clinicians than a detailed description of patient experience / or full account of the assessment process which will be much more in depth. Also it's not perfect- These are working definitions that change and develop over time (this is by no means unique to GD). Of course there will be some differences in behavioural markers for adults and children as children and adults have different behaviours. But what gender dysphoria is remains constant - it's the same experience which is very well described in that blog and has nothing to do with stereotypes.

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.

Funny how puberty blockers are fine with CIS kids and only does it become a problem when they’re trans! Gotta love feminist identifying transphobes! Well done Netherlands, stick it to the captured UK

But what gender dysphoria is remains constant - it's the same experience which is very well described in that blog and has nothing to do with stereotypes.

From the blog you posted:

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.

So what is this gender role referring to if it's nothing to do with stereotypes? Can you give some examples of what sort of things this is describing?

Preoccupying thoughts about a different gender
Recurring, sustained thoughts about what it would be like to live as a different gender.

How does someone "live as a different gender"? If this isn't about stereotypes can you give some examples of what living as a different gender means?

The thing is in small children how they explore and express gender can be in very stereotypical/ basic ways. Thats normal for all children regardless of gender. Of course that doesn't mean every little boy who likes princess dresses thinks they are a girl, but dress up and role play can be part of how trans children express and explore gender, just like all children. Of course people latch onto criteria like that and say this proves that gender dysphoria is all about stereotypes but it really isn't. That's a misunderstanding. The description I shared from that online blog, which includes questions about experiences during puberty is much more useful in explaining the symptoms and experience of gender dysphoria

The ICD- 11 is more of a basic checklist / list of diagnostic criteria for clinicians than a detailed description of patient experience / or full account of the assessment process which will be much more in depth. Also it's not perfect- These are working definitions that change and develop over time (this is by no means unique to GD). Of course there will be some differences in behavioural markers for adults and children as children and adults have different behaviours. But what gender dysphoria is remains constant - it's the same experience which is very well described in that blog and has nothing to do with stereotypes.

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.