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

[ForZingyCat]

https://www.gezondheidsraad.nl/adviesonderwerpen/behandeling-en-begeleiding/transgenderzorg-voor-jonger

why not allow for the possibility that other people are motivated by much the same underlying needs and are making a similar judgement about the balance of benefits and risks?

Because they are children.

A child's view of risks and benefits is never going to match that of an adult's. And if they and their parents are being told that they'll likely commit suicide if they don't transition, they are going to feel an urgency to "pause" puberty without having a full understanding of what that means. It's not a pause if it never happens.

You say it's about gendered categories, but then you describe sexed categories.

We can call them "sexed categories" if you prefer; it doesn't change the point. The point is that society recognises these categories and organises many aspects of social life around them.

These categories exist, and so does the experience, for a minority of people, of being in the wrong one, together with the profound distress that can accompany it. That is the phenomenon referred to as gender dysphoria.

There was a suggestion earlier that if we removed the categories themselves, we could remove the experience of being in the wrong one. There's a certain logic to that. The difficulty is that these categories are deeply embedded in society because they arise from real biological differences that have social significance. It therefore seems unrealistic to imagine that they could simply be abolished.

I don't think many clinicians would describe trans people as believing they literally have a "gendered soul", and I don't think that reflects how most trans people describe their own experiences either.

The many of them who refer to themselves as, for example, "a man in a woman's body," do explicitely refer to a non-bodily essence separate from the body, in effect a soul.

If someone believes the correct name for the colour "red" should actually be "loud", and the quality of volume previously known as "loud" no longer needs a name, it doesn't mean the visual quality of redness has now become a sound or that sounds that were previously thought loud are now silent.

Similarly, if someone believes their gender identity is what makes them a man or a woman, it doesn't follow that gender identity is now the actual basis on which people are men or women, and nor does it follow that the people formerly understood to be men or women because of their sex have now lost the quality of sex.

Nothing has changed. It's just moving words around.

It's a trite example, but lack of money causes distress and suffering to far more children globally than gender dysphoria, and that could be remedied very very easily by taking money away from some people and giving it to others. Yet we do not do that.

So it seems that some distress is worth addressing even though we can't even be sure the interventions work, and other distress is not even though there is a clear and obvious remedy.

Odd that. It's almost like actually, sometimes the impact on other people does matter too.

Nothing has changed. It's just moving words around.

Yep. If gender identity is separate from biological sex, by very definition it has to be a feeling or a "soul". Even if those who feel they have a gender identity that differs from their sex don't describe it that way.

They can wriggle about trying to say that sex is not binary all they like but they are objectively wrong on that. Everyone is either male or female. And we've already been around the DSD loop on this thread. I skipped through all of that. I have a horrible feeling we're going back there 😬 I'll skip it again if we do.

That didn't really answer my question, but either way -

Ah, sorry. I didn't understand it then. Can you maybe try to re-formulate it?

I think you're assuming that other trans people are motivated differently from you, but you haven't really established that. Why assume that your motivations are unique, or that other people necessarily have less realistic expectations?

I doubt my motivations are unique! In fact, I would be surprised if I were the only one of my type of trans people.

As for expectations, however: I've listened to a lot of trans people, both online and offline, and way too many of them expressed unrealistic expectations.

Moreover, when it comes to the Dutch Protocol, those extremely high expectations are the entire point of the treatment. Getting kids on puberty blockers is to stop them developing the sexual traits of their own sex so they will pass better once they go onto cross-sex hormones. That has been the entire goal of the protocol all along. So the sky high expectations are baked into the treatment for so-called trans kids.

We can call them "sexed categories" if you prefer; it doesn't change the point. The point is that society recognises these categories and organises many aspects of social life around them.

Can you give some examples? There are very few aspects of social life now which are only for women or only for men. Sometimes there are separate categories for men and women such as in sporting events, but that's because of the difference in male and female bodies, not because of a womanly or manly essence that someone claims to have.

There was a suggestion earlier that if we removed the categories themselves, we could remove the experience of being in the wrong one. There's a certain logic to that. The difficulty is that these categories are deeply embedded in society because they arise from real biological differences that have social significance. It therefore seems unrealistic to imagine that they could simply be abolished.

I don't think anyone has suggested removing sex categories (unless you did). But a man who's upset because he can't join a women's football team just needs to get over it.

I've listened to many detransitioners recount their 'journeys' and the one thing they all have in common in being encouraged ( usually via socia media or by their social group) to use a gender identity/dysphoric framework through which to view their distress or discomfort.

There is no confusion in understanding that male people can never be women - regardless of them, perhaps, adopting a belief in a concept of 'gender identity' - and no confusion in understanding that women and girls have dignity and integrity in their sex. People who believe they are something they are not, though, are most certainly confused.

Dysphoria is by definition a mental health issue ( DYS = dysfunction/maladaptation and PHORIC relates to the mind).

I have no doubt some people may well fell better about themselves if they present in ways typical of the opposite sex - but the confusion arises when they actually believe themselves to be the other sex and then start demanding that other people validate that belief.

This.

Plus one young transitioner I know has had sundry health issues pop up that never existed before, and is now on permanent medication for them, as well as hormones.

This assumes that you also have a particular strong belief and a certain destination in mind too - if that is what you mean by 'productive'. You seem to think that an exchange of views that doesn't lead to the other person validating your belief, in some form, is not worthwhile.

Therapists should also be prepared to unpack what is meant by 'gender dysphoria' - and not just treat is as a given. Beneath supposed 'gender distress' there are usually deeper roots. 'Gender' has been the most recent and popular framing device through which many have come to view their discomfort. But the framework is not the exact same thing as the actual feeling of distress.

Those you refer to as experts in this field are nothing more than activists who have signed up to the concept of gender identity and a belief in the existence of the 'genuine' trans child. What is required is someone who can see beyond, beneath and behind the framework of 'gender identity' - whilst simultaneously providing a holding space for the feelings expressed through it - in order to reach the roots of the distress.

It would be profoundly wrong for a professional to validate a child's belief in something that is ultimately not true ( that a girl is a boy or a boy is a girl) along with a belief that the circumstances of the child's life going forward are ever going to be able to validate that untruth. A therapist needs to encourage emotional resillience in a child and not a fragile sense of self that is utterly dependent on others for its existence.

All the evidence so far is that the most effective way to alleviate that distress is to go through the vulnerable stage of development known as puberty. It doesn't fix dysphoria for everyone, the usual figure is 80%-ish, but that's a far better succcess rate than any medication.

Talking about "persistent" is a circular argument because "persistent gender dysphoria" often means dysphoria that isn't fixed by going through puberty. Without a time machine how can you know if a child who hasn't gone through puberty yet has that or not? Well, unless you're using a much weaker meaning of "persistent" but then it's likely to go away at puberty and not have such devastating consequences.

And exactly what "devastating consequences" do you mean? Like I say, the worst consequence of not getting the blockers that Cass raised was taking illegal medication.

I did give examples earlier: pronouns, names, toilets, and you've mentioned another yourself—sports. Recent developments like the EHRC guidance arguably increase the significance of sex categories in some areas of everyday life.

My point isn't really about whether these categories are ultimately justified by biology or not. It's simply that they exist, and society organises many aspects of life around them. That's enough for the point I'm making.

Gender dysphoria is the persistent feeling of being in the wrong body/ social category. People were asking what the social aspect of that meant if not stereotypes. I was trying to explain that the issue isn’t that people feel they need to perform a particular social role (cooking, dress up, football), it’s that they feel that they are in the wrong sexed category. So anything that society does to recognise and give meaning to those categories causes them acute distress.

if we eliminated any meaning or social consequence to sexed categories, perhaps we could eliminate the feeling of being in the wrong one, but that is not something that is simple to eliminate because there are real biological differences which have social consequences and give rise to these categories.

The point is that these categories are real, and so is the experience of feeling like you are in the wrong one. This isn’t something that a person can “just get over”. They can get over being excluded from a particular sporting activity or team, but they can’t get over the distress that results from feeling they are in the wrong sexed category.

So the real questions are - how can we support these people to eliminate their distress? Should a democratic and justice society care about this minority and accommodate them? How? Should healthcare professionals try to “treat” this distress? What interventions are effective? How do we balance the harm that could be caused by interventions against the harm caused by leaving the distress “untreated”. These are normal questions we grapple with in all areas of medicine (and social policy more broadly).

I should have been more precise here:

“Gender dysphoria is the persistent feeling of being in the wrong body/ social category. People were asking what the social aspect of that meant if not stereotypes. I was trying to explain that the issue isn’t that people feel they need to perform a particular social role (cooking, dress up, football), it’s that they feel that they are in the wrong sexed category. So anything that society does to recognise and give meaning to their placement in the “assigned/ observed/ correct” (whatever word you prefer) sexed category causes them acute distress. whether that’s referring to them by their birth sex pronoun, or making them wear a particular uniform, or use the toilet according to their birth sex, or anything else.

I have to say that I really don't have a clue what you mean when you talk about people "feeling they are in the wrong sexed category".

The only time sex categories matter is when sex matters. Surely someone "feeling they are in the wrong sexed category" is suffering from a delusion that they should be the opposite sex. This is a condition which requires psychological treatment, not physical treatment to make their body look more like the opposite sex.

Sex categories for sports and single sex spaces are there for reasons of fairness, privacy etc. It really doesn't matter how unhappy a man is at being excluded from women's sports and spaces: the women have the right to privacy and fairness. It doesn't matter how much he feels he's "in the wrong sexed category", his sex category is male.

Will come back to this shortly :)

I think we're talking past each other a bit.

When I say someone "feels they are in the wrong sexed category", I'm describing the experience of gender dysphoria, not endorsing a particular belief about sex or making a claim about treatment.

By "sexed category" I simply mean the social categories of male or female. Society distinguishes between these categories in lots of ways—names, pronouns, toilets, changing rooms, sports, official documents, and so on. Whether each distinction is justified and how we should organise society around sexed categories are separate questions.

I was simply trying to explain what gender dysphoria is - it is the persistent distress associated with one's sexed body and the social category that goes with it. That's why simply saying "your category is male, get over it" doesn't address what gender dysphoria actually is.

You may think the appropriate treatment is psychological rather than medical, and that's a legitimate topic for discussion. But that's a different question from whether the experience itself exists or what people mean when they describe its social aspect.

So anything that society does to recognise and give meaning to their placement in the “assigned/ observed/ correct” (whatever word you prefer) sexed category causes them acute distress. whether that’s referring to them by their birth sex pronoun, or making them wear a particular uniform, or use the toilet according to their birth sex, or anything else.

What you seem to be saying here is that these people have difficulty in adapting to the normal rules of the society in which they live.

In English, third person pronouns are normally used according to the sex of the individual. Many people find it difficult or impossible to do otherwise, even when they don't want to upset the person making the demands. It can also cause acute distress to some people when these demands are made. It's unreasonable for the person distressed by their sex to make these demands on everyone else. We all have rights, not just the people distressed by their sex.

You seem to be suggesting that the solution to someone's distress at being unable to adapt to the normal rules of society is for everyone else to adapt themselves to that person's needs. Can you not see how unreasonable that is?

This.

"The person has gender dysphoria" is not any kind of explanation because this use of "gender" doesn't refer to anything material or practical. So what is the dysphoria about exactly? Is it about the body itself, and if so, in what way? Is it about what the person feels they are allowed to do or wear? Is it about something else, still?

A person who doesn't like the shape of their genitals should not be treated the same as a person who feels they can't do something because it's considered to be something only the opposite sex does. They shouldn't get the exact same diagnosis, and certainly not the same treatment.

It's time the professionals started to look under the hood and figured what's going on specifically for each patient, so that the treatment can be adapted to each profile.

We don't treat everyone who has a persistent headache the same way, and nor should we do it for gender dysphoria.

There’s a difference between describing a condition and expressing an opinion about how society should respond to it.

The fact that someone experiences distress because of their body/ social role doesn’t by itself, tell us what accommodations society should or shouldn't make. That's a separate ethical and political question.

My point has been much narrower. Earlier people asked what the social role aspect of gender dysphoria meant if it wasn’t based on “stereotypes”. My answer was that it refers to anything that derives from the social recognition of the categories “male” and “female” (names, pronouns, toilets, etc.).

Those categories are real and socially significant, so it's unsurprising that someone who persistently experiences themselves as belonging in the other category experiences distress in social as well as bodily contexts.

You may conclude that society should make very few accommodations, or none. Someone else may conclude the opposite. But neither position changes what gender dysphoria is. Before we decide if and how society should accommodate people with this condition, it’s really important to understand and clarify what it actually is.

A person who doesn't like the shape of their genitals should not be treated the same as a person who feels they can't do something because it's considered to be something only the opposite sex does. They shouldn't get the exact same diagnosis, and certainly not the same treatment.

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. Likewise, I used to be furious that, as a girl, I was expected to take sewing classes instead of playing rugby at school. That didn’t mean I was suffering from gender dysphoria, I was just an active kid and I found sewing really boring.

If someone hates their penis because they have a persistent , unshakeable sense that they are female/ a woman despite having been born with male physical characteristics - that is gender dysphoria. What causes the distress is not the shape of the genitals themselves, it’s the reminder that they are somehow in the wrong sex category. In exactly the same way, if someone has gender dysphoria, addressing them as ‘he’ or ‘Dave’, or insisting that they play football with the boys, might cause them distress. It’s not that they don’t like the name Dave or that they don’t enjoy playing football, it’s the reminder that they are somehow in the wrong sex category.

That is what gender dysphoria is.

Thanks for your attempts at clarification, but I don't think we're getting any further forward.

someone who persistently experiences themselves as belonging in the other category experiences distress in social as well as bodily contexts.

They don't "experience themselves as belonging in the other category" though, do they? They just think they belong in the other category. They can't actually experience something that isn't real. Someone who thinks they're experiencing something which isn't real is suffering from a delusion.

The way to fix this is to find out why there is this mind-body disconnect and help them to find a way forward from there.

That ‘thinking’ they are in the other category is a real experience. It’s not a choice, or something they have active control over.

In terms of whether it is appropriately characterised as a delusion - that’s a really complex and contested question, philosophically and scientifically. It raises really interesting and unanswerable questions about both sex development, and cognition, and how the brain processes and represents information about the body.

The way to fix this is to find out why there is this mind-body disconnect and help them to find a way forward from there.

I agree with you here. The medical questions are why and how to resolve. If we can’t resolve the disconnect, and it is causing acute distress, one simple way of thinking about it is - do we change the body to better align with the mind - or change the mind to align with the body?

It seems many users on this thread are assuming it has to be the latter. But changing the cognitive and psychological aspects of the mind is actually much harder and more complex than administering hormonal therapies, for example. We know how to induce hormonal changes very well - this can be done through administering medications. When it comes to aspects of how the brain/ cognition work/ mental processes work - we are so much more in the dark.