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

[ForZingyCat]

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

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.

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have the evidence to say what proportion of children who have gender dysphoria desist post puberty - the 80% is an outdated and widely challenged statistic.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.

@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.

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?

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.

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.

The Cass review itself acknowledges the limitations.

Also see
Steensma, T. D., McGuire, J. K., Kreukels, B. P. C., Beekman, A. J., & Cohen-Kettenis, P. T. (2013). Factors Associated With Desistence and Persistence of Childhood Gender Dysphoria: A Quantitative Follow-Up Study. Journal of the American Academy of Child & Adolescent Psychiatry, 52(6), 582–590.
https://doi.org/10.1016/j.jaac.2013.03.016

Temple Newhook, J., Pyne, J., Winters, K., Feder, S., Holmes, C., Tosh, J., Sinnott, M.-L., Jamieson, A., & Pickett, S. (2018). A critical commentary on follow-up studies and “desistance” theories about transgender and gender-nonconforming children. International Journal of Transgenderism, 19(2), 212–224.
https://doi.org/10.1080/15532739.2018.1456390

Defining Desistance: Exploring Desistance in Transgender and Gender Expansive Youth Through Systematic Literature Review (2023)
Chen, D., Berona, J., Chan, Y.-M., Ehrensaft, D., Garofalo, R., Hidalgo, M. A., Johnson, L. L., Olson, J., & Rosenthal, S. M. (2023).
Defining Desistance: Exploring Desistance in Transgender and Gender Expansive Youth Through Systematic Literature Review.
Transgender Health, 8(3), 205–213.
https://doi.org/10.1089/trgh.2021.0096

If we can’t resolve the disconnect,

Thing is: we're not even trying. I literally don't know of anywhere in the world where a talking therapy is under trial to resolve that disconnect. I don't know of a single mental health professional in my country who is specialised in helping trans people deal with that disconnect.

We're not trying.

Worse: in many countries, it's considered "conversion therapy" and thus abusive to the trans patient.

So of course we can't resolve the disconnect: we're not trying to!

Can you answer my questions?

That is one possible pathway, but it is important to recognise that a "wait and see" approach is not risk-free or a neutral option. For some young people, waiting may provide valuable time to explore their feelings; for others, delaying any form of intervention while distress persists can have significant consequences.

Persistent gender dysphoria can be associated with substantial distress, and adolescence is a time when irreversible physical changes occur. The question is therefore not simply whether we can wait, but whether the potential benefits of waiting outweigh the potential harms for a particular young person.

A careful approach should involve recognising and validating distress, exploring all possible contributing factors, and considering the risks and benefits of different pathways rather than assuming that delay is inherently the safest option.

surely there must have been something that wasn't coming across in the 'benefits' pile, that goes beyond 'likes body a little better, maybe'?

True. In fact, "liking my body a little better" is my second benefit, not the main one. The main one is that I no longer feel the weight of the impression that I'm lying to people by presenting as female. Since I see myself inside as male, it felt wrong to present as female, like I wasn't telling the truth to people. Now I present as a woman who presents as male, which is my full truth, so that aspect is gone.

On the one hand, you argue that expectations of being able to "pass" are often unrealistic

Oh but I wasn't talking only about expectations of passing! I meant also, for example:

• the expectation that everyone in your family or friend circle will eventually be okay with your transition;
• the expectation that once you reach passing stage, you will never again wonder if you're truly passing or if people are only pretending to humour you;
• the expectation that you will have a normal dating life;
• the expectation that you can avoid every situation where your birth sex would be relevant;
• the expectation that the medical treatments and their side-effects will be easy to handle;
• in general, the expectation that gender dysphoria will be a thing of the past;

And so on. Far too many trans people I listen to are way too unreasonable about what life after transition should be or is going to be. And children are even worse at properly measuring and understanding what their future adult life might be like, even more so when they are being fed lies about how idyllic it will be.

I would disagree that we are not trying. The main intervention GIDS offered to the vast majority of children referred to the service was psychotherapeutic exploration.
Now with the dissolution of GIDS services are more uncertain, but the proposals are to scale up mental health interventions even more, and restrict access to physical ones.
In terms of a trial of psychological interventions - it's a interesting question. There actually have been studies that have explored whether psychological interventions can improve wellbeing, but the evidence is limited and we do need more. In terms of a trial that looked at whether therapy could 'cure' gender dysphoria in the absence of any other intervention, I think that would give rise to some significant ethical challenges. But more studies exploring whether psychological interventions , and what types, can help improve wellbeing as part of a service seems really important.

thanks that's really informative.

@Sunnibee 80% is an outdated and widely challenged statistic

You can't just keep saying this sort of thing for evidence that you don't like. The medical profession, encouraged by activists, have squandered the last few decades, when they could have trialled a variety of non-affirming psychotherapeutic approaches and collected decades-worth of longitudinal data following up children well into adulthood.

So if I've understood this correctly, 'Dave' is a boy who likes playing football, is totally happy about having a penis, but thinks he's in the wrong sex category because he wants to change with the girls and play on the girls' football team. This is gender dysphoria?

No I think you misunderstood the post and it's context. :)

I was explaining that for a person who has gender dysphoria aspects of their body can be upsetting as well as aspects of social interactions. What is upsetting is not the look of the body/ social interaction itself, but what the body part/ social interaction signifies in terms of the reminder to the person that they are somehow in the wrong sex category.

they are somehow in the wrong sex category

Somehow? In what way do they think they are in the wrong sex category?

Still finding the argument that if someone's sense of reality is deeply distorted and that causes them distress, the right thing to do is to try to move reality as close as possible to their delusion and who care what consequences that creates for wider society very weird.

I think we are going round in circles at this point :).

I think a lot of the challenge is that is incredibly hard to imagine the experience of gender dysphoria/ incongruence if you don't have it, even harder to explain, make sense of it.
I shared that blog earlier which contained some descriptions of the way it feels.

A pp on this thread just described his experience a couple of posts above
"The main one is that I no longer feel the weight of the impression that I'm lying to people by presenting as female. Since I see myself inside as male, it felt wrong to present as female, like I wasn't telling the truth to people"

What's so interesting to me about @Seethlaw 's description of his experience is that GC posters so often accuse trans people of "lying" by presenting / claiming to be the opposite sex. But from a trans persons perspective, what feels like lying to people is presenting as their birth sex.

I think this highlights what a difficult situation trans people can be in when they live in a society that doesn't understand , recognise ir accept gender incongruence.

I think a lot of the challenge is that is incredibly hard to imagine the experience of gender dysphoria/ incongruence if you don't have it, even harder to explain, make sense of it.

I think a lot of the challenge is that it is incredibly hard to imagine the experience of being female if you're male. It's impossible to explain, the only way to experience it is to be born and grow up with a female body. It's impossible to explain how offensive it is for male people to say their experience of having a male body and looking on female bodies with envy makes them remotely the same as our experience of having a female body in and at various stages cursing it (at least once a month from 15-ish to 50-ish for a start).

I think actually many women here have a pretty good idea what it feels like to wish you were a boy and feel desperately constrained and alienated by the roles being pushed on us as girls. Of dreading then hating growing boobs and getting periods and feeling like our bodies had gone all wrong. Of feeling like we'd never fit in. Of other girls feel like an alien species.

That was us as teens. That's part of the reason we're so disturbed at girls like we were being told that yes this means they're boys. And being encouraged to damage their perfectly healthy bodies for life in service to this idea.

@Sunnibee I think a lot of the challenge is that is incredibly hard to imagine the experience of gender dysphoria/ incongruence if you don't have it, even harder to explain, make sense of it.

I think most of us can see that some trans-identified people are feeling something that causes them distress. What we cannot accept is that this 'something' means that trans-identified men really are female or that it gives them the right to claim the label of 'woman' for themselves.

I think the problem here is that you are interpreting this conversation through the lens of your own experience, when it is not actually a statement about your experience of being female. It's this projection that gives rise to the offence. A person can experience gender dysphoria without making a claim about what it means to be a woman, or suggesting that their feelings about their body are identical to the experiences many women have had with puberty, sexism or gender expectations.

I also think there is an important distinction between recognising that many young women experience distress, discomfort or alienation during puberty, and assuming that all experiences of body discomfort have the same cause or meaning.

Many girls and women can relate to feeling uncomfortable with the changes of puberty, struggling with gender expectations, or feeling alienated from stereotypically feminine roles. I certainly can. Those experiences are real and deserve support. But the existence of those experiences does not mean that every young person experiencing gender dysphoria is simply expressing the same thing.

The challenge in healthcare is not to assume one explanation for everyone, but to understand each individual's experience: what is causing their distress, how persistent it is, what support they need, and what interventions are most likely to improve their wellbeing.

Recognising that some young people experience gender-related distress does not require dismissing the very real struggles many girls have with puberty, sexism or expectations placed on them. Both things can be true.

Also think people underestimate the capacity of the human brain for being consistently, persistently and with massive conviction wrong about things. Brains run on pathways. The more a pathway is reinforced, the stronger it becomes. Truth value of the pathway is pretty immaterial.

Thing is, though, this is not how so many other trans people and TRAs present the trans experience.

They don't say, "I need to present as a wo/man," they say, "I am a wo/man," which is a completely different proposition, one that is both impossible (no, we can't be the opposite sex) and offensive (on what basis do we assume that we know what being the other sex is like?)

They also don't satisfy themselves with presenting their truth by presenting as the other sex; they demand/expect that people affirm them 24/7.

In fact, that's one reason I think there should be urgent research into a psychotherapy for gender dysphoria: because I think a lot of trans people would be happier if they didn't let themselves be convinced by TRAs that they need to believe they are the other sex, or that they are mistreated every time someone misgenders them, or that they need to reach for as complete a transition as possible. I think they'd be a lot happier if they received psychological support to give them the necessary space to decide how far they want to take their transition, and what goals they want to reach.