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

[ForZingyCat]

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

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.

Ooh that sounds exactly like anxiety when you've managed to avoid a trigger. The relief! And avoidance is exactly what anxious people have to resist, because the relief is wonderful but it is temporary and in the long run it makes the anxiety worse. The triggers expand and the only way to slow that down is to stop avoiding triggers and experience the anxiety.

So I wonder if after that experience of "relief or quiet joy" people start seeking out more and more situations where they will be percieved, addressed or treated as the sex they are not, and feel more and more stress in other situations, in the same kind of self-fulfilling circle.

I think this conflates several different questions. Whether someone experiences relief from social recognition does not require everyone to believe they have literally changed biological sex. Many aspects of social interaction involve recognising people's identities or experiences without making claims about underlying biology.

For example, in a family with two mothers, one mother may not have given birth to the child and may have no biological relationship to them. Referring to her as the child's mother is not generally understood as "lying" about biology; it is recognising the familial relationship she occupies - the biological facts remain unchanged.

Equally, I don't think it follows that because an intervention has a social component it is therefore illegitimate. Many treatments depend partly on how other people behave or on changes in a person's social environment. Rehabilitation after injury, autism accommodations, and many mental health and disability interventions for example all involve adjustments by others as well as changes within the individual.

On your final point, I don't think this is particularly controversial. Young people should receive clear, developmentally appropriate information about what medical treatment can and cannot achieve. Hormones and surgery cannot change chromosomes or reproduce every aspect of the other sex, and clinicians should not suggest otherwise. The relevant question is whether, despite those limitations, treatment improves wellbeing sufficiently to justify its risks and benefits for carefully selected patients. That is an empirical question, not one that can be answered by assumptions about what people "should" believe.

Please read this @Sunnibee.

This is not a real medical condition.

I've read it.
The article is largely just a list of unsupported claims. It repeatedly says that gender incongruence isn't a real condition, but it never actually demonstrates why. Instead, it relies mainly on assertions and analogies rather than engaging with the clinical evidence or explaining why major diagnostic bodies are wrong. It's simply rhetoric. Some brief examples (there are many others):

"There is only one possible answer: No."
This is just an assertion, not evidence based reasoning or argument. The author acknowledges no uncertainty or alternative interpretations despite the existence of disagreement among clinicians and researchers.

"There has never been any way to predict which adolescents will...persist...and which...will desist."
This is an empirical claim. It would require evidence. There are certainly limitations in prediction, but saying there has "never been any way" is just asserting an absolute position without anything to back it up.

It repeatedly says that gender incongruence isn't a real condition

A real medical condition: the "medical" is important. Gender incongruence is certainly something that some people feel, but that doesn't mean it's a medical condition necessitating the involvement of medical professionals, and even less the administration of medicine or the practice of surgeries.

"There has never been any way to predict which adolescents will...persist...and which...will desist."

This is an empirical claim. It would require evidence. There are certainly limitations in prediction, but saying there has "never been any way" is just asserting an absolute position without anything to back it up.

The evidence is that it doesn't exist. That's what "there has never been" means: that so far, it hasn't existed, that it doesn't exist as of now. Which is true: we don't know how to determine which children will benefit from intervention and which will be harmed by it, which is kind of a major problem. "First, do no harm" and all that.

There is nothing "wait and see" about the approach I have outlined. It actively unpicks and directly addresses the issues that the child is distressed about. In the example that I gave, the underlying issue was autism-related puberty distress. There are plenty of other reasons why a child may feel distressed about themselves (who they "are") and/or their body during puberty. Plus puberty is a weird and often confusing time anyway.

adolescence is a time when irreversible physical changes occur.

Yes. It's called puberty. Every child deserves to go through it, even if it's really difficult to get used to those changes.

Your response to my comment suggests that the approach I outlined is somehow stifling a trans person's true inner self. It's interesting that you consider it "waiting". Watchful waiting is definitely a term but it simply means waiting to see how the child's sense of self develops. It's also only half the story. In the approach I've outlined there is both watchful waiting (regarding trans identity) and active support to discover and alleviate the most likely cause of the distress.

I'm not a therapist but I can say from my experience as a mum that understanding and directly addressing autism-related puberty distress over a number of years can alleviate what originally presented as gender dysphoria. I would expect the same to be true for children who experience internalised homophobia, trauma from sexual assault and other reasons which have led to a child coming to believe that their body is the wrong sex for how they feel about themselves. They feel a deep sense of distress and unease about themselves, whilst being bombarded by Be Kind messaging that signposts them towards the answer being that they have a gender identity that differs from their sex. Without that suggestion, and with a full understanding of sex-based stereotypes and societal expectations of conformity towards them, they may never have considered it the answer.

Hannah Barnes book Time to Think highlighted some very interesting stats. It's difficult to read in the image below but in the red section it says that 97.5% of Tavistock referrals had an underlying condition such as autism, depression or other problems.

Not RTFT but a point earlier in the thread about needing to be experts to carry out review ignores the fact that carrying high quality systematic reviews of evidence IS a specialism. Knowing how to assess trial quality, the impact of various biases, doing effective searches, understanding statistics and potential issues with techniques used etc etc is a specialism of its own. Clinicians often have incredibly poor understanding of all this and also lack independence and have vested interest in their own way of working. The researchers who carried out the reviews in the Cass report were highly trained specialist teams.

That many young people referred to gender services have autism, depression or other co-occurring difficulties is well recognised. But comorbidity is not the same as causation. It doesn't establish that gender dysphoria is simply a manifestation of those conditions, or that treating them will resolve it.

Puberty related stress may be caused by many underlying issues, and unpacking that is the purpose of assessment. Two different children may experience this distress while the nature, focus, and underlying mechanisms of that distress differ. The fact that both are distressed doesn’t mean they are experiencing the same phenomenon or that the same intervention is appropriate. Clinical assessment isn’t just about recognising that distress exists; it’s about understanding its nature, context, and likely causes before deciding how best to respond.

I just wanted to also respond to this -

Yes. It's called puberty. Every child deserves to go through it, even if it's really difficult to get used to those changes.

That is a strange way to frame it. Saying that every child “deserves” to go through puberty implies that experiencing those changes is inherently preferable, even when they are causing significant distress. I’m not sure how that conclusion is justified. We don’t usually argue that children should endure a biological process regardless of the impact it has on their wellbeing simply because it is natural. The relevant question is not whether puberty is “deserved”, but how we respond when a child is experiencing severe distress associated with it.

People can feel dysphoric about all sorts of things and also feel deeply uncomfortable with their bodies - that is what anorexia is - a form of bodily dysphoria which tends to have its roots in deeper psychological issues.

'Gender' dysphoria only exists if you are using or applying a model of 'gender' to assess why somone is feeeling distressed or dysphoric. If a very small child is firmly suggesting that they are really of the opposite sex that can only have come from people in their environment imposing or exposing them to heavily sex based stereotypes, roles, expectations or personal longings for a child of the opposite sex to the child that they have ( See 'La Petite Fille' - french documentary about a boy who thinks he's a girl - very much aided and abbetted by his mother)

This was certainly the case for the child of Susie Green - whose dysphoric feelings arose when he had his preferred 'girl toys' removed from him because his father didn't like that he wanted to play with them and not 'boys toys'.

Lots of nascently gay children tend to have preferences for cross sex 'gendered' items or for associating or identifying more with the opposite sex or for feeling alientaed from the social expectations of their own sex. And lots of other children do too.This is normal and part of the process of coming to realise what you and don't like in life.

Yes but review teams typically include both - you need subject matter expertise and methods expertise, you can't just substitute one for the other.

It is preferable because it is a normal and healthy path of human development - not a pathology. The pathology is the distressed feelings.

Saying that every child “deserves” to go through puberty implies that experiencing those changes is inherently preferable, even when they are causing significant distress. I’m not sure how that conclusion is justified.

Yes, experiencing the result of those changes is inherently preferable. Even if getting there is distressing. Any child experiencing distress associated with going through puberty deserves therapeutic support to navigate their feelings and alleviate their distress.

I chose the word "deserve" deliberately re going through puberty because the opposite (not going through puberty) is abhorrent. Puberty blockers + cross-sex hormones does not equal puberty. It equals no puberty and a few physical facsimiles of the secondary sex characteristics of the opposite sex. It means people will look a bit like the opposite sex, will have a lifetime of medical complications to maintain this and will likely have brain damage due to impact of PBs.

Children deserve to grow up into adulthood with physically healthy brains and physically healthy bodies. The only way to achieve this is to go through puberty.

Edited for clarity.

I think we have reached the point where we are repeating the same points of disagreement. Your position is that puberty is an inherent good that must be experienced; my position is that clinical decisions should be based on an assessment of evidence, benefits, risks and individual circumstances. That assessment also needs to take children’s own experiences, distress and developing capacity to participate in decisions seriously, rather than relying on a predetermined ideological position. You are also continuing to make assertions that are not evidence based - like children "will likely have brain damage due to impact of PBs" and presenting them as self evident facts.

I don’t think continuing to repeat the same points is productive, so I’ll leave it there.

Are you really saying that you think doctors keeping a child in a permanently immature state, because the pre-pubescent child thinks that is what they want, is an acceptable thing for medical professionals to do?

Once again, I really hope I have misunderstood what you're saying.

Posted this on the PB thread, but it might be of interest here too.

SEGM have a report on a recent Acta Paediatrica article (by a Swedish gender psychologist) which basically points out that "gender identity" and "gender incongruence" are undefined terms that shouldn't be used as a basis for medical intervention:

https://nitter.net/segm_ebm/status/2082853108648997110

https://segm.org/gender-identity-conceptual-clarity

https://onlinelibrary.wiley.com/doi/10.1111/apa.70686

Suddenly thinking about the judgment of Solomon. No idea why
https://en.wikipedia.org/wiki/Judgement_of_Solomon

No, she's saying that puberty is a perfectly natural, normal and healthy developmental path in human beings that occurs because its appearance and timing are hard-wired into our genetic and chromosomal blue print. It is not an additional add on; it is integral to our development as mature adults.

That's certainly my understanding.

@Sunnibee You appear to believe it's cruel not to do this. I believe it's cruel to do it. I agree that it's a good idea to leave it there, as neither of us looks likely to concede to the other's viewpoint.

However, this point is worth following up:

You are also continuing to make assertions that are not evidence based - like children "will likely have brain damage due to impact of PBs" and presenting them as self evident facts.

This is a great video where Sallie Baxendale explains the impact on brain development if puberty blockers are used beyond the age at which puberty should be starting i.e. outside their purpose for treating precocious puberty:

Yes, you have misunderstood. No one has suggested keeping children permanently in a pre-pubescent state — I’m not sure where that idea has come from.

The purpose of PBs is to temporarily pause the irreversible effects of endogenous puberty, giving the child and clinicians more time for reflection and exploration before a decision is made about whether to allow endogenous puberty to proceed or to consider the use of cross-sex hormones. PBs are intended as a temporary intervention and should be used for the shortest period appropriate.

The question then becomes how to balance the young person’s capacity to consent to cross-sex hormones against the potential need to initiate them earlier for physiological and other reasons.

If the purpose is to pause in order for decisions to be made on whether to continue endogenous puberty, why do you believe only 2% of patients continue with that puberty? What reflection and exploration do you think takes place?

Those who progress onto cross sex hormones are still held in a prepubescent state - just with the addition of side effects from exogenous hormones. They never go through puberty. Puberty blockers have been repeatedly shown to lock children into a pathway to cross sex hormones.

Why do you think sterilising children is a good thing?

Talk about deliberately missing the point. In a family with two mothers, no one pretends that the "other" mum who didn't give birth literally gave birth. Everyone is open about who gave birth and who didn't. That's completely different from demanding that everyone pretends to see you as the opposite sex.

Your other false comparison of people adjusting behaviour to mental health and disability interventions is also completely different from requiring the whole of society to view trans-identified people as the opposite sex. Autism and mental health adjustments are done on a case-by-case basis among a small group around the individual. We are being asked not only to pretend that men are women, but to have men compete in women's sports, men enter women's toilets and changing rooms, lesbians being pressured to be open to dating men, etc.

At least you acknowledge that identifying as trans is a mental health issue and that men can't actually become women.

No one has suggested keeping children permanently in a pre-pubescent state — I’m not sure where that idea has come from.

You did @Sunnibee

I appreciate you may not be aware that that's what you're suggesting. But that doesn't stop it being factually true that this is the outcome of PB "treatment", with or without cross-sex hormones taken subsequently. Unless PBs are stopped before puberty should naturally become starting (e.g. from the age of 8/9), there is no other outcome.

It is impossible to go through the puberty of the opposite sex. There is either puberty or no puberty.

Edited for clarity.

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.

This is bollocks though. I loved it when people mistook me for a boy. If you're distressed about developing as a girl for all sorts of reasons of course you'll be happy if people don't notice that in you. Particularly if you for whatever reason have hung the label 'because I'm really a boy' on your distress.

you appear to believe it's cruel not to do this. I believe it's cruel to do it. I agree that it's a good idea to leave it there, as neither of us looks likely to concede to the other's viewpoint.

Agreed. Just to quickly clarify my position - it's not that I think it's cruel to do it or not to do it. I don’t think there are simple absolutes in terms of what is or is not “cruel” in these situations.

Whether a particular pathway is preferable depends on the individual child, their circumstances, the evidence available, and a careful assessment of the potential risks and benefits of different options. That is why these decisions require individualised clinical judgement rather than assuming that one approach is inherently compassionate or harmful in every case.

Thanks for sharing the youtube clip, its really interesting.
I think there are some important points to note:

• this evidence comes from 11 animal studies. Of these, 8 were done in the same single flock of sheep . 2 were in monkeys and one was in mice
• Only one of the studies - on sheep - had any length of follow up (around 40-55 weeks follow up). The rest looked at immediate outcomes with no follow up at all. I don't think anyone has any doubt that suspending puberty has strong physiological effects while on the drug, the question is do these effects reverse after ceasing or are there long term effects.
• The presenter concludes herself - particularly given that there isn't any evidence of follow up - that the point is that we simply don't know, rather than long term cognitive impairment has been proven.

Finally, it's important to recognise that this is one expert's interpretation of a complex and contested area of medicine. It is entirely reasonable to discuss possible long term risks of puberty suppression, including questions about neurodevelopment. However, there is a very important distinction between “this is an area requiring further research” and “this intervention is known to cause brain damage”. The latter requires a level of evidence that currently has not been establised.

Ok have to get back to the day job :)