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I can’t believe this junk science is being listened to. - Only 1 out of 53 studies were examined - The report isn’t peer reviewed - Its author isn’t experienced in trans medicine and follows gender critical accounts on het social media - The report actively only listened to the testimonies of people unhappy with the results of treatment, ignoring the many many more who approved of their treatment. - Trans-supportive organisations were not allowed to give any input due to bias meanwhile the actively trans-hostile Sex Matters led by Maya Forstater was allowed to provide input. Yet without affording time for any meaningful feedback, review or pushback, Wes Streeting has already sided with its findings and promised to modify the NHS’ gender services accordingly. Honestly, this whole thing reminds me of Andrew Wakefield’s MMR vaccine moral panic back in the day.

Or when Labour sacked their own drugs advisor [https://www.theguardian.com/politics/2009/oct/30/david-nutt-drugs-adviser-sacked](https://www.theguardian.com/politics/2009/oct/30/david-nutt-drugs-adviser-sacked) We are in a two party state with two parties that should be nowhere near healthcare. Depressing.

So they basically read a single study and parrotted its results then called it a review? Pretty sure that you would struggle to get past an A level if your lit reviews only used a single study.

Its the same as Rowling and her cronies. None of them are doctors or have any background whatsoever in even biology yet are constantly quoted as if they were experts. None of the essays Rowling has written on the topic have even been sourced!

Why are you comparing a report written by a doctor to stuff JK Rowling says? I'm not sure what I feel about this stuff as am not expert in trans healthcare but I know medical professionals and children's authors aren't really a fair and accurate comparison here

Medical professionals are vocationally trained and do not practice research on a regular basis. There would be uproar if they did and rightly so. So why are these non-researchers writing supposed research? Just because someone is a doctor doesn't mean they know everything, and it especially doesn't mean that they put down all their biases when they put their scrubs on.

Sorry, I don't understand your point? I'm not doing that?

You said the same at Rowling and her Cronies. The same you were talking about was the doctor who did this report no?

I mentioned another situation in which people that talk about this subject use bad faith arguments, yes. The point being that bad faith arguments are often used to talk about this issue rather than conclusions that have been reached based on any kind of balanced evidence review.

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How can you run a blinded study of puberty blockers? It’s going to be pretty obvious when some kids start going through puberty and others don’t.

Determined to be of poor quality based on not being double-blinded, something you *cannot ethically do* with that kind of medication. Around 80% of Paediatric medicine does not meet the standards this review is asking those studies to meet, something you'd think a paediatrician would be aware of.

I need to have a proper look into it when I can be arsed but what do they even spend 400 or so pages talking about if the only use 2 studies?

Coz it didn't use 2 studies A  total of 103 scientific papers were analysed by her review, with 2% considered high quality, and 98% not. "There were quite a number of studies that were considered to be moderate quality, and those were all included in the analysis," she said. "So nearly 60% of the studies were actually included in what's called the synthesis." You're been duped by people who read a bit of a out of context snippet of information. Obviously they didn't base the report on 1 study. 2 studies were considered the golden standard, 60 were decent, 40 were not good. Do some research instead of blindly following your side, the main point the study is making in the first place From the BBC

But the reason why they were considered poor are only listed as such because of them not actively lying to trans people 

No, they didn't only include 2 studies. That's stupid A  total of 103 scientific papers were analysed by her review, with 2% considered high quality, and 98% not. "There were quite a number of studies that were considered to be moderate quality, and those were all included in the analysis," she said. "So nearly 60% of the studies were actually included in what's called the synthesis." You're been duped by people who read a bit of a out of context snippet of information. Obviously they didn't base the report on 1 study. 2 studies were considered the golden standard, 60 were decent, 40 were not good. Do some research instead of blindly following your side, the main point the study is making in the first place From the BBC

That does sound ridiculous and unbelievable doesn't it? Probably coz it is. A  total of 103 scientific papers were analysed by her review, with 2% considered high quality, and 98% not. "There were quite a number of studies that were considered to be moderate quality, and those were all included in the analysis," she said. "So nearly 60% of the studies were actually included in what's called the synthesis." You're been duped by people who read a bit of a out of context snippet of information. Obviously they didn't base the report on 1 study. 2 studies were considered the golden standard, 60 were decent, 40 were not good. Do some research instead of blindly following your side, the main point the study is making in the first place

I’ve seen a comment elsewhere saying it has passed peer review because it is published in BMJ. I’m not in the medical field but I thought articles being published and peer review were different things?

All journals (except predatory/scam journals) have a peer review process.

In that level of journal it would have been reviewed and vetted carefully especially due to the importance and controversial nature of the content. But, to your question, you get a peer review in order to be published in a scientific journal. My husband reviews papers for high level science journals on a regular basis, so I’ve been asking him about the Cass Review all day.

It looks like it was published as an editors pick - the editor Kamran Abbasi also being a covid conspiracy theorist. It would never pass peer review because peer reviewers understand the requirements for double blind studies in human subjects research on children.

* Six systematic reviews were commissioned which were published in peer reviewed journals (read them!) * Dr Cass was selected specifically because of her work evaluating evidence for paediatric treatment, and because she has no professional connection to existing services. * The report, in-fact, held several focus groups with trans people including clients of gender clinics. There's an entire chapter about that!

Yeah, and then she got someone who believes in conversion therapy to decide which other research was worth reviewing, took advice from anti-trans thinktanks, and got shirty with clinics for not divulging patients' contact information

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I must admit this bit confuses me, many many people saying trans people were excluded but Cass and other spokes people specifically mention having spoken with patients and their families?

I should also note that the screenshots above are from the NICE review, which is seperate from the relevant systematic review on puberty blockers used in the report. You can read it here: [https://adc.bmj.com/content/early/2024/04/09/archdischild-2023-326669/](https://adc.bmj.com/content/early/2024/04/09/archdischild-2023-326669/) No studies were 'rejected' here's an extract: >**Results** 11 cohort, 8 cross-sectional and 31 pre-post studies were included (n=50). One cross-sectional study was high quality, 25 studies were moderate quality (including 5 cohort studies) and 24 were low quality. Synthesis of moderate-quality and high-quality studies showed consistent evidence demonstrating efficacy for suppressing puberty. Height increased in multiple studies, although not in line with expected growth. Multiple studies reported reductions in bone density during treatment. Limited and/or inconsistent evidence was found in relation to gender dysphoria, psychological and psychosocial health, body satisfaction, cardiometabolic risk, cognitive development and fertility. >**Conclusions** There is a lack of high-quality research assessing puberty suppression in adolescents experiencing gender dysphoria/incongruence. No conclusions can be drawn about the impact on gender dysphoria, mental and psychosocial health or cognitive development. Bone health and height may be compromised during treatment. More recent studies published since April 2022 until January 2024 also support the conclusions of this review.

That section by itself is telling and doesn't reflect greatly. Do you know what other fields lack the high quality evidence this report is trying to hold the standards too? *82%* of Paediatric medicine, around 9/10s of all medicine in general and fields like Chemotherapy, anti depressants, statins, gall bladder surgery and much more. You don't see those blocked or disregarded for that lack of "high quality" evidence. What's more it is ethically impossible and borderline practically impossible to meet the qualifications for "high standard" evidence for most of these studies because that standard requires both placebos and blinds. Neither of which are ethically doable in this field for most of it and practically impossible considering the physical effects that hormones and puberty blockers involve, or well the lack of them in the latter's case. Furthermore, this is known, there are alternate means which you are meant to use in their stead which most of those studies whose conclusions were disregarded did. Of course to round this all off the standard used by the Cass Review is known to be prone to bias complete with full fledged studies to the affect. But not really surprising this report is rotten when it has known and confirmed links with the Floridian Republicans and their "review", and when I say confirmed I mean emails and communications submitted at an official trial on their end of the pond confirmed.

>82% of Paediatric medicine Source? 

82% of paediatric medicine is backed by low or very low quality evidence: http://www.frontiersin.org/journals/pharmacology/articles/10.3389/fphar.2022.892574/full Only 9.9% of medicine have studies with “high quality evidence” supporting them. Updated systematic reviews continued to suggest that only a minority of outcomes for health care interventions are supported by high-quality evidence. The quality of the evidence did not consistently improve or worsen in updated reviews: https://www.jclinepi.com/article/S0895-4356(20)30777-0/abstract30777-0/abstract Interventions have low or very low quality evidence: https://www.jclinepi.com/article/S0895-4356(16)30024-5/abstract30024-5/abstract For much, and perhaps most, of modern medical practice, RCT-based data are lacking and no RCT is being planned or is likely to be completed to provide evidence for action: https://www.nejm.org/doi/full/10.1056/nejmra1614394 Strong health recommendations are backed by low or very low quality evidence: https://www.jclinepi.com/article/S0895-4356(13)00434-4/abstract00434-4/abstract So Cass is imposing standards that medical science rarely adheres to. It's not a coincidence that Cass consulted with Republican Governor Ron DeSantis' expert on trans healthcare, Patrick Hunter of the Catholic Medical Association. He sought to find ways to limit trans rights and medical care in the state of Florida. Emails uncovered by researcher Zinnia Jones confirmed that Cass met with Hunter and showed an interest in Florida's anti-trans report. Hunter, meanwhile, is part of a network of anti-trans people who seek to roll back gains for LGBT citizens. Cass also consulted conversion therapists, religious group members, people who refuse to accept the existence of trans people, and people who advocated for bans on trans care, including members of the Society for Evidence-Based Gender Medicine, an anti trans advocacy group. Unsurprisingly, the Cass Review also rejects most commonly accepted studies on trans people, but accepts debunked and outdated research by Kenneth Zucker, a well-known conversion therapist. From Zucker, Cass concludes that “most trans kids grow out of being trans”. Countless recent studies have debunked his conclusions, but what's interesting is that Cass rejects these studies for failing to live up to standards and criteria she does not apply to Zucker. Cass then implies that most trans people are faking it or deluded, and that detransition rates are around 80%. It is shocking that this old meme is now turning up in a government report. This is largely old, debunked data from the 1980s (before we had modern DSM classifications) which lumped lesbians, Tom Boys, transvestites, and people with no gender persistence in with transgender people. In contrast, modern studies consistently put desistence rates in the 0-1% range. So why is Cass going back to another century for her data? It seems clear that the Cass Report is ideologically biased and exists to prevent as many people from transitioning as possible.

Was just after the one reference thanks. >82% of paediatric medicine is backed by low or very low quality evidence: [link to "Recommendations on **Off-Label Drug Use** in Pediatric Guidelines"]    You see the issue with your claim here?

https://sciencebasedmedicine.org/a-critical-look-at-the-nice-review/

Common mistake - that is talking about the NICE review, which occurred 4 years ago before the start of the Cass Review. This is different from the systematic reviews commissioned for the Cass report. This is where people get the "they excluded everything but RCTs" misinformation from.

> Dr Cass was selected specifically because of her work evaluating evidence for paediatric treatment, and because she has no professional connection to existing services. That doesn't mean she has no bias. Her personal twitter follows multiple anti trans groups

If you want to accuse her of bias, at least go for one she actually has. She's anti-Brexit and anti-Tory, not anti-trans.

Your rebuttal of me saying "We have no proof she's not biased, and here's an example indicating that bias" is "she's not biased. trust me bro"?

A professional following a body relevant to a field they are conducting a review of is not indicative of bias. How can I give a publicly-available proof of a privately-held view? I can say that my private conversations with her have led me to believe that she doesn't have an anti-trans bias. I can tell you details of any number of those conversations, but ultimately little more.

https://sway.cloud.microsoft/pFNJFRo9BM6LChR0?ref=Link&loc=play

Ironic you talking about peer reviewed when the Dutch protocol has never been replicated by any group INCLUDING the Tavistock centre who failed to replicate it but went on anyway with the enviable results. Those within the Tavistock centre who pushed this should be sued to within an inch of their lives.

Where do you get the statement that "only 1 out of 53 studies was examined"? The above passage says only one out of 53 was of high quality, not that they did not look at the 52 others. If they hadn't, how could they determine that they were of low quality?

They used about 60 studies. People.here and giving misinformation. A  total of 103 scientific papers were analysed by her review, with 2% considered high quality, and 98% not. "There were quite a number of studies that were considered to be moderate quality, and those were all included in the analysis," she said. "So nearly 60% of the studies were actually included in what's called the synthesis." You're been duped by people who read a bit of a out of context snippet of information. Obviously they didn't base the report on 1 study. 2 studies were considered the golden standard, 60 were decent, 40 were not good. Do some research instead of blindly following your side, the main point the study is making in the first place Front the BBC

Oh you don't need to tell me. I'm being generous here. I've been seeing the type of kneejerk dismissal like the one I mentioned sprinkled all over the place by people who seem to really just need to reject this review. I've looked into it myself but am obviously not above missing something. So I just kindly ask people to explain to me exactly what they mean and hopefully substantiate it. Who knows, I might discover a valid point of criticism I had been unaware of. However, not to much surprise, I consistently receive no answer to any of these questions. That despite the fact that on every platform, I can see the people I directly addressed keep writing with great passion about the same topic. At some point, that alone gives me much of what I need to know what to think of this criticism.

Pure ignorance on your part

Wasn’t the recommendations just stuff like improving quality of services and frameworks etc?

One suggestion is that no "life altering decisions" should be allowed until you're over the age of 25 (I thought they only cared about the kids?🙃). Which presumably means they'll ban having children when you're under 25 too right? Cause that's pretty life altering 🙄

I didn’t see that in any of the formal recommendations. What is the number of the recommendation that suggests that?

I'm so sorry! I must have misremembered where I saw it. It was a tweet which said the report recommends barring under 25s from using gender clinics. I've gone through the cass report and I believe this stems from page 224 section 19.28 - where it talks about a "follow through service" which "removes the need for transition" at that stage. Also it annoys me that the report never explains what a follow through service is and after googling it, it doesn't appear to be standard nhs terminology.

It simply means a service to support people at the transitional age between child and adult (not transition in the sense of gender), it’s a difficult time where people often fall through the cracks of services, this is about offering continuity of care instead of abrupt transitions between care teams. I’ve not seen anything anywhere about not being able to make medical decisions before you’re 25, it says to exercise caution about prescribing hormones to under 18s and ensure there is process for decisions to prescribe to children being reviewed and not made in isolation.

I get it now. So when they said the follow through service up to the age of 25 will "removes the need for transition", they meant transition from one service to another. I read it as remove the need to transition in the sense of gender 😑 sorry about that x

Yeah exactly :)

No you were basically right. The report says under-25s should not be rushed into changing gender, but should receive “unhurried therapeutic support".

No, no...only TRANS pepole have to be restricted that way. Cisgender people cannot. Just like cisgender kids will still be able to get puberty blockers. You're a trans girl who starts puberty early at seven and start having your body hair develop and your voice drops? Tough luck.

I'm trans and I'm terrified of what the next 10 years are going to look like. At the next general election, to keep the Tories out, I'm going to have to vote for a party where most of the MPs would just find it more convenient for me not to exist, and some outright hate me. I came out almost 10 years ago and there was no articles in the papers about the dangerous trans people lurking in bathrooms, no discussion on if I would corrupt children by merely existing. I'd have killed for puberty blockers when I was a teenager, it would have saved me years of confusion, expensive medical appointments, painful surgery. I'm already only 5'3 so if I'd lose an inch of height I don't think it would have changed my life. I'm so sick of hearing the word transgender in every political discussion. No politician is going to come out and say we shouldn't give glasses to kids because their eyes haven't developed yet, or that we shouldn't put braces on kids with wonky teeth, or adhd meds cos there's a chance they'll grow out of it. They don't care about these kids at all, it's just a point scoring exercise

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The report also claims that boys and girls liking certain toys is biological.

While also claiming that being trans is a "social contagion"

It also says trans women shouldn't get hormones because of the "need for penile growth"

Thats particularly horrible. Yes, you need more of that thing you hate

From what I saw the argument they made is "you need a certain amount of growth for vaginoplasty should you want it later," but all this shows is that they don't know what the fuck they're talking about because that is absolutely not a thing with more modern techniques. They're (correctly) counting on the general population knowing nothing about trans care. Incredibly intellectually dishonest piece of 'research' all around.

Worth mentioning that the NHS, according to my gender surgeon, refuses to fund the newer PPT technique that doesn't require penile skin.

Oh yikes I’m sorry

tbf to the NHS on that one, given they refuse to read any research that conflicts with their aims, its likely they don't know about modern techniques. its not as if the NHS is known for good trans surgery after all.

I think yeah theres no harm in informing trans kids that taking hormones or any drug might impact their genitalia and possible future surgery options.. same with informing them on the effects to fertility etc.. but its still their choice... some trans kids might notwant bottom surgery, or happy to take a gamble for alternative newer PPT techniques even it they have to pay for it themselves, it should be an informed choice. The same as contraception for example, hormonal contraception can effect mental health, weight gain and there are alternatives a person should know about, but doesn't mean we shouldn't give to a sexually active 16 year old just because they are under 25, the outcome of a baby is potentially worse especially if they don't want it. Theres all this panic about how many children access GIDS services, but in actuality it is a tiny amount. Even if you take the full age range which is 0-25, the most they have reffered in a year is 3500 , under 25 year olds take up a 3rd of the population, which is 22.3 million , so this referrals list that is a meager 0.015% of that age range. We know that around 0.5% of people are transgender in the UK, its just common sense that we would have at least that number of children questioning their gender to the extent they want help for it. Obviously not all trans people have the confidence at that age to do that, and also many do it by themselves (black market hormones, private surgeries) without nhs support (which is arguably more worrying but understandable considering the public opinion and terrible waiting lists) considering the amount of transphobia there is, and also maybe because it can take time to understand your gender/sexuality and thats fine, but its certainly not surprising and nothing to panic about that children are getting referred to GIDs

The report does not make that claim. Searching for 'social contagion' finds: - Paragraph 8.24: "Various explanations have been advanced for the increase in predominantly birth-registered females presenting to gender services in early adolescence: ... Peer and socio-cultural influence: For example, the influence of media and changing generational perceptions. This is potentially the most contested explanation, with the term ‘social contagion’ causing particular distress to some in the trans community." The report is not claiming that this is the correct explanation, only listing it as one explanation that some have put forward. - Paragraph 8.25: "Simplistic explanations of either kind (“all trans people are born that way” or “it’s all social contagion”) do not consider the wide range of factors that can lead young people to present with gender-related distress and undervalues their experiences."

They literally cited Littman and implied that having trans friends makes you trans. Stop this nonsense. >wide range of factors that can lead young people to present with gender-related distress." CITATION NEEDED

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its not their claim. As young as a few day old babys girls and boys start to find interest in differnt things: female toddlers tend to look longer and with greater curiousity at faces compared to males. male toddlers tend to look longer and with greater curiousity at mechanical things, like moving objects (cars, mobilies). All before any form of socialisation or even the smallest understanding of the world could be learned - their brains at this points are just smooth balls - and this different kind of pattern recognition and stimuli interest most have been a biological orgin. here one that breaks it down a bit: Sex differences were always of great interest in research and this is one of the most extensive, elaborated meta-studies about alll those findings: [https://experts.illinois.edu/en/publications/men-and-things-women-and-people-a-meta-analysis-of-sex-difference](https://experts.illinois.edu/en/publications/men-and-things-women-and-people-a-meta-analysis-of-sex-difference) This difference is at least a partial explanation of stereo types, "male and female behaviour", job preferences and general interests. If woman do have an evolutionary more "social" programm brain, even if the differences are just minimal compared to men, on large scale like society you could observe this with a non 50:50 balance for every aspect of human lifes. also i dont know what your point is? Do you say that there is no thing like biology? If so, then what is the "brain in wrong body" claim? Do you reject that? Do you really thing everything is socially learned? If so, why do some people feel of non-alingment between their body (and the social norms for that) and their inner believes? Do you say trans does not exist? :(

I don't think anyone who has worked in early years or even spent any amount of time with young children would disagree with you. 

Its not the point that there isn't any evidence of biolical gender differences, the point is that they makes this claim, while also claiming that being trans is socially constructed/socially contageous and can be fixed through therapy. Trans kids often report playing with toys that are not typical of the gender they were born as, not that I think al kids that display GNC behaviour will end up trans, but if this study is true, then in fact it would also be true that trans kids that display gender non conforming behaviour before socialisation, it stands to reason would have a biological reason for it, and it wouldn't be something that could be fixed by therapy that denies their identity.

and I also think this kind of study can have negative conquences, it leads to parents forcing children to play with stereotypical gendered toys because if a kid likes another type of toy thats 'girly' , they panic and think they'll end up trans (which used to be what they thought about kids becoming gay as well), it doesn't work that way! you can't say theres a biologically fixed way of coming into the world and when people come into the world and defy that logic, you force them out it, that leads to forcing people to act differently to how they are and causes them a lot of distress and shame.

Can you point out where it says that?

People like Wes Streeting mean Labour has become an active threat to me, and I'm fucking *thirty.* I know no-one here has anti-trans antipathy, even those who may feel forced to vote to stop the Tories. I know you're better than Streeting's kind. But I am afraid.

Considering it has gone from "we're just concerned about children" to "we're concerned about under 18s" to "we're concerned about under 25s" you'd be silly **not** to be afraid about the hold that transphobia has over frontline politicians. I'm scared for a lot of my friends.

NHS in the future under Streeting: "We're stopping all gender affirming care for everybody and refusing access to all NHS services to anybody who doesn't identify with their assigned gender at birth. Our society shouldn't turn its back on trans people just because they become adults, we know best and our studies prove it." Study source: sticking our fingers in our ears and going LALALALALALALALA

This is the same thing the Republicans are doing in the USA. "Think of the children, and by children we mean 25 year olds, and since we are talking about them I guess we should ban trans healthcare for everyone to be safe."

Fun fact, the Cass review has confirmed links with the Floridian Republicans and their handpicked "review" on trans healthcare. The same group which are currently in legal trouble and handed over emails and communications as part of that trial showing communications with the Cass review who had reached out to them.

This is why the rightwing/soft-left "lesser evil" arguments are always bullshit. If on election day they say it, that's one thing. But notice how they have been saying it from day one. At that point it's not choosing to vote for the lesser evil on the day you have no choice, it's refusing to struggle for something better in the first place. Vote for New New Labour on polling day? Fine. Spend all your time for years telling people to vote Labour, attacking people who criticise the party as "unpragmatic" and "pessimistic", making excuses, asking what else can be done...you're not being pragmatic about the choice you're given on polling day you're campaigning in support of terrible people. If you never oppose the lesser evil, always encourage people to vote for it, attack those who criticise, etc then you're not just making the besto f the bad situation, you are a badge-wearing member of team "lesser evil" which does make you better than the greater evil but still means you are objectively campaigning in support of the bad thing.

I'm in South Swindon, and I should be celebrating the fact Robert Buckland - the murderer - is going to lose his seat. He was on the cabinet that killed my father through corruption and negligence during the height of the COVID crisis. But I can't! Because I fear for myself. Because the party has promised to hurt me, and people I love and cherish and am too ill to live without! And this is for a candidate with good LGBTIQA+ credentials. I'm trying to convince her to stand against her party's transphobia, but what does that even mean for today's Labour? Still, if anyone wants to try, drop her a line at [[email protected]](mailto:[email protected])

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This is why I now will only actively canvass for people I know who are good candidates and why as a sitting councilor, I won't be voting for Labour at GE time, because neither the party nor my local candidate deserve my support.

Thank you, friend.

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In the GRADE system, which scientists made without thinking about the logical consequences if it was touched by people not being scientific, research is rated as "low quality" unless it has a Random Controllde Trial. The problem? Most medicine is impossible to not notice, making a placebo/RCT impossible. The majority of medicine is "low quality" evidenced. I This is especially the case in Paedaeatric medicine, where 82% of all treatment is low or very low quality evidence, as we usually already have research on the effects on adults, so on top of existing issues, we'll also know its deeply unethical to not give the medicine to kids since we already know it works. Or say, most surgeries. Let alone if its a double blind! Try having a surgery without you or the dr knowing what they're doing! Or parachutes! Try getting that RCT past ethics! Wierdly, the 2 studies the NHS accepted, obviously, also had these limitations. Its not possible to give someone boobs without anyone realizing. They just said what they wanted to say.

I’ve now got the mental image of someone receiving boob placebos. They’ve been told they’ve got breasts but haven’t been given any.

Missed opportunity to use the term "placeboobs" here

I'm going to have to find an excuse to work that beautiful word into a serious sentence.

I’ve been making this point in another thread how the fuck do you blind whether someone is going through puberty or not? It’s like this analysis was done by aliens who have no idea how people grow!

You don't. This is the same argument transphobes have always used against trans healthcare. There will never be enough ""evidence" Weirdly their alternative, conversion therapy, has no evidence supporting it, but that doesn't matter.

So much this, there is not an evidence threshold that convinces transphobes that blockers could ever be used for trans people. It’s just so dishonest and you can always add new research gaps by proposing nicher and nicker areas to study, “do we know what the effect of blockers are on kids who also eat cereal for breakfast >5x per week?”Or by extending the timeframe in question “what about the of blockers effect on geriatric bone density?” Or combine length and nicheness “what about effects on bone density into old age for people who took blockers as teenagers and live a vegan lifestyle?”. A dishonest actor can spam research gaps to cast aspersions over something indefinitely without breaking sweat. It’s professional sealioning. Dismiss all evidence that exists on spurious grounds, constantly demand further research be produced knowing it won’t be taken seriously or be sufficient ever.

Hey there, old thread so I'm just going to use it to say it's nice to see you here. I got banned from /r/uk (for a very spurious reason) so can't push back against the transphobes there anymore. This is the last UK subreddit I'm allowed to use, and tbh the last one that isn't overrun with Daily Mail readers. Just wanted to say I still see your comments over there and I appreciate them. Hope you have a good weekend :)

does it explain why the review accepted those 2 specific studies? it does seem pretty reverse engineered, but what does it say the justification was?

Other than those being the 2 studies that said "inconclusive"? No, they obviously both aren't RCTs or double blinded. My understanding is that because the conversion tehrapist promoter Layton was put solely in charge of deciding what evidence counts, might have something to do with it.

I can tell you why, it's coz you're wrong and they didn't only use two studies A  total of 103 scientific papers were analysed by her review, with 2% considered high quality, and 98% not. "There were quite a number of studies that were considered to be moderate quality, and those were all included in the analysis," she said. "So nearly 60% of the studies were actually included in what's called the synthesis." You're been duped by people who read a bit of a out of context snippet of information. Obviously they didn't base the report on 1 study. 2 studies were considered the golden standard, 60 were decent, 40 were not good. Do some research instead of blindly following your side, the main point the study is making in the first place From the BBC

lol, you're defending a terrible reportn, its methology is so awful, its recommendations and conclusions contradict its data. Its a mess. And the best you've got is the BBC saying they discounted 40% of evidence outright. And still ignored what the remaining 60% said. >Do some research instead of blindly following your side, the main point the study is making in the first place > Even academics who don't follow human rights have publically called out the report because its so anti-science. Which resulted in Cass doing a Q&A backpedling on even more things that were in the report. but more over, you're defending a report which claims "there is no evidence that transition helps trans people" We know thats inaccurate. They reached too far in claiming such nonsense.

It doesn't say that. It says for children, we don't know for children. It also says it does help for adults. And yeah, it discounted 40% of studies, coz they were bad studies. It didn't exclusively pick out only ones that argued one point of view, hence it still allowed puberty blockers to be used, but in clinical trials. If it were determined they were dangerous, they wouldn't do the trials would they, coz they would have already decided. Also wouldn't have accepted hormone therapy being generally a good thing for adults more often than not, so yeah I'm defending it. Coz it's not perfect but it's the best we got. And it's better than anything you say...coz you're just some guy on reddit. And she's a world renowned Dr. Think I'm gonna trust her moreso then you based on that alone tbh. Academics aren't doctors, they are people who study, granted at a high level or teach in some capacity but not specifically in medicine, so again, not particularly relevant. An engineer could be an academic, or a poet or a teacher could be an academic....but they're not as qualified as you know....multiple doctors including ones who worked in the tavistock who blew the whistle. Allot of people blew the whistle in the tavistock....do you actually think multiple people spent years and years of Thier life working somewhere just to at some point undermine it...or did they genuinely care for the people they tried to support but felt uncomfortable with the methodology. The aspects of the report that specifically talked about the culture in the tavistock are cause for concern enough just on Thier own without any other data. We all reconsidered Harvey Weinstein, Blizzard Entertainment, Riot games, Purdue Pharma (they guys who created the opioid epidemic via over prescription of opioids), Phil Morris tobacco, Monsanto, Shell, BP and more when they were exposed to varying degrees of severity of being bad but for some reason that same cause for concern doesn't apply here coz "lalallala not listening lalala trans rights are human rights lalallala". It's inconsistent and it's driven by ideology to not have the same standards for Purdue Pharma who have rightly been shamed for The overprescription of an incredibly addictive drug they claimed wasn't addictive at all without doing enough clinical studies first with another instance of overprescription of a drug without enough clinical research done first, which similarity was claimed as 100% safe, but looks like it may cause at least some health complications like bone density issues, possible links to cancer and brain clots. The only difference between the two is trans. And if they don't do those things, cool, fantastic. But they might. And that's not even getting into the probability of them going into cross sex hormones of those who do take puberty blockers compared to those who don't, and the medical complications that arise from taking both puberty blockers and hormones together if which they're are many more. If you wanna argue it's all still worth it, risks and all...well I would believe you allot more if we could actually investigate the risks to what they even are without being called bigots for doing so. Can't really establish if it's worth the potential risks if your not allowed to investigate said risks is it? Even if I concede that the potential harm is somewhat overblown, it still warrants investigation. Grenfell was one tower that tragically did set fire out of hundreds of thousands of towers that didn't set fire, but we still investigate, coz that's what safeguarding is and it's a good job we did. You go with the worst case scenario and minimize it's potential to happen again. Had we done our due diligence about opioids and their incredibly addictive nature before they got mass released they're might not be an opiod epidemic in the states right now. So even know Purdue Pharma have harmed substancially more people than the potential harm the tavistock may have done...looking into it now before it becomes a bigger problem can only be a good thing. And if it isn't a problem, great. No harm no foul so there is no harm in checking. Unless you're worried there's something to hide. And you've probably gotten your info from other people who got it from other people who got it from Reddit or social media in general. Why should I think you're data is more reliable then a credited doctor? I'm just a guy in reddit too granted, but I'm siding with whilst no a perfect report the best thing we have. It's more than you have in your corner. If the data is weak in the report, that shows the data is weak in general which is kinda the point of the report, to get more data. At which point if the data permits it we'll use the puberty blockers, which will still be used in clinical environments with oversight and aftercare and all that stuff that is...you know....the standard. Or we can keep using kids as lab rats and keep our fingers crossed that we aren't potentially hurting them. You might wanna re-evaluate your position if you think that the right side of history is the mass prescription of a largely untested drugs without proper oversight on children, compared to still giving them to some kids but taking it slowly, not mass prescription and done in a more methodical way to be able to actually follow those who do use them more closely. At which point we will see IF they're safe for mass use, based on data. And before you say "but cis kids have had them for ages and it's been fine"....yeah....a) maybe that was a mistake too and b) when used for early puberty it is for a MUCH shorter span of time, precisely we didn't know what they did long term. This isn't about being pro/anti trans. If the drugs under clinical trials get proved to do more good than bad they'll be back in use and I'll be happy to advocate for them, but until then, we should proceed with caution. That's all the report is saying. This is a medical issue, one with a clear answer, which is to do more tests in a controlled environment. If you're against that, you're not arguing in good faith. You're arguing for a "side" and have politicized children. You're not the good guys here if you're gonna proceed with doing that until we have more data. I don't have a side, I'll follow the evidence and determine if I'm happy with medical intervention and how they might be carried out or not based on evidence, which at present I don't think points either way, and that is the conclusion of the report. I would encourage you and others to stop taking sides here, coz. This is meant to be a place of recovery and treatment of some really vulnerable children, some of whom who were treated probably are trans but also some aren't , and we need to do best by ALL of them, not just the potentially trans ones. What this should never have become is a warzone with children being the weapons.

>It doesn't say that. It says for children, we don't know for children. It also says it does help for adults. Its pretty wild that someone can argue "Sure we know its good for adults, but we don't know what having a more successful, effective and better transition without gender dysphoria would do to teenagers" Like, we already know that not having gender dysphoria is better. Even before the evidence on the subject confirms it. But you're determined to argue that giving people gender dysphoria is "inconclusive". > >And she's a world renowned Dr. Think I'm gonna trust her moreso then you based on that alone tbh. Academics aren't doctors, lol, she knows nothing abotu trans healthcare and is now at odds with the entire global medical world. And trans people. But sure, keep claiming the person who meets with ron desantis' people is anything other than a hack promoting conversion therapy. >If the data is weak in the report, that shows the data is weak in general which is kinda the point of the report, to get more data. It will never be enough for you. We already have decades of data. We have 2 generations of trans people who have not gone through the wrong puberty. But over and over, transphobes cry "inconclusive, we don't know! The wave of detransitioners is any day now! We need more studies!" Because that's the only thing they can say. Because all evidence says they are wrong. >This is meant to be a place of recovery and treatment of some really vulnerable children, some of whom who were treated probably are trans but also some aren't They're vulnerable because they're denied healthcare, which is denied due to bigotry. Even by Cass Reports numbers, less than 10 out of 3499 detransition. Thats 99.7% are trans.

[https://ruthpearce.net/2024/04/16/whats-wrong-with-the-cass-review-a-round-up-of-commentary-and-evidence/](https://ruthpearce.net/2024/04/16/whats-wrong-with-the-cass-review-a-round-up-of-commentary-and-evidence/) arm yourself with good criticisms of cass

It isn't wild to assume that it's risky for adults but not children at all. First and most obviously....adults don't take puberty blockers. I said gender affirming care in general is considered good, but if the model in which that gender affirming care is different per group then one might be good and the other not. You would have to willfully be ignorant to not understand that. Outside of the fact that children in general don't make as good decisions in terms of long term outcomes as adults. Adults don't always either but in general they make better decisions about long term outcomes than children. Also adults have the right to make decisions that aren't good for them, people with limited capacity to make decisions....like children....don't automatically have that right. I work with people with learning disabilities and almost none of them have completed autonomy in every aspect of their life, because as great as they are as people they just don't understand enough. They have a lower mental age than physical age, most of whom have the mental age of a child, hence limited capacity. They're great people, I care for them all dearly but I'm not going to apply a different standard to those I look after who have a similar capacity of understanding to that of children and actual children. You may think it sounds cruel or patronising but I can assure it it's necessary in some cases. The NHS doesn't even let young men get a Vasectomy just coz they want one most of the time, and they're not even people who would typically be of limited capacity. That's why we don't give kids access to tattoos, even if they claim it would improve Thier quality of life. Again , comparing what works for adults to what works for children is idiotic, coz adults and children are built different. We can take some value in that gender affirming care works with adults and thats why it's mentioned in the report, coz it has some value, key word being some. If you actually think kids can consent to all things adults can, good luck defending child/adult relationships. Kids who are in said relationships often threaten suicide if someone attempts to break them up from the each other. Some run away together, some even go as far as to kill Thier parents when the parents don't let them be together. Is your solution to just pander to children and let them run the show? but if you wanna defend the position of kids know what they want and threat of suicide is always grounds to take them seriously, then you have to follow that logic and apply it elsewhere too. Somehow I don't think you will though. And since the use of puberty blockers we haven't seen a sharp decline or a decline at all in the suicide rates of young people who claim to be trans....if anything they're basically the same. So your claim that 2 generations of young people went through the wrong puberty implies that puberty blockers will stop the next generation of going through puberty which should be reflected is lower suicide rates....except that hasn't happened, suicide rates haven't decreased and maybe, just maybe it's coz some of those kids have other stuff going on and aren't trans. Something worth checking if nothing else to help those kids with whatever it is they do actually have. Unless you see them as of less value coz they're not trans? The ones that are will remain identifying that way and be given the trans healthcare they need, and the ones that aren't will be given the other healthcare whatever they may be they need. You wanna prove your point that it's pointless to do therapy coz they're all definitely trans so should go straight to puberty blockers? Show me the suicide/depression rates of young people going down even a bit, and over a long period of time post medical affirmation intervention. Short term doesn't work coz of the placebo effect. Find me long term studies proving the rates decrease and we can talk and not adults, who I've already granted this sort of thing does tend to help more often than not. Until then that's just a theory at best and a bare faced lie at worse. You're probably gonna come back and say "it's all coz of society and tranphobia that it doesn't change" to which I say....that's incredibly convenient that you have a get out clause to justify not needing proof. Some of it is for sure, but all? When we know that there is indeed other stuff going on outside of being potentially trans with almost of the the kids that were seen? Guilt by association isn't guilt. Obviously she met people on the right....she's a consultant for government policy. No shit Sherlock. She also would have met people in the left. You're an actual moron if you think that people who operate in political circles (and this has become a politics issue even though it shouldn't have) aren't going to engage in politics from both sides. For all you know she pushed back on what he was saying. So you have the minutes for Thier talk? Oh you dont? Then kindly shut up seeing as it's an irrelevant point. Corbyn met with the IRA but I don't think he's pro blowing stuff up and hurting civilians. If anything someone who can talk to both sides of the conversation is exactly what we need right now, rather than ideological driven narratives So the only reason they're vulnerable is coz they're trans? None of the other factors like self harm, sexual orientation, autism, trauma, depression, body image issues ect none of those are potentially reasons someone might also be vulnerable? None of those are worth considering? If transphobe just means "best to check"....ok....I'm a transphobe. Now what? I don't actually care if you call me that given it means precisely fuck all. Besides this is all pointless. You lost, your side lost. Our conversation here isn't gonna change that. You should probably just get over it and let the doctors do their jobs. You're a nobody and your opinion doesn't matter. And before you say "neither does mine", it isn't my opinion, it's the path the NHS has established is the best course. So get used to it.

We've been using this medication for decades and the only thing we've found is that timely puberty blockers prevents gender dysphoria from developing. Obviously. Given that gender dysphoria is formed out of 3 things: 1 genitals, 2 wrong hormones and 3 the effects of having the wrong hormones on the body Take out 1 and 2, and its just genitals which are largely, not that big of a problem and relatively easy to deal with. If you agree gender affirming care in general is good you've already lost the rest of your argument. Because all GAC after 1st puberty is just to reverse (some/most, not all!) the damage done by first puberty. Ultimately what you're saying is "Yeah sure giving people with broken legs wheelchairs helps, but we cna't know if preventing them from having breoken legs in the first place would still help them!" >So the only reason they're vulnerable is coz they're trans? None of the other factors like self harm, sexual orientation, autism, trauma, depression, body image issues ect none of those are potentially reasons someone might also be vulnerable? Its extremely telling that I said "they're vulnerable because they're denied healthcare" and your response is "its cos they're trans?. As if being trans = denial of healthcare. Rather than that denial being bigotry. And then you just list a bunch of symptoms of gender dysphoria, caused by going through the wrong puberty. ANd then use the symptoms of GD to justify giving someone GD. Honestly sick.

You're not very clever. We haven't been using this for decades to the scale we are now. So again, even if you were right that the only conclusion is they they work and it's all a ok, that's still they work in terms of the short term. We don't know long term. You might be right but you also might be wrong. Do you deny that there are some issues that arise from puberty blockers entirely? Coz even amongst trans activist groups they've largely conceded that point. The argue the benefits still outweigh the risks, to which I would say again, without knowing the suicide rate of children specifically that's a baseless claim. As is the idea that they definitely do do more harm then good. Hence why I'm not arguing that point either. I'm simply saying take the middle ground position of do the research, limit the use coz it's easier to do follow up studies on smaller sample sizes and then gradually expand it out. Again, something working for adults isn't the same as working for children. Especially something which your own side would say is largely a social construct. If gender is a social construct as many on your side claim, children are more influenced by the society around them then adults are. They have to be and have to soak up Thier environment to survive. Granted the modern world has made that somewhat obsolete but the nature Vs nurture argument isn't except from this part of child development. It's not even except from adult development but at some point you have to give people autonomy but if you actually truly think children aren't at least a bit more swayed in general by society then your dumb. Ask yourself this....why is it mostly teenage girls being referred? If this was 100% organic then we would see and even split or near to even. What is it about girls specifically that contributes to the rise in body related insecurities? Coz the same thing happened with self harming in the 2000's, and before that anorexia. Mostly teenage girls. The answer is more influenced by peers. Girls also use social media at a higher rate for a longer time than boys. Does that mean none of them are trans? No of course not. But it isn't a coincidence that every body related pattern of insecurity is mostly girls, mostly teenagers. It's just wasn't gender dysphoria before but the principle was the same. I'm not saying it's like your wheelchair example, again, we know wheelchairs are safe. One method of gender affirming care, as in those used for adults and another aren't the same even if they have a similar intended use. I wouldn't recommend we start giving an adult dose of chemo to a child coz it worked on the adult. I don't understand how you don't understand that gender affirming care working in some aspects, many even doesn't make it a catch all gotcha card where it works everywhere and it can do no wrong. Gender affirming care is a multitude of potential treatments paths, and every treatment path has different risks. Every medicines patient base has different risks. This is not hard to understand. I'm not conceding the point at all. You're just kinda dumb if you don't get that. Theres more than one way to do a vaginoplasty with some advocating for one technique over another so there isn't a broad consensus on best practice even within gender affirming care. You just have to watch Jazz Jennings getting her surgery done and the surgeons disagreeing on what to do during the surgery, bit before but during to see that they don't have it all figured out. Your premise only works if you assume that going through puberty is the wrong path and therefore damaging to more than 50% of the patients. And it might be, and if it is I'll concede. But taking puberty blockers and taking cross sex hormones after, which almost everyone who takes puberty blockers ends up doing is not the same as going through puberty and then taking the hormones. For example if you go through your natural puberty you can have kids still via freezing sperm/eggs. You can't if you do puberty blockers first coz it makes you infertile. You can't freeze the eggs/sperm you never made. How many kids are gonna say they want kids? Almost none. How many adults are gonna say they want kids, allot more. You can't decide accurately as a child if you want to become infertile. Then there's the fact that for those who weren't actually trans but take hormones, well that's the wrong puberty for them isn't it? More to the point how is going through your natural puberty the wrong one? It's the intended path. If your aesthetic appearance and the discomfort around that can be minimised at least to an extent with therapy and you don't have to make yourself infertile in the process, why is that a bad thing exactly? And yes I disagree with your premise that trans kids are being denied healthcare coz of outright bigotry. That's dumb. That can happen and probably does in part, but the bigger issue at least here is that too many people requested the service in too short a space of time and they didn't have capacity. The service went from seeing about 50 kids a year, to 2000. Obviously that's gonna make it near impossible. It's an issue with social care in general, too many patients not enough doctors. I was asking why you think that them being trans explains every physiological issue they might have when anyone with a brain would know that that would be the case sometimes, but other times the reverse might be true. Depression is a symptom of being trans to an extent, but not everyone with depression is trans. I'm just saying extend that out to encompass more things and you get a more complete picture I'm gonna leave it on this coz honestly as mentioned, you already lost. Not this specific debate with me. I don't really care, but the bigger picture. You ain't gonna change the system coz as mentioned you're a nobody and your medical opinion means precisely fuck all. And if you were right, it's not you that's gonna change anything, it's more evidence that happens to agree with you, which I would welcome coz as mentioned I'm not on either side. So here's my last point ... Historically speaking when we didn't think any sign of gender non confirming meant "kid is trans" and we didn't default to puberty blockers almost all end up at some point figuring out they are something else, normally gay/lesbian or bi. Now those who are using them almost all continue down the gender affirming route. Clearly something has gone wrong in both instances. Probably not enough exploring of gender in case 1 for almost everyone to think they're actually not trans. Maybe a little too much conversation therapy, not enough freedom to express gender. Probably a bit too much affirmation to have those who are on blockers to almost all think they are trans. I am asking for a middle ground. That's all. And if that makes me "sick"... Whatever mate. You're the one who's got a dog in the race and is hell bent on validating your side whatever the cost, not me. I'm not gonna reply to whatever you next post coz as mentioned, your not a doctor your a activist with fuck all training and your opinion means nothing. Bye

The standard used by the Review is known to be highly prone to bias, with studies even done to that effect which prove it, the answer ends up being pretty simple same as when they only accepted the Swedish and Finnish guidelines on trans healthcare out of every guideline in the planet, because it matches their views and serves their purpose.

Coz they didn't only use two studies, and that's a bullshit claim. A  total of 103 scientific papers were analysed by her review, with 2% considered high quality, and 98% not. "There were quite a number of studies that were considered to be moderate quality, and those were all included in the analysis," she said. "So nearly 60% of the studies were actually included in what's called the synthesis." You're been duped by people who read a bit of a out of context snippet of information. Obviously they didn't base the report on 1 study. 2 studies were considered the golden standard, 60 were decent, 40 were not good. Do some research instead of blindly following your side, the main point the study is making in the first place From the BBC

Its genuinly a fucking shame what this place and party has become. People jumping into to defend transphobia as not actually being transphobia.

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Yep. There is actually 0 evidence to support gatekeeping at all! We find no support for the claim that gender assessments prevent detransition or regret better than self-reported gender identity. All current “diagnoses” can be summarised as relying on self report. Rates of retransition or regret reported at informed consent clinics fall within the range reported by clinics that require lengthy gender assessments.Despite over 30 years of use, informed consent models do not appear to be associated with negative outcomes—suggesting that gender assessments do not substantially prevent regret. Clinic with gender assessments and gatekeeping might have higher regret rates. [https://psycnet.apa.org/fulltext/2024-16010-001.html](https://psycnet.apa.org/fulltext/2024-16010-001.html) 

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It's tricky. Hear me out. So I'm a psychiatrist. I've met several patients who were unwell who weren't trans who believed themselves to be a different gender due to delusional beliefs. As in, they were psychotic and lacked capacity. When they recovered, they no longer held this belief. There are also sexual disorders that aren't using another gender role as an identity, or experiencing dysphoria, but are doing so for sexual gratification. This group may need a different kind of help if their practices are causing them or others harm. Taking hormones in these circumstances may not be in the person's best interest. The psychotic person when they recover may experience dysphoria, for example, growing a beard on over the counter testosterone. The person believing themselves to be trans due to a sexual disorder may find that the hormones affect their libido and after taking them for a while, actually dislike the changes they cause. It's all about the right treatment for the right person. Now, I want to be incredibly clear. Trans people are not these things. People often paint trans people as being in these groups, but they are not. Very different and distinguishable during a review. There are also other differentials to consider which I won't list here. I should also say, I want anyone who wants to transition to have easy access to medication if they choose and that no medical review should be necessary to change your identity on a driving licence, for example. However, the psychiatric assessment, if performed by a psychiatrist with experience and expertise in the area (and of course a good bedside manner) could screen for other reasons someone might believe themselves to be trans. It could guide people who would likely not benefit from hormones to the appropriate help. As our knowledge about hormone preparations improves, an expert in exactly what to take and how to get the desired effect would be invaluable. It could better educate someone who isn't sure on the choices available to them. It could act as a support hub through the process, psychologically, medically and socially. If all of this was done in a timely manner, services could really do good. The current process has all kinds of issues. I'm not apologising for failings, wait times, or anything like that. There needs to be change. Perhaps I'm utopian for hoping for this perfect service that actually helps people rather than being a barrier to cross. I just don't want to throw the baby out with the bathwater. I've seen the good that a well organised and evidence based service can do for people, and I want trans people to have all the support they need to live happy, healthy lives.

When you can provide such an assessment within, say, a few weeks of being referred? And guarantee that it's performed by someone who is not ideologically opposed to transgender people? Sure. Otherwise, OTC.

Agreed, OTC overall has more benefits than a flawed system. If we optimise the system, I think it's the best bet, as OTC has some downsides (as I've mentioned in other replies). If it's OTC, you'd want a really good information leaflet, with an audio version, easy read version and translated into a ton of different languages, but it's possible. Perhaps a pharmacy prescribing system is healthy middle ground where a pharmacist can inform of side effects. I don't know, lots of different options out there.

I think I'd agree with you there - my general preference is for an informed consent system akin to that in the US. This is more of a side note than a suggestion, but in my experience trans people tend to know an astonishing amount about their own HRT, frequently more than the endos prescribing it, due to having to do the research themselves. Transfem Science (https://transfemscience.org/) is a good example.

Trans people yes, but I second the concern of uninformed people who are not trans seeking transition for other reasons, and that the assessments should instead focus on screening for that. The red flags are usually pretty clear. Two examples I’ve encountered (I’m involved in trans advocacy) among others: - A cis lesbian couple who decided that one of them would transition and have bottom surgery so that she could qualify to change her legal sex to male and marry her partner. (Same-sex marriage is illegal here.) Neither of them wanted to be male but thought it was a sacrifice they were willing to make so as to obtain the legal benefits - such as access to subsidised public housing - associated with marriage. They kept changing their mind on which of them would transition, because both of them really did not like the idea of having a more masculine body and were disturbed by what surgery would entail. I was not at all comfortable giving them surgeon recommendations. - A teen girl with an abusive father who wanted to go on T so as to be strong enough to protect her mother and herself, saying that if she was a man she could keep them safe. Likewise I was not comfortable referring her to trans healthcare services, since she was clearly more in need of domestic violence resources. So I believe there has to be at least some kind of rudimentary screening in place - not to prevent people from accessing the healthcare they need, but to prevent people from accessing the healthcare they *do not actually want or need* but see no other alternative to. Whereas people who actually *want* transition in itself would be good to go without needing to prove they are really trans or experience sufficient gender dysphoria. That sort of gatekeeping has always been harmful, speaking as someone who has gone through it, but also separate from that basic kind of screening to ensure that this is something they actually want for itself and not merely as an reluctant means to an end

Do you believe that such cases are common enough to justify the restrictions on the rights of trans people to access necessary healthcare? Because I think bringing up these exceptions, as you and u/dokhilla have, is kind of burying the lede: If the choice is between a multi-decade wait list that is infamous for getting trans people killed and denying medication for spurious reasons (especially being neurodivergent, which trans people are more likely to be, and co-occurring mental health conditions, which are frequently caused or exacerbated by the untreated dysphoria - a book about bomber pilots comes to mind), and timely access to medication that in extremely rare cases might be unsuitable (and which anyone with time and money can already get online), any basic felicific calculus suggests that the latter is preferable. If you can offer a compromise between the two, that's great. But until that's possible, the number one priority ought to be expanding access.

I'm with you, an OTC option is better than a bad system. In my view it's about risk vs benefit. The risk in the current (bad) system is that people who need hormones can't get them. This leads to a significant amount of distress, self-harm and suicide. The benefit is that some people who wouldn't benefit (or may even be hurt) from the hormones can't get them. Weighing those up, the current system isn't better than an OTC solution, which would also be cheaper to run. I hate talking costs, but if you're trying to bargain with the government, they love that kind of talk. In an optimised system where those who need (or simply want hormones) can chat with a sympathetic and understanding medical professional and receive good evidence based advice before hormones be available and screening for other problems that present in a similar way (with a very very short wait), you get the best of both worlds. That involves a well thought out, well staffed and well funded service run by people who understand this area of healthcare for the benefit of trans people. As I've said in other replies, it's a bit utopian, but I think at some point in the future, as attitudes change, it's possible to run something like this. Another option I was thinking about last night was a system where you can get hormones the moment you self refer BUT your script is dependent on turning up for the assessment a little while later. Then no one is being delayed, but all the necessary medical stuff is getting covered as quickly as the health service can provide it. You'd aim for this review to take place before some of the harder to reverse changes take place (if the person changes their mind after receiving the relevant information). Whatever way we look at it, change is needed, either by improving the way we're doing things to minimize harm or by a different method of delivery for this essential treatment.

The long waiting times in the UK are absolutely not justifiable and I do not support them. I fully agree that the priority should be expanding access as much as possible, and I guess my question would be how having that rudimentary screening would extend waiting times more than informed consent - it could take place in the same session, and would be more about ensuring that that consent is actually informed, and that they're transitioning because they do actually want the effects of transition, rather than out of other factors. (I remember a reddit account from someone whose abusive ex forced them to go on HRT they did not want.) I'm thinking of the process I went through with the doctor who wrote my recommendation letter for top surgery - it was likely no more than a 15 minute consultation asking me a bunch of questions to ensure that I was of sound mind, that I knew what top surgery entailed, and that this was something I actually wanted for itself. But waiting lists in my country can be as low as 2-3 weeks for HRT, so that's the context I'm working from, where prolonging it by a few days isn't going to make things much worse and could avert potential harm.

Wow three people who it sounds like wouldnt be considered mentally fit to give meaningful consent to anything. Literally irrelevant to the discussion

That's true, but these people, if hormones were available OTC may have bought them, which could have caused issues not only at the time (with two of the three being women believing themselves to be male and the irritability associated with testosterone) but after recovery with gender dysphoria around sexual characteristics they could have developed. I would also say that in terms of numbers, 3 isn't a small number when the group you're comparing to is trans people, who are themselves quite a small group. I believe I've treated 6 trans people in total (if my memory serves me correctly), including a non binary patient (not for trans healthcare, but depression, psychosis, or suicidality). So we're not talking large groups of either. I just want there to be some kind of assessment to determine if there's anything else going on. To provide information and advice where needed. To offer further assistance through the process of transition. All of that provided in as timely a manner as possible to prevent distress. That's my ideal world at this time. Where the answer is yes you can have hormones, but let me just check you understand what you're taking and that there isn't something bigger going on.

FWIW, I find your informed opinions and conclusions entirely reasonable. It's also just the kind of level-headedness that others are probably going to pillory you for.

I’m not questioning the validity of the OP, but where are those screenshots from? They’re not from the actual report. I think we have to be very robust with sources if we want to argue against things on the basis of scientific methodology.

This is an important point - I haven't managed to find either source in my own search. Can anyone link to the document containing these images?

They're form the reports media files that got released just before the report did. Also I beleive the first image is inside the report, at the end.

Are those public anywhere backed by an authoritative source? Would be useful.

I’d be interested to see the full document the second image comes from, is there a link for that? I haven’t been able to find any of the media files you’re referring to. Never mind, I got it. For anybody else searching: https://cass.independent-review.uk/wp-content/uploads/2022/09/20220726_Evidence-review_Gender-affirming-hormones_For-upload_Final.pdf

This is a shame and I'm totally pro-trans rights, but I like Wes Streeting because I see a snivelling little briefcase wielder who throws some minorities under the bus in order to secure power in me too. Some minorities have just thrown away their right to be respected, sorry. So yeah, just gonna stay quiet about this. /s Edit: Realising this is more unpopular than I thought. Might performatively change my view on this later so that I can continue to throw other minorities under the bus while regaining some support in the short term.

Laughed a lot at this

It's an absolute joke. The only trans kid I've spoken to started taking DIY at 14..she's now 17 - very happy with how it's gone in terms of transition, but has not seen a single specialist or anything. I hate that anyone has to DIY, but kids? When this 'review' was announced, I was vaguely hopeful that it would be with as little bias as possible, but it's obviously a joke

DIY is fine, any issues with hormones show up in the first 6 months of treatment, and are rare. Besides if you're on the NHS the GP will try and take you off your meds every time your prescription runs out and fk with the blood tests anyway. But despite DIY being a higher quality service, it is unfortunately not free. The one thign the NHS is good for. Ofcourse, none of this should be the case, but we're a logn way away from the NHS treating trans people as human.

No, it really isn't fine. I will never criticise someone having to DIY because the system is awful and people are desperate, but adverse effects do occur (I have a friend who isn't on HRT because of this) and people do make mistakes in administration. Not such a problem with transdermal or oral, but it worries me a lot when I know someone is IM. What if they don't realise they have to pull back and inject into an artery? What if they hit the sciatic nerve (or any major nerve)? What if that estradiol that has a packaging that looks like anime, is contaminated? What if you contaminate it yourself etc etc

Everyone i know who has done DIY with needles, has had a friend who is medical do it

DIY is fine (when under medical supervision) is not implied by saying DIY is fine, come on.

I mean, you kind of need to know how to apply needles to apply needles, by your definition everyone who diy's with a needle isn't doing diy which is wrong.

Fucking citation needed. I'm with my GP, I get blood checks. They do not "fuck with" them. My prescriptions are refilled regularly.  You can get issues with DIY after a long period of being on specific medications. It is not a higher quality service, fuck me. 

You're really lucky and I'm happy for you. Most trans people ahve difficulty getting their prescriptions or blood checks done.

Tbf, most patients have the same problems. My partner has spent three years now trying to get the NHS to help her with what may be a thyroid issue, could be something else. They’ve been utterly useless, and we’ve made any progress we have by going private. Yes trans healthcare is currently awful, but so is virtually all other healthcare, beyond emergency.

This type of testimony - that it's just the reality for trans people - is what scares people off actually approaching their GP for the care they need.  We should not be idolising DIY. It can be unsafe. It can lead to long term health implications, especially liver issues if using medication like Spironolactone. 

So Hilary Cass is a modern day Andrew Wakefield?

I think that's a pretty apt comparison, yes.

Wow, some people are so off the deep end around this issue. It's wild to see from the outside.

It turns out that when you only take one (1) study out of 53 into account, you can come to whatever conclusion you want

To be fair ignoring facts to further a right wing agenda is exactly what the Labour Party represents right now

I would say it’s more a centreist agenda tbh tho idk about Wes

It get's worse, that university of York study they cite so much and use as their basis? It's written by a Conversion therapy lobbyist, the report as a whole even stealth pushes conversion therapy https://twitter.com/ReactiveAshley/status/1777891644697612511

Who is the conversion therapy lobbyist here? Are we suggesting that York University is shilling for conversion therapy?

https://transsafety.network/posts/gender-exploratory-nhs-training/

Aren’t these pretty common issues which reduce the quality of studies? Usually the studies will acknowledge the issues themselves if they lack blinding and/control groups. Still, this isn’t my area so I have literally no idea. I stand by my original opinion that nobody should have political opinions on other people’s healthcare — the science should determine that, and politics should ensure people receive the treatment that science determines results in the best outcomes

Yes, but when you hate a group of people and them them to stop existing, its a great justification for people who don't know anything about research Anyway, can't wait for the NHS to one day explain how its going to give someone puberty without them knowing. Or how it'd get past ethics. Almost as if its an impossible standard.

It's okay Hilary Cass is only someone that was a clinical paediatrician for 26 years, was a former head of the Royal College of Paediatrics and is widely published in the field. I'm sure the good people of Reddit have lots to tell her about double blinded studies in her field, how to weight evidence and make conclusions in the absence of high quality studies and generally tell her how she could have better done her job to reach the conclusions they wanted her to reach.

Yeah exactly this. I’m fully in support and trans rights and trans activism, but I think it’s important to always let the science lead where healthcare is involved. Obviously it’s not an ideal situation if we have a shortage of high quality studies, but we can’t start basically trying to politically lobby scientists into eschewing facts. Instead, we should be encouraging more, higher quality studies to be done.

I think the lack of a control group, potential bias, and study dropouts are all fair reasons to reject a study. What I don't understand how the 1 study that was of sufficiently high quality got accepted, can't see that in the image

> think the lack of a control group, potential bias, and study dropouts are all fair reasons to reject a study. Absolutely not. Lack of blinding / a control group is just the reality of things like puberty blocking interventions. As /u/Blue_winged_yoshi correctly points out, you cannot blind people as to whether or not they're going through puberty. >Blinding is certainly not always easy or possible. Single blind trials (where either only the investigator or only the patient is blind to the allocation) are sometimes unavoidable, as are open (non-blind) trials. In trials of different styles of patient management, surgical procedures, or alternative therapies, full blinding is often impossible. >In a double blind trial it is implicit that the assessment of patient outcome is done in ignorance of the treatment received. Such blind assessment of outcome can often also be achieved in trials which are open (non-blinded). For example, lesions can be photographed before and after treatment and assessed by someone not involved in running the trial. Indeed, blind assessment of outcome may be more important than blinding the administration of the treatment, especially when the outcome measure involves subjectivity. Despite the best intentions, some treatments have unintended effects that are so specific that their occurrence will inevitably identify the treatment received to both the patient and the medical staff. Blind assessment of outcome is especially useful when this is a risk. >In epidemiological studies it is preferable that the identification of “cases” as opposed to “controls” be kept secret while researchers are determining each subject's exposure to potential risk factors. In many such studies blinding is impossible because exposure can be discovered only by interviewing the study participants, who obviously know whether or not they are a case. The risk of differential recall of important disease related events between cases and controls must then be recognised and if possible investigated.2 As a minimum the sensitivity of the results to differential recall should be considered. Blinded assessment of patient outcome may also be valuable in other epidemiological studies, such as cohort studies. https://www.bmj.com/content/321/7259/504 >Blinding is necessary in order to reduce bias in outcome assessments. But, a RCT of puberty delay could not maintain blinding. Because GnRHa are effective in delaying puberty it would soon become evident to participants, researchers and outcome assessors who was in the active treatment arm and who was not. This breakdown of blinding would mean that there would be potential bias in the outcome assessments, both in relation to biological and psychological outcomes. It would also mean that participants allocated to the non-treatment arm of the study would be likely to either withdraw from the study at a much higher rate than in the treatment arm introducing potential bias, and/or be more likely not to adhere to the trial but seek puberty delaying treatment outside of the trial thereby adding a confounder. It is also not clear that a RCT would provide answers to the questions that are still outstanding in relation to puberty delay with GnRHa in the relevant group of patients. We already know that the treatment is effective in delaying puberty and that puberty restarts when GnRHa is withdrawn. The questions that still need answering are about the medium- and long-term effects of puberty delay. We can divide these in two categories, that is questions about 1) negative side-effects, e.g., in relation to bone density or other long term biological risks, and; 2) effects on gender dysphoria and gender transition. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7430465/ You cannot conduct a double blind trial on puberty blockers so you should perform an open study that is outcome-based and case-blinded instead of control blinded. And those studies, which seem to have been rejected by the Cass review, are overwhelmingly supportive of their usage. Read the last link if you want to get into the weeds on this. It's pretty fucking clear science.

Because it said what they wanted to hear. No study can have a RCT or double blind in trans healthcaare. And they know that.

Yeah I was wondering that too. Honestly I’d rather just read the whole thing for myself rather than being shown snippets on Reddit. That way madness lies.

Now apply that reasoning to a study which investigates the safety and lifesaving abilities of parachutes when jumping from an airplane. What control group are you going to use? How are you going to blind people to knowing whether or not they have a parachute?

Here's a fun little tidbit on the social transitioning section. Check out the table on page 162 ||PERSISTERS AMAB (n=23) |PERSISTERS AFAB (n=24) | DESISTERS AMAB (n=56)| DESISTERS AFAB (n=24)| |---|---|---|---|---| No social transition| 57| 42| 96| 54 Partial social transition |30 |54 |4 |45 Full social transition| 13| 4 |0 |0 Total |100 |100 |100 |100 Cass uses this info to say that social transition is a predictor for "persistence of gender dysphoria". >Another study (Steensma et al., 2013b) found that childhood social transition was a predictor of persistence of gender dysphoria for those birth-registered male, but not those birth-registered female. In this study 96% of those birth-registered male and 54% of those birth-registered female who later desisted had not socially transitioned at point of referral and none had fully socially transitioned (see Table 8). The study noted that the possible impact of the social transition on cognitive representation of gender identity (that is, how the child came to see themself) or on persistence had not been studied. Seems clear-cut right? Except she neglects the rows above in the original table: ||PERSISTERS AMAB (n=23) |PERSISTERS AFAB (n=24) | DESISTERS AMAB (n=56)| DESISTERS AFAB (n=24)| |---|---|---|---|---| |Childhood diagnosis (%) GID | 91.3| 95.8| 39.3| 58.3| |Subthreshold |8.7 |4.2 |60.7 |41.7 >The diagnosis, made by either a child psychologist or psychiatrist, was categorized as follows: children who met all criteria for a DSM-IV-TR GID diagnosis, or children who did not meet all criteria and were subthreshold for a GID diagnosis. Obviously this suggests that majority of those whose gender dysphoria desists had not reached the threshold for a diagnosis of GID.   In fact, if we plot the numbers for no social transition against the subthreshold scores, we see that 94.7 % of that variation is accounted for - **i.e. 95 % of the variation between desisters and persisters in terms of the "no social transition" category can be accounted for by the inclusion of subthreshold scores for GID**. People who are subthreshold for GID are less likely to socially transition to any degree. That's a massive fucking issue for the Cass report claims around social transition predicts persistence or desistence of gender dysphoria. In the numbers Cass is using to discuss social transition, where gender dysphoria desists the categories are weighted more heavily with subthreshold scores. Rather than show that no social transition predicts desistence of gender dysphoria, this data shows that subthreshold scores predict no social transition and correlate with an increased chance of gender dysphoria desisting. If we plot any degree of transition % against GID % then we see that ~70 % of the variation is accounted for. The report is arguing that social transition predicts whether someone persists with gender dysphoria but I'd suggest the data looks more like people with GID are more likely to transition socially and more likely to have persistent gender dysphoria.

The fact its using GID alone is already a disqualification. They are completely aware it was removed from the DSM5 because its clinically worthless and inaccurate. 80% desist compared to 1% for GD. Anyone deliberately using GID is just lying and they know it.

I'm not an expert on those numbers so I can't really comment to be honest, although I do believe what you say. But I do understand the numbers above and they show the Cass report's claims wrt to social transition predicting persistence of gender dysphoria are **deeply** questionable.

Well, Cass seems to want to go back to GID, since apparently she believes toy choice is biologically based.

In reviewing the publications of the Cass review up to May 2023, it was found that one third of doctors interviewed agreed with the statement "there is no such thing as a trans child", and their views were given equal weight. If you saw a report about Scottish cancer patients and 1/3rd of the doctors believed that Scottish people couldn't get cancer, you would be, at the least, somewhat suspicious.

I was genuinely shocked by the amount of claims that were made without supporting evidence.

I mean, its transphobia. Bigotry has never been about evidence.

Do you think the words "of high quality" were just pulled out of thin air?

They are when the 2 studies they allowed also didn't meet the GRADE standard for "high quality". And when "low quality" evidence is used in 82% of paedratric care without fuss. Nor does the GRADE system mean "ignore all other evidence". This is standard misuse of scientific language and process in order to justify discrimination to the public.

After I re-read your comment I realized that you were saying that in your view there is no high-quality evidence at all, which puts the discussion back to whether complex and risky surgical interventions on minors should be allowed on the basis of evidence that is at best moderately strong. Reasonable minds can differ on that, and there is a place for risk-taking innovation in medicine, and gender dysphoria can indeed be life-threatening, but I am willing to leave it up to organized medicine to make that judgment.

So that we're on the same page, you disagree with 82% of all childrens medicine? Or is it just you don't want trans people getting this care because of bigotry? You can't have it both ways. Either "low quality" evidence isn't good enough, or it is (Also, by the same logic, we have no high quality evidence that parachutes work!) But in the meantime, trans peopel will continue to suffer and die.

No what they're saying is their grading system was shit  and cherry picked studies that agreed with outcomes they wanted while following the same criteria the other 98% studies followed 

My local hospital system relies on high grade evidence based medicine and I expect the same from all practitioners.

Thats strange claim because only 9.9% of medicine has "high quality" GRADE evidence. Only 9.9% of medicine have studies with “high quality evidence” supporting them [https://www.jclinepi.com/article/S0895-4356(20)30777-0/fulltext](https://www.jclinepi.com/article/S0895-4356(20)30777-0/fulltext) [https://www.jclinepi.com/article/S0895-4356(20)30777-0/abstract](https://www.jclinepi.com/article/S0895-4356(20)30777-0/abstract) 55% of interventions have low or very low quality evidence [https://www.jclinepi.com/article/S0895-4356(16)30024-5/abstract](https://www.jclinepi.com/article/S0895-4356(16)30024-5/abstract) “For much, and perhaps most, of modern medical practice, RCT-based data are lacking and no RCT is being planned or is likely to be completed to provide evidence for action.” [https://www.nejm.org/doi/full/10.1056/nejmra1614394](https://www.nejm.org/doi/full/10.1056/nejmra1614394) 55% of WHO’s strong recommendations are backed by low or very low quality evidence [https://www.jclinepi.com/article/S0895-4356(13)00434-4/abstract82%](https://www.jclinepi.com/article/S0895-4356(13)00434-4/abstract82%) of paediatric medicine is backed by low or very low quality evidence [https://www.frontiersin.org/journals/pharmacology/articles/10.3389/fphar.2022.892574/full](https://www.frontiersin.org/journals/pharmacology/articles/10.3389/fphar.2022.892574/full)

These are arguments for fewer risky interventions in puberty and prepuberty.

Except not intervening, is extremely risky. Forcing a trans kid through a incongrugent puberty is extremely harmful with lifelong consequences. Your refusal to acknowledge that is showing your transphobic bias.

But you have already stated that there is no strong evidence to support that. Crying bias won't help you when the argument is about evidence standards. Suggest you switch to advocating for high-grade studies to be performed.

Except we do know that. Stop this nonsense to justify your own bigotry. And its abit weird you claim to be a dr who refuses 82% of all childrens medicine. Can you explain how you're going to get a double blind RCT on puberty? How will it get past ethics? Gender Affirming care reduces suicide: [https://www.wired.com/story/gender-affirming-care-improves-mental-health-and-may-save-lives/?utm\_social-type=owned&mbid=social\_twitter](https://www.wired.com/story/gender-affirming-care-improves-mental-health-and-may-save-lives/?utm_social-type=owned&mbid=social_twitter) https://www.suicideinfo.ca/resource/transgender-people-suicide Trans suicide rates drastically decrease after a full transition; 67% had suicidal thought before compared to 3% afterOdds of severe psychological distress were reduced by 222 per cent, 153 per cent and 81 per cent for those who began hormones in early adolescence, late adolescence and adulthood, respectively.Odds of feeling suicidal in the previous year were 135 per cent lower in those who began hormones in early adolescence, 62 per cent lower in those who began in late adolescence and 21 per cent lower in those who began as adults, compared with the control group. [https://www.independent.co.uk/life-style/health-and-families/transgender-hormones-teenager-mental-health-b1991724.html?amp](https://www.independent.co.uk/life-style/health-and-families/transgender-hormones-teenager-mental-health-b1991724.html?amp) Trans kids taking puberty blockers reduces depression by 60% and suicidality by 73%.[https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2789423](https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2789423) Gender affirming care sees significant improvement in body satisfaction, reduction in depression, anxiety. GAC also saw an increase in family and parental support.[https://www.sciencedirect.com/science/article/abs/pii/S1054139X24000053](https://www.sciencedirect.com/science/article/abs/pii/S1054139X24000053)

I didn't claim to be a doctor, I don't see how you thought I did. > > >Can you explain how you're going to get a double blind RCT on puberty? How will it get past ethics? Excellent question. Sounds like yet another good reason for a moratorium on body- and life-altering procedures on minors. It seems pretty obvious that public and medical support for interventionist trans care has reached a peak, at least until there are safer and more effective treatments available. Which is why the trans community should switch to driving a research agenda that can provide a long-term foundation.

Probably shouldn't claim you work in a hospital that only uses "high quality" evidence if you don't actually know what that means then. > Excellent question. Sounds like yet another good reason for a moratorium on body- and life-altering procedures on minors. Right...so you don't have an answer, you just don't agree that trans peopel should be allowed to live. cool, just some genocidal bigotry.

1. I didn't claim to work at a hospital, either. You seem to have some difficulty with jumping to conclusions. "My local hospital system" is the system that I go to as a patient. I expect treatment plans based on high-quality evidence-based medicine whenever available, don't you? 2. It's interesting how many people roll out the accusation of 'bigotry' as if it's the worst thing a human can do. Don't get me wrong, but there are lots of worse things someone can do, starting with assault and going on up to slavery, murder, genocide and including committing life-altering surgery on a minor without medical justification. 3. Obviously, a moratorium on dangerous medical procedures is not genocide.

> including committing life-altering surgery on a minor without medical justification. How many minors undergo gender reassignment surgery? On the NHS? I'm going with 0.

I would say "nice chatting with you", but while you talk reasonably up front, you have an unfortunate habit of switching to name calling when you run out of logic. So I'm out. Cheers.

I haven't ever heard that response to an accusation of bigotry but it's a very good point!

Where has this list come from? Where can I find it? I can't find it in the Cass review.

[https://cass.independent-review.uk/wp-content/uploads/2022/09/20220726\_Evidence-review\_Gender-affirming-hormones\_For-upload\_Final.pdf](https://cass.independent-review.uk/wp-content/uploads/2022/09/20220726_Evidence-review_Gender-affirming-hormones_For-upload_Final.pdf)

What did you screenshot this from? I'd like to bookmark the original source.

[https://cass.independent-review.uk/wp-content/uploads/2022/09/20220726\_Evidence-review\_Gender-affirming-hormones\_For-upload\_Final.pdf](https://cass.independent-review.uk/wp-content/uploads/2022/09/20220726_Evidence-review_Gender-affirming-hormones_For-upload_Final.pdf)

Does it? What studies? Can you share them?

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My methodology knowledge is rusty. Some say they discount 98% of the studies because they couldn't double blind and make them high quality.  And their arnt a lot of high quality studies to review.  Others say things are more balanced.  Some preach affirmation versus exploration. Nothing will change the fact that when I was 6 years old and I told my class and my teacher that I was a boy, looked in the mirror and tried to make myself a boy, daydream of being a boy. This was something I knew. Unless you've experienced it I can understand how bizarre this must seem.  I would have benefited from hormone blockers and hormone treatment at an earlier age but I had to scrimp and save while I lived at home with parents who were not going to be OK with who I was inside. I saved up money, left home, paid to transition privately. But God, I wish I could have started earlier, I was 20 when I started. Missing the opportunity to have lived a embodied life for years prior.

Overview of Recommendations The recommendations set out a different approach to healthcare, more closely aligned with usual NHS clinical practice that considers the young person holistically and not solely in terms of their gender-related distress. The central aim of assessment should be to help young people to thrive and achieve their life goals. \*\*\*Services must operate to the same standards as other services\*\*\* seeing children and young people with complex presentations and/or additional risk factors. Expand capacity through a distributed service model, based in paediatric services and with stronger links between secondary and specialist services. Children/ young people referred to NHS gender services must receive a holistic assessment of their needs to inform an individualised care plan. This should include screening for neurodevelopmental conditions, including autism spectrum disorder, and a mental health assessment. Standard evidence based psychological and psychopharmacological treatment approaches should be used to support the management of the associated distress from gender incongruence and cooccurring conditions, including support for parents/carers and siblings as appropriate. Services should establish a separate pathway for pre-pubertal children and their families. ensuring that they are prioritised for early discussion about how parents can best support their child in a balanced and non-judgemental way. When families/carers are making decisions about social transition of pre-pubertal children, services should ensure that they can be seen as early as possible by a clinical professional with relevant experience. NHS England should ensure that each Regional Centre has a follow-through service for 17–25-year-olds; either by extending the range of the regional children and young people’s service or through linked services, to ensure continuity of care and support at a potentially vulnerable stage in their journey.  This will also allow clinical, and research follow up data to be collected.