After the Cass Report, what now for puberty blockers?

Dear Editor, Your editorial on the Cass report [1] was encouraging for its boldness in tackling a sensitive and crucial clinical topic. The opening paragraph is apt in decrying the systemic weaknesses that led clinicians to abandon the basic tenets of evidence-based medical practice. In this instance, evidence-based medicine was abandoned in favour of socially desirable clinical outcomes. Perhaps a further study of clinicians’ decisions should be undertaken to fully understand how such a contentious practice became ‘routine clinical practice’ despite the weak evidence base. The issue of comorbidity associated with gender incongruence and dysmorphism also raises important issues of diagnostic fidelity and the nosological value of these diagnostic categories. The foregoing further highlights the physician’s role in objectively interpreting subjective phenomena and enhancing the repeatability of diagnostic determinations. My own experience, as a frontline clinician, is that many patients with gender identity disorder have, on detailed exploration of their longitudinal personal history, distinct adult emotional dysfunction, manifesting as abnormal personality traits, related to, or even arising from, adverse early experiences and attachment difficulties. These markers of psychological dysfunction often appear to predate the overt manifestation of the recognised symptoms of gender dysphoria and should be carefully considered in differential diagnosis.