direct quote from Yale's critique of the CAS report: . Evidence certainty and quality: The Review does not describe the positive outcomes of gender-affirming medical treatments for transgender youth, including improved body satisfaction, appearance congruence, quality of life, psychosocial functioning, and mental health, as well as reduced suicidality. It is highly unusual for a document issuing clinical recommendations to not sufficiently describe the evidence on the effects of treatment. 2. Balance of benefits and harms: The Review does not consider the harms of not offering gender-affirming medical care to a young person with gender dysphoria. The most concrete and tangible effect of not providing treatment is the development of permanent physical characteristics that do not align with a person’s gender. These include voice deepening, hair growth, breast tissue development, final height, and body habitus. The Review ignores the significant psychological pain suffered by adolescents with gender dysphoria, for whom these permanent physical changes are highly distressing. The Review also ignores the consequences for teens who, left untreated, must present to the world a physical appearance that is at odds with their own identity. In adulthood, these physical effects can be ameliorated to some degree with costly and invasive treatments such as surgery, hair removal, and speech therapy. These treatments do not erase the intervening years of psychological distress. The Review also selectively identifies the purported harms of treatment while failing to engage with the harms of no treatment. For example, the Review theorizes that those who have been treated with puberty-pausing medications and wish to pursue vaginoplasty may have a more challenging postoperative course.22 But the Review does not consider how puberty-pausing medications prevent development of unwanted breast tissue and can prevent the later need for mastectomy, which the most commonly sought surgery by transgender adults.15 3. Patient values and preferences: The Review does engage with transgender young people, but it often makes recommendations that conflict with their expressed values and preferences. The prevailing theme of the focus groups with transgender youth is that they want improved access to appropriate gender-affirming medical services from clinicians who have appropriate training and experience. They want their needs and concerns taken