Hierarchy and ranking in fencing and tennis.

We disagree with Ruuska et al.'s interpretation of data purporting that youth referred for gender‐affirming healthcare (GAH) show persistent psychiatric morbidity, and suggesting that GAH ‘…might even have a negative impact’ []. This interpretation is particularly remarkable given the authors did not engage with the established literature showing quite the opposite []. The study refers to ‘need’, but measures utilization. Because psychiatric assessment is required to access GAH, and prior contact predicts future contact, transgender people may be more likely to continue services than cisgender people with similar needs. While the authors exclude utilization within 2 years of GAH, this remains a confound. Despite reporting utilization frequency (Table 1), the analyses reduce data to a binary variable. This is inconsistent with the authors' conclusion that transgender patients have ‘…long‐standing psychiatric morbidity and/or particularly severe symptoms’, as they did not measure symptom severity/duration. The manuscript suffers from a lack of preregistration; models appear to be largely . For example, the authors argue for a cohort effect by dividing the sample by GAH initiation pre/post 2011, with little justification. More plausible than a difference between GAH‐seeking youth pre/post 2011, the WPATH Standards of Care 7 removed the requirement that mental health concerns be ‘reasonably well‐controlled’ prior to accessing GAH in 2011 []. Before this change, many transgender people minimised mental health concerns or avoided psychiatric services to access GAH []. Indeed, the earlier cohort shows a utilisation pattern post‐index date akin to the later cohort. Lower service usage before GAH access pre‐2011 likely reflects changes in access, not disparities in need.