Thread by @jk_rowling on Thread Reader App – Thread Reader App - "Over the last four years, Hilary Cass has conducted the most robust review of the medical evidence for transitioning children that's ever been conducted. Mere hours after it was released to the press and public, committed ideologues are doubling down. These are people who've deemed opponents 'far-right' for wanting to know there are proper checks and balances in place before autistic, gay and abused kids - groups that are all overrepresented at gender clinics - are left sterilised, inorgasmic, lifelong patients. I understand that the review's conclusions will have come as a seismic shock to those who've hounded and demonised whistleblowers and smeared opponents as bigots and transphobes, but trying to discredit Hilary Cass's work isn't merely misguided. It's actively malign. Even if you don't feel ashamed of cheerleading for what now looks like severe medical malpractice, even if you don't want to accept that you might have been wrong, where's your sense of self-preservation? The bandwagon you hopped on so gladly is hurtling towards a cliff. And if I sound angry, it's because I'm bloody angry. I read Cass this morning and my anger's been mounting all day. Kids have been irreversibly harmed, and thousands are complicit, not just medics, but the celebrity mouthpieces, unquestioning media and cynical corporations. The consequences of this scandal will play out for decades. You cheered it on. You did all you could to impede and misrepresent research. You tried to bully people out of their jobs for opposing you. Young people have been experimented on, left infertile and in pain. I thought the last tweet was going to be my last, but I just burst into tears. The #CassReview may be a watershed moment, but it comes too late for detransitioners who've written me heartbreaking letters of regret. Today's not a triumph, it's the laying bare of a tragedy."
Konstantin Kisin on X - "BREAKING NEWS: Cass Report finds that cutting bits off confused children is bad. If only somebody had said something."
Watson on X - "I'm trying, I promise I am trying, to discuss the Cass findings with TRAs but literally none of them have read the report. They either block me or say some stupid shit that is easily proven wrong with a single screenshot. HOW did these illiterate fuckwads gain so much influence?"
Wilfred Reilly on X - "Fear. Same with BLM. Their leaders were half-literate hucksters telling obvious lies, and white libs gave them $11B and an open floor for 10 years. For God's sake, just stand up for yourself, and say obviously true things that make sense, across these fights."
TRAs don't want their reproductive "rights" threatened
Mia on X - "Remember when I said WPATH was an activist group masquerading as a medical group? Well, they have this to say in response to the Cass Report: "Cis-supremacy calls attention to the axes and forces of cis-power that actively dominate and oppress trans people, producing and perpetuating systemic and sustained injustices." I rest my case."
Thread by @buttonslives on Thread Reader App – Thread Reader App - "π¨ New systematic review exposes deceptive practices among medical organizations that endorse youth transition. Rather than relying on robust evidence, medical authorities fabricated consensus by deferring to each others' guidelines... The new review reveals that medical organizations have misled the public by basing their recommendations on insufficient evidence, inaccurately labeling their approach as "evidence-based," and engaging in a corrupt practice known as "circular referencing." The review found that clinical guidelines globally used to treat gender-questioning children and adolescents were crafted in violation of international standards for guideline development and recommended medical interventions for minors despite insufficient evidence. The review identified initial guidelines recommending youth transition, published by the Endocrine Society (ES) in 2009 and the World Professional Association for Transgender Health (WPATH) in 2012, that were foundational to numerous other national and regional guidelines. Dr. Hilary Cass highlighted the ways in which WPATH and ES were closely interlinked, noting their mutual co-sponsorship and input into each other’s drafts. This coordinated effort suggests that WPATH and ES were colluding to grant undue credibility to their guidelines. The corruption persisted in the formulation of national and regional guidelines by prominent organizations. Rather than grounding their recommendations in robust evidence, these guidelines deferred to the endorsements from the initial guidelines of WPATH and ES. Years later, when WPATH and ES updated their guidelines, they referenced the same national and regional guidelines that had initially drawn from their recommendations. This perpetuated a cycle, each time without sufficient evidence to support the recommendations. Dr. Cass highlighted the problematic nature of this circular referencing, stating, “The circularity of this approach may explain why there has been an apparent consensus on key areas of practice despite the evidence being poor.” This figure shows how nearly all the national and regional guidelines identified were influenced by ES (2009) and WPATH (2012) guidelines, how these guidelines cite and rely on each other, and how the latest ES (2017) and WPATH (2022) guidelines have cited and drawn on others. By engaging in circular referencing, these medical bodies have actively deceived healthcare professionals and the public, leading them to believe in the validity and reliability of recommendations founded on weak evidence. WPATH, which aims to promote "evidence-based care," and ES, which calls its approach "evidence-based transgender medicine," along with any organization advocating medical transition for minors, mislead the public by claiming to be "evidence-based." Dr. Gordon Guyatt, a highly respected figure who pioneered the evidence-based medicine (EBM) movement, stated that the current guidelines in the United States for managing gender dysphoria in adolescents should not be considered evidence-based. The systematic review team arrived at the same conclusion:
In the end, the review team was only able to recommend two guidelines for practice: the 2020 Finnish guideline and the 2022 Swedish guideline. Both adhere to the best available evidence and do not recommend medical transition treatments for minors. WPATH, ES, and any medical authority that misrepresents guidelines recommending medical transition for minors as “evidence-based” betray public trust and fail those seeking reliable guidance. Healthcare professionals and regulatory bodies must hold guideline developers accountable for these deceptive practices and ensure transparency in the basis of future recommendations."
Trust the Science!
Wesley Yang on X - "This is how you manufacture consent. A handful of activist professionals and professional activists create a series of circular citations of each other's papers and guidelines to create an illusion of scientific method and consensus. It doesn't have to be done well; it was done in a laughably slipshod fashion that any educated person could see through quickly if they knew what to look for. It was enough to make the truth unsayable and give them running room to conduct macabre experiments on the bodies of children for a decade -- and perhaps forever."
Leor Sapir on X - "π¨ The American Academy of Child and Adolescent Psychiatry (@AACAP ) is refusing to inform its members about the publication of the Cass Review, the biggest news in the field of pediatrics since COVID, and arguably in the 21st century. On Wednesday, AACAP member Dr. Kris Kaliebe sent Rob Grant, AACAP's communications director, the @nytimes article about the Cass Review, which came out the day before. But as Dr. Kaliebe informed me, "no one at AACAP responds to my emails." The screenshots below are from AACAP's newsletter from yesterday (Thursday). Still no mention of the Review. AACAP is home to prominent gender clinicians including @jack_turban and @LGBTDoc ."
The TRA cope in the comments is hilarious, e.g.:
"The Cass review isn't research, calling it groundbreaking is absurd. It took 150 papers about trans health, ignored almost all of them and recommended policy based on shit from the 80s that is less reputable than OJ Simpson. The idea it should be "recommended" is just.. lol"
""I love pretending right wing propaganda is 'science'""
kflarpk on X - "Deliberately ignoring the Cass Review should increase the American Academy of Child and Adolescent Psychiatry @AACAP's financial liability when lawsuits start and they get sued for perpetrating the atrocity of "gender-affirming care.""
v.f. on X - "As you said the other day on the chat, it would be catastrophic for any of these orgs to begin to admit how wrong they were about this issue. But the scandal isn't going away. It's impossible for it to go away. Lawsuits incoming. They're trapped."
KarenStepp on X- "It’s the same as the WPATH files last month; people who work with children refused to acknowledge it, much less read it. We have to start pulling licenses and pressing charges."
Kamran Abbasi on X - "Critics of the methodology of the systematic reviews that form the basis of the Cass Review are displaying their limited understanding of research methods and evidence based medicine — but that’s what got us into this mess in the first place"
The Cass review: an opportunity to unite behind evidence informed care in gender medicine | The BMJ - "One emerging criticism of the Cass review is that it set the methodological bar too high for research to be included in its analysis and discarded too many studies on the basis of quality. In fact, the reality is different: studies in gender medicine fall woefully short in terms of methodological rigour; the methodological bar for gender medicine studies was set too low, generating research findings that are therefore hard to interpret. The methodological quality of research matters because a drug efficacy study in humans with an inappropriate or no control group is a potential breach of research ethics. Offering treatments without an adequate understanding of benefits and harms is unethical. All of this matters even more when the treatments are not trivial; puberty blockers and hormone therapies are major, life altering interventions. Yet this inconclusive and unacceptable evidence base was used to inform influential clinical guidelines, such as those of the World Professional Association for Transgender Health (WPATH), which themselves were cascaded into the development of subsequent guidelines internationally. The Cass review attempted to work with the Gender Identity Development Service (GIDS) and the NHS adult gender services to “fill some of the gaps in follow-up data for the approximately 9000 young people who have been through GIDS to develop a stronger evidence base.” However, despite encouragement from NHS England, “the necessary cooperation was not forthcoming.” Professionals withholding data from a national inquiry seems hard to imagine, but it is what happened... People who are gender non-conforming experience stigmatisation, marginalisation, and harassment in every society. They are vulnerable, particularly during childhood and adolescence. The best way to support them, however, is not with advocacy and activism based on substandard evidence. The Cass review is an opportunity to pause, recalibrate, and place evidence informed care at the heart of gender medicine. It is an opportunity not to be missed for the sake of the health of children and young people. It is an opportunity for unity."
Clearly, the Editor in Chief of the BMJ is a science denier
Meme - Jesse Singal: "Epistemic closure doesn't even come close to capturing what's going on here. The algorithm Reed and Caraballo rely on is simple: any journal or outlet that publishes anything that remotely disagrees with their preferred everything-is-great-with-youth-gender-medicine approach is automatically 'suspect,' 'scandal-plagued,' 'transphobic,' or insert whatever derogatory phrase you want. The idea that it *helps* trans people to pathologize normal scientific processes and debates and to constantly poison every possible well... No."
Alejandra Caraballo reposted: Erin Reed @ErinInTheMorn: "This is the editor in chief of the BMJ. The BMJ has been a parking journal anti trans articles that are not otherwise published in fringe journals like Archives of Sexual Behavior. The journal is thoroughly captured and has supported the scandal plagued DeSantis' Florida review."
Coddled affluent professional on X - "Caller: 'They reviewed 53 studies, they rejected 50 of them - 95% or 98% - that had support for trans healthcare for being low quality.'
Seder: 'So, they cherry picked the studies. What you're saying is that they cherry picked the studies.'
Caller: 'Yeah.'"
Dunkle Fumb on X - "The strategy is therefore to flood the scene with low quality garbage studies that affirm one’s ideology and then claim cherry picking when people point out that they are low quality. All to maintain a social contagion and ongoing child mutilation. I am giga brained."
Throwing out low quality research, like is normal for systematic reviews, is "cherry picking". Clearly it cannot be the case that most pro-trans studies are shit
Gavin Barrie ππ΄σ §σ ’σ ³σ £σ ΄σ Ώπ¨π»❤️π¨π»π¦π€π©ΌπΈ on X- "I’m curious. What are your professional qualifications and experience, vs Dr Hilary Cass’?
- consultant paediatrician
- previous Head of the Royal College of Paediatrics and Child Health (2012-2015)
- OBE (2015) services to child health
- honorary fellowship from the Royal College of Nursing in 2015
On what basis are you asserting that opinion?"
TRAs are even more block-happy than normal left wingers. Probably because their beliefs are even more batshit insane than the average left winger's
Stephen Knight π️ on X - "Two recommendations of my own after seeing the predictable responses to the #CassReview:
1. Stop expecting that individuals who place no value on evidence will suddenly begin to value it simply because you present more evidence to them. There is no evidence you can provide some people that will penetrate their worldview. Their worldview isn't built on evidence, it's built on feelings of righteousness. They cling to it like a religion. The 'affirmation model', kids 'trapped in the wrong body' and the mantra of 'believe trans kids' are unalterable truths. Any contradicting evidence will only ever be interpreted as blasphemy. So, we must move forward without people like this.
2. The only weapon in the arsenal of gender activists is to smear any dissenter as a bigot. So, stop caring about being called a bigot when you know you are not and don't be silent when others are treated this way. Say what you know to be true and don't be cowed by the smears of deeply unserious people. The stakes are too high for unserious people and they have nothing to offer that we need anyway. So, we must move forward without people like this."
Meme - PsychoSocialism's TwΓ¬tter ππ @SocialismPsycho: "The Cass review isn't research, calling it groundbreaking is absurd. It took 150 papers about trans health, ignored almost all of them and recommended policy based on shit from the 80s that is less reputable than OJ Simpson. The idea it should be "recommended" is just.."
Lola @thefempire50: "One of those ‘pro trans’ studies even says there’s not such thing as a ‘trans child’. So now what?"
"Because a diagnosis of transsexualism in a prepubertal child cannot be made with certainty, we do not recommend endocrine treatment of prepubertal children."
Meme - Owen Jones @OwenJones84: "The Cass review claims that boys play with trucks and girls play with dolls partly because of "prenatal and postnatal hormonal influence". I will definitely take a review which offers that kind of claim seriously, if I ever start taking crack."
Generic English Teacher @TabitaSurge: "Cass review says that 'prenatal and postnatal hormonal influence' is why there are Boy toys and Girl toys. Well done, 'feminists: I hope you're all very proud of yourselves."
"6.18 A common assumption is that toy choice and other gender role behaviours are solely a result of social influences; for example, that boys will only be given trucks and girls will only be given dolls to play with. Although this is partially true, there is evidence for prenatal and postnatal hormonal influence on these behaviours, which will be discussed later."
Readers added context: "The influence of prenatal sex hormones on gendered behaviour is well demonstrated in both humans and animals. Females exposed to high levels of androgens prior to birth exhibit higher levels of male typical behavior:"
Readers added context they thought people might want to know: "This is a misrepresentation by the poster of a simple, illustrative example in the Cass Report, which considered the different behaviours of the two discreet human sexes and pointed out they're not the result of social influences alone, but also biological differences."
Trust the Experts. Unless they hurt the left wing agenda
Colin Wight on X - "There’s a pattern developing to all the academics criticising the Cass Review; they’re mostly commenting from fields only mildly adjacent to the content of the review; they’re mostly claiming to have expertise in epistemology and research methods they clearly don’t have; most of them are queer theory advocates; they generally have pronouns in their bio. π€·♂️"
rutheday99 on X - "They also accuse the Cass report of cherrypicking and manipulating data for its own predetermined conclusion, because that's what their side has been doing all these years. They think everyone operates like them."
Darryl T on X - "Exactly, it’s also straight out of their handbook, accuse the other side of what you do."
Doctor Tiger Ninestein on X - "I’ve seen a lot academics (usually psychotherapists, saying the methodology was flawed and does not meet research standards. They never elaborate when invited to do so."
Christopher O’Flynn, M.Ed on X - "I’d love to know how they have research superpowers to debunk and discredit a 400 page review in a few hours… That’s honestly miraculous."
elliotranch on X - "Their entire philosophy is based on post-modernism (there is no truth) and critical theories (empiricism is oppression). Of course they can't do science right. They fundamentally oppose it. That's why it's been so galling to see them bastardise it then wear it as a badge."
Assigned Media (Evan Urquhart) on X - "I've just become aware that a certain journalist who is known for his obsessive and unpleasant behavior online has shared this thread. Not wanting to dignify that person with a direct response, I'll add some additional thoughts here."
Jesse Singal on X - "Journalists are allowed to criticize other journalists. It isn't "obsessive and unpleasant" to do so, and those sorts of smears are part of why American journalism has fumbled the ball so disastrously on this subject. It's, well, unpleasant to be tarred as some sort of weirdo for doing your job, so most journalists would prefer to either not touch this subject or to act as PR mouthpieces for activist groups. More substantively, Evan himself screenshots a part of the report listing, in the center column, concerns on clinics' parts about patient confidentiality, and the Review's response (right column) that patient confidentiality is already protected under British law. Which of course it is! This is a developed country and these are experienced researchers who obviously know how to extract/use anonymized patient data. The mere existence of a complaint doesn't mean it's accurate or makes sense."
Once again, when left wingers complain about "harassment" and "abuse", they mean being criticised or being confronted with ideas they disagree with
Meme - @godblesstoto: "He's unintentionally said something that 100% supports the argument against unnecessary surgery and other medical interventions on children. Imagine that. He said something I agree with. He didn't mean it that way like. But every stopped clock and all that."
India Willoughby @IndiaWilloughby: "No circumcisions until 25 because the brain isn't mature enough - plus, it's unscientific #Cass"
Meme - Jesse Singal @jessesingal: "Man, this is just so freaking incompetent and/or dishonest -- I'm not even sure which! They're absolutely making stuff when they claim that anyone was asking patient confidentiality to be violated. A *major* theme in both the Cass Report and Hannah Barnes' book is that GIDS did a horrible job record-keeping and producing long-term outcome data. This can be anonymous data! Why is Evan, a journalist supposedly concerned with trans people's well-being, running cover for an institution that completely failed to do its job ensuring trans people's well-being? GIDS repeatedly delayed or outright refused to release data that could have helped answer some of these questions. On top of that, the Cass Report provides *no* meaningful estimate of detransition rates, one way or another. The tiny scraps in there refer to instances in which a detransition was captured in a patient's notes, and even this was a partial/biased subset of the data. These are just absolutely wild claims that no decent, qualified journalist would make. It's all right there in the report."
Assigned Media (Evan Urquhart) @assignedmedia: "The Cass Report, which took 4 years to examine treatment for gender dysphoria in youth, wound up making very few conclusions. They particularly failed to find evidence that detransition is anything but extremely rare. This has resulted in speculation (frankly verging on the level of religious certainty) that if the adult gender clinics had only shared private patient data with Cass the Report would have found the imagined detransitioners or other evidence of harm/scandal. This, in turn, has resulted in anger and paranoia directed at the adult clinics. The anger at the adult clinics is present in the Report itself, which complains about the data Cass didn't get and blames the adult clinics for the shortcomings of the Report."
Clearly, clinics refusing to share data though they were supposed to is because they don't want the data to be "abused" to spread "transphobia". They can't have had anything to hide
Britain Confronts the Shaky Evidence for Youth Gender Medicine - The Atlantic - "In a world without partisan politics, the Cass report on youth gender medicine would prompt serious reflection from American trans-rights activists, their supporters in the media, and the doctors and institutions offering hormonal and surgical treatments to minors. At the request of the English National Health Service, the senior pediatrician Hilary Cass has completed the most thorough consideration yet of this field, and her report calmly and carefully demolishes many common activist tropes. Puberty blockers do have side effects, Cass found. The evidence base for widely used treatments is “shaky.” Their safety and effectiveness are not settled science. The report drew on extensive interviews with doctors, parents, and young people, as well as on a series of new, systematic literature reviews. Its publication marks a decisive turn away from the affirmative model of treatment, in line with similar moves in other European countries. What Cass’s final document finds, largely, is an absence. “The reality is that we have no good evidence on the long-term outcomes of interventions to manage gender-related distress,” Cass writes. We also don’t have strong evidence that social transitioning, such as changing names or pronouns, affects adolescents’ mental-health outcomes (either positively or negatively). We don’t have strong evidence that puberty blockers are merely a pause button, or that their benefits outweigh their downsides, or that they are lifesaving care in the sense that they prevent suicides. We don’t know why the number of children turning up at gender clinics rose so dramatically during the 2010s, or why the demographics of those children changed from a majority of biological males to a majority of biological females. Neither “born that way” nor “it’s all social contagion” captures the complexity of the picture, Cass writes. What Cass does feel confident in saying is this: When it comes to alleviating gender-related distress, “for the majority of young people, a medical pathway may not be the best way to achieve this.” That conclusion will now inform the creation of new state-provided services in England. These will attempt to consider patients more holistically, acknowledging that their gender distress might be part of a picture that also includes anxiety, autism, obsessive-compulsive disorder, eating disorders, or past trauma. This is a million miles away from prominent American medical groups’ recommendation to simply affirm an adolescent’s stated gender—and from common practice at American gender clinics. For example, a Reuters investigation found that, of 18 U.S. clinics surveyed, none conducted the lengthy psychological assessments used by Dutch researchers who pioneered the use of medical gender treatments in adolescents; some clinics prescribe puberty blockers or hormones during a patient’s first visit. Under pressure from its members, the American Academy of Pediatrics last year commissioned its own evidence review, which is still in progress. But at the same time, the group restated its 2018 commitment to the medical model. The Cass report’s findings also contradict the prevailing wisdom at many media outlets, some of which have uncritically repeated advocacy groups’ talking points. In an extreme example recently noted by the writer Jesse Singal, CNN seems to have a verbal formula, repeated across multiple stories, to assure its audience that “gender-affirming care is medically necessary, evidence-based care.” On a variety of platforms, prominent liberal commentators have presented growing concerns about the use of puberty blockers as an ill-informed moral panic. The truth is that, although American medical groups have indeed reached a consensus about the benefits of youth gender medicine, doctors with direct experience in the field are divided, particularly outside the United States... Her report is a challenge to the latest standards of care from the U.S.-based World Professional Association for Transgender Health, which declined to institute minimum-age limits for surgery. The literature review included with her report is notably brutal about these guidelines, which are highly influential in youth gender medicine in America and around the world—but which, according to Cass, “lack developmental rigour.”... Medicalized gender treatments for minors became wrapped up with a push for wider social acceptance for transgender people, something that was presented as the “next frontier in civil rights,” as Time magazine once described it. Any questions about such care were therefore read as stemming from transphobic hostility, full stop. And when those questions kept coming anyway, right-wing politicians and anti-woke comedians piled on, sensing an area where left-wing intellectuals were out of touch with popular opinion. In turn, that allowed misgivings to be dismissed as “fascism”... In Britain, multiple clinicians working at the Gender Identity and Development Service (GIDS) at the Tavistock and Portman Trust, the central provider of youth gender medicine, tried to raise their concerns, only to have their fears dismissed as hostility toward trans people. Even those who stayed within the service have spoken about pressure from charities and lobbying groups to push children toward a medical pathway... This hostile climate has hampered attempts to collect robust data about real-world outcomes... Cass has since wondered aloud if this decision was “ideologically driven,” and she recommends that the clinics be “directed to comply” with her team’s request for data... the intense polarization of the past few years around gender appears to be receding in Britain... The Cass report is a model for the treatment of fiercely debated social issues: nuanced, empathetic, evidence-based. It has taken a political debate and returned it to the realm of provable facts. And, unlike American medical groups, its author appears to have made a real effort to listen to people with opposing views, and attempted to reconcile their very different experiences of this topic... What a difference from America, where detransitioners are routinely dismissed as Republican pawns and where even researchers who are trans themselves get pushback for investigating transition-related regret—and where red states have passed laws restricting care even for transgender adults, or have proposed removing civil-rights protections from them... If you still think that concerns about child medical transition are nothing more than a moral panic, then I have a question: What evidence would change your mind?"
Clearly, medical experts in the world outside North America are transphobic bigots
Cass review: Health secretary criticises gender care 'culture of secrecy' - "former health secretary Sajid Javid called for "a no holds barred government investigation" into obstruction of the research. Mr Javid introduced legislation in 2022 which allowed the Cass review access to some medical records. "Despite it being the unanimous will of Parliament, it is clear vested interests have deliberately frustrated the important data access legislation I brought forward to support Dr Cass's review," he said. "A no holds barred government investigation should be launched into this obfuscation, documents retrieved and, if necessary, individuals held accountable for failing to provide records." Labour's shadow health minister Wes Streeting also expressed anger that some clinics had refused to take part in research."
Thread by @jessesingal on Thread Reader App – Thread Reader App - "The Cass Review explains, in detail, why we need to trust systematic reviews over both doctors' anecdotal evidence and low-quality standards published by professional associations. The CBC responds by publishing an article that cites professional associations and is dominated by doctors' anecdotal accounts. Science journalism seems screwed at the moment. This might be the worst bit: "Surveys and interviews are considered low-quality evidence in medicine, said [Pediatrician Dr. Tehseen Ladha], but that might be misleading to the general public. 'Many people would see low-quality evidence and think well, that means this could harm our children. But that's not what it means.' " That's... exactly what low-quality evidence for a major intervention means. It means we don't know if the intervention offers a net benefit, because the true effects might differ significantly from what the studies in question present. Stuff like this isn't just the normal incompetence and sloppiness that plagues this subject. It is critically dangerous science miscommunication disseminated by the most important outlet in Canada. It's absolutely inexcusable and has to stop. Just wanna be clear about this: Let's say "low-quality" studies seem to tell us that an intervention improves things .5 points on a 10-point scale for patients. Doesn't matter what you're measuring. What that means, to oversimplify, is that we don't have confidence the intervention in question will actually have that effect on people. It could be higher, but it could be lower, changing the direction of the sign entirely. I'd argue more structural forces within science publishing nudge us toward overstating rather than understating benefits, but whether or not you agree, the idea of this intervention being harmful is *absolutely* on the table in this sort of situation. The CBC is spreading rank BS here -- it's so, so bad. I don't understand how this keeps happening."
Trust the Science. Unless it hurts the left wing agenda