User talk:Void if removed

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Your submission at Articles for creation: Rebecca Wait (October 15)

Your recent article submission to Articles for Creation has been reviewed. Unfortunately, it has not been accepted at this time. The reason left by Asparagusus was:  The comment the reviewer left was: Please check the submission for any additional comments left by the reviewer. You are encouraged to edit the submission to address the issues raised and resubmit after they have been resolved.

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—asparagusus (interaction) ^sprouts! 16:33, 15 October 2023 (UTC)

Hello, Void if removed! Having an article draft declined at Articles for Creation can be disappointing. If you are wondering why your article submission was declined, please post a question at the Articles for creation help desk. If you have any other questions about your editing experience, we'd love to help you at the Teahouse, a friendly space on Wikipedia where experienced editors lend a hand to help new editors like yourself! See you there! —asparagusus (interaction) sprouts! 16:33, 15 October 2023 (UTC)

Wikipedia library

Has anyone pointed you at Wikipedia:The Wikipedia Library? -- Colin°^Talk 07:52, 24 October 2023 (UTC)

Yes I got access to that last week - it is a thing of beauty! Void if removed (talk) 09:40, 24 October 2023 (UTC)

And I will have a look at creating a GC draft article like you suggested, as soon as I can. If nothing else, it would serve as a discussion point. Void if removed (talk) 10:50, 25 October 2023 (UTC)

Your submission at Articles for creation: Rebecca Wait has been accepted

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asilvering (talk) 18:39, 1 November 2023 (UTC)

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Your submission at Articles for creation: Dead Lions (January 18)

Your recent article submission to Articles for Creation has been reviewed. Unfortunately, it has not been accepted at this time. The reason left by Asilvering was:  The comment the reviewer left was: Please check the submission for any additional comments left by the reviewer. You are encouraged to edit the submission to address the issues raised and resubmit after they have been resolved.

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asilvering (talk) 20:23, 18 January 2024 (UTC)

Tangent

Your comment here reminds me of a years-long problem with Multiple chemical sensitivity. Forever ago, someone wrote to the German health system and asked about MCS. The reply they received said (in German) that providers should use a particular ICD-based billing code if they want to get paid for treating people with MCS-like symptoms. A scanned copy of this letter has been all over the internet with English speakers declaring that "the German government officially recognizes MCS as a real disease caused by chemical exposure!" Except, of course, that it doesn't. The letter didn't say anything like that.

I'm sure the people posting these things don't intend to be misleading, and most people don't read any German. They trusted the source that described the letter, and that source trusted the source it received the letter from, and little by little, the telephone game turned into an easily exploded myth. All you have to do is read the original letter (which, in that case, was usually passed along with the incorrect description of its contents). WhatamIdoing (talk) 18:11, 20 March 2024 (UTC)

Fascinating! There was also the recent high profile case of a heavily cited "study" supposedly demonstrating that opioids weren't addictive turned out to be a 1-paragraph letter in a 1980 journal, but it had been cited so many times and embellished each time that its humble origins were completely hidden.

And yes, it is always interesting digging into the many levels of confusion introduced between a source and its origin. Though obviously many times for Wiki purposes that ends up being OR and mainly a matter of satisfying personal curiosity... Void if removed (talk) 11:13, 21 March 2024 (UTC)

I liked the comment "I don't think it mattered that it didn't say much, what mattered was its title and its publication, and those two things went a long way".

I've sometimes looked up our citations and of course many times our source document text relies on another cited document (for we love secondary sources) but when you read the other cited document (and follow the chain if necessary) you find it isn't quite as well stated as one might like. That they have summarised the source in a way that is either entirely misleading or potentially misleading or lacking vital information. A bit like someone citing this letter and missing out that the patients were hospitalised, or had no previous history of addiction. And when we want to write our text in our own words we need to be confident of the real meaning, in case our rephrasing veers off the path. I don't know if we have any guidelines on digging into the source of a claim, to get a better feel for it, rather than just paraphrasing what you think your secondary source was saying.

When this happens I think to myself that this is the limitation of Wikipedia being (nearly always) written by non-experts, and that real experts in the field would know all this stuff already and be citing for citing sake, rather than utterly relying on the text for our knowledge. But, well, maybe the experts are as guilty of this as we can be.

I suppose if you really want something to be so, even really weak evidence can get asserted with confidence. I'm not sure about the claim "It would be taken apart overnight on Twitter". Seems like Twitter is the source and amplifying voice of many of these "evidence" claims from, well, all sides of most arguments. -- Colin°^Talk 14:19, 21 March 2024 (UTC)

Oh, and I liked the "Definitions for the taxonomic categorization method" in the NEJM article appendix. It seems this comes from doi:10.1108/00220410810844150, which you can read in the Wikipedia Library. What I don't see in that list is

• "Dishonest: cited work does not support the citing work, though is cited as though it does"
• "Egotistical: cited work is by the same author"
• "Pretentious: cited work is not the scholarly text readers might assume. "Johnson (2010)" turns out to be a rant in The Telegraph.

-- Colin°^Talk 14:35, 21 March 2024 (UTC)

It sounds like you are looking for https://users.cs.northwestern.edu/~riesbeck/proofs.html WhatamIdoing (talk) 21:26, 21 March 2024 (UTC)

That's similar, indeed. -- Colin°^Talk 08:36, 22 March 2024 (UTC)

We would also want "Proof by hallucinated citation" or "Proof by non-existent source". WhatamIdoing (talk) 18:38, 22 March 2024 (UTC)

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Void, I think you could put that up for {{db-author}}. WhatamIdoing (talk) 00:53, 15 April 2024 (UTC)

Social justice approach

Twice the Cass Review mentions the "social justice approach". First is when they write Despite the best intentions of everyone with a stake in this complex issue, the toxicity of the debate is exceptional. I have faced criticism for engaging with groups and individuals who take a social justice approach and advocate for gender affirmation, and have equally been criticised for involving groups and individuals who urge more caution. and later when they say Although some think the clinical approach should be based on a social justice model, the NHS works in an evidence-based way. Whilst navigating a way through the surrounding ‘culture war’, the Review has been acutely and increasingly aware of the need for evidence to support its thinking and ultimately the final recommendations made in this report.

While I can guess who they are referring to, I'm wondering what they mean by this "social justice" language? @Sideswipe9th and WhatamIdoing: for opinions too. Are they sort of saying in a slightly patronising way that one group's intentions towards a people-group are so full of good intentions, that their do-gooding exceeds the evidence they are actually doing good? Or do they mean something else that my ignorance of this topic doesn't realise?

I'm wondering if this is some way we might frame the two approaches to puberty blockers (and other matters). Because on a strictly MEDRS evidence-based pov, the various systematic reviews, especially the most recent commissioned by the Cass Review, are decisive imo on how we should write about the evidence. But I'm also realistic that there's little chance the article will be permitted to contradict WPATH, especially so when the review came from Terf Island.

So is there actually two schools of thought about how to address how evidence should influence medical care, especially medical care for a group like this which is under political and social attack from many fronts? Is that some way we could include both POVs? Anyone written about this? -- Colin°^Talk 19:44, 13 April 2024 (UTC)

I would not choose those words, but my understanding would be that "social justice" would cover those who start from the position that trans people are disadvantaged and deserve justice, and an essential part of that justice is ready access to medical transition with as few barriers as possible.

Cass is starting from the position that children and young people are presenting in a state of distress, and we need to follow the evidence on how best to understand and treat that distress.

This leads to all sorts of intractible conflicts.

For example, if you take the view that a young person presenting at a gender clinic as trans, is trans, then any route other than affirming that identity and finding ways to explore and express it as fully and freely as possible is an affront to human dignity.

If you take the view that the roots of their gender questioning need to be understood, which may reveal they are depressed, possibly autistic and same-sex attracted and in a state of distress as a result of those factors and misinterpreting those as a desire to be the opposite sex, focusing on the "gender" aspect of the distress overshadows the other contributing factors which actually, if properly understood, alleviate the gender distress.

Which is where it becomes existential - because to the former, you are taking a trans person and making them not trans. But to the latter, you are subjecting a potentially distressed and (statistically) LGB person to treatments that they may regret in later life, with no actual evidence it will give benefit.

The social justice model is all about personal autonomy, and insists there is no pathology to be "treated". Demanding evidence of benefit and medical gatekeeping is anathema. This is following the line of argument that gay rights took, with the depathologisation of same sex attraction.

Exploring the roots of a child's psychological distress to determine the best evidence-based pathway to alleviate it is basic medicine. To the social justice model, the psychological distress is a result of an uncaring and unaccepting society, and not something to be "treated" - indeed, attempts to do so are the very roadblocks causing the distress.

I think people are trapped in their analogies.

Basically, if you read the Cass review and mentally substitute "trans" with "gay" to imagine she's talking about gay people, and how to check if they're really gay with randomised controlled trials, before letting them just be gay, it must come across as awful. I think that's how the "social justice" model would understand it, so to speak.

But if you read the cass review and understand she is actually talking about mostly LGB kids with mental health issues, and whether they should be given experimental medical interventions, with shoddy evidence and nonexistent followup data, its a very different picture.

Cass is, I think, bending over backwards to try to bridge this divide, in a compassionate way, acknowledging the conflict, and how young people are being failed by it. But I think it is unbridgeable. Void if removed (talk) 20:36, 13 April 2024 (UTC)

There is a different wrt trans and gay, though, in that the old medical response to someone being gay was cross-gender drugs to feminise and control the immoral urges, whereas there isn't a new medical response to someone being gay at all. It becomes that the healthcare professional really couldn't care less if you are gay, straight or both or fluid, and not really interested in finding out for sure. So there's no pathology and no treatment.

And while I can understand the no pathology argument wrt being trans, the response being demanded is not no medical treatment. And treatment typically requires an assessment of whether your case is best treated that way, along with evidence of efficacy and assessment of harm. Furthermore is the statistical correlation that lots of people presenting as trans for healthcare have mental health issues or are neurodivergent so the mental health practitioners get involved anyway.

Is the difference a difference of opinion about what the treatment is trying to achieve. On the one hand some are looking for mental health improvements (and not finding them, according to the systematic reviews) but on the other hand, if one is looking for a treatment to change physical body to align with gender, then one doesn't need an RCT to know that these drugs have that effect. But if that's the case, why make all the effort arguing that the treatment of mental health has evidence, if that's not really your requirement (albeit one that would be nice to have).

I'm trying to see if there is a way where both sides have a case to make. -- Colin°^Talk 21:12, 13 April 2024 (UTC)

I agree there are substantial differences, I'm just trying to steelman that position. That is how it is seen, if "trans" is like "gay", then there's no pathology, hence being trapped in the analogy. Any attempt to explain the difference runs afoul of the historic mistreatment of homosexuality.

I think it would be better described as a depathologised medical model, where the "social justice" angle is the basis of the depathologisation.

The end result is a model where medical interventions are necessary, but evidence that is based on describing an underlying pathology is inherently suspect, on social justice grounds.

The shift has been from gender identity disorder, to gender dysphoria, to affirmation of gender identity. Dysphoria is therefore considered not a condition to be treated, but a symptom of a non-affirming environment, and the result is when someone tries to gather an evidence base around effective treatment of gender distress, the response is "omg you think being trans is an illness to be cured". Void if removed (talk) 10:32, 14 April 2024 (UTC)

On the original question, https://blacktrans.org/about-us/ says they're a social justice trans group, so presumably what is meant is whatever they and other groups like them do. I believe that anyone in the Mad Studies range would also be including in the social justice group. For example, doi:10.1007/978-3-030-90413-5 opposes a Biomedical model of understanding trans-ness. The general goal for social justice groups is freedom and fairness for marginalized and oppressed groups. I believe that the groups self-identifying this way generally run closer to "just give the kids whatever they ask for" than the "Um, just because someone says they're trans doesn't mean that they actually are trans" end of the spectrum.

About comparing to de-pathologization of being gay, I'm not sure that's the best comparison. Gay and trans people both reject the idea that they are sick, but gay people add "and we don't really need anything special from medicine", whereas trans people add "but we need lifelong medical interventions to be ourselves". Once you need something from the system, the system needs something back from you – beginning with a reliable way to identify which "you" will actually benefit (and in what ways) from which interventions.

I have been thinking about how much this sounds like the Multiple chemical sensitivity communities. In practice, the definition of MCS is self-identification. If you say that 'chemicals' bother you, then you have MCS. There is no objective test or agreed-upon diagnostic protocol. It is probably a syndrome in the old sense (a collection of symptoms that may or may not have a single underlying etiology) rather than a single disease entity. Every now and again, a study gets published saying that some percentage of self-professed MCS sufferers have a treatable psychiatric condition (usually anxiety or depression) instead of MCS, and that when those people were correctly treated for that problem, their alleged MCS symptoms completely clear up. The researchers usually think this is great news: some people can be correctly diagnosed, correctly treated, and feel better! But the response from MCS communities doesn't sound like "how nice that those self-mis-diagnosed people finally got diagnosed correctly, but us real MCS people still exist" or "lucky for them that they can be successfully treated". Instead, it sounds like "how dare you claim that some MCS people might have a treatable psychiatric condition instead of being poisoned by chemicals!" They are, in part, looking for safety in numbers (a bigger affected population usually leads to more research money), but also they are also reacting this way because the people who aren't misdiagnosed can't imagine how or why anyone who didn't really have MCS could possibly be mistaken on the point, and they worry that public discussion of any misdiagnosed person will create doubt about their own self-identification.

I don't think the fear of being questioned is at all unreasonable, because I think that if questioning is "allowed", it will happen. I think that part of the "caution" argument is motivated by wondering how many people (particularly young people) who say they're trans are "really" trans. If your parents had friends who were Lesbian until graduation and see Bisexual chic identifications on social media, if they know people who have cycled through multiple religions, each one more strongly presented as "the" one than the last, might it not be reasonable for them to wonder whether any unexpected coming out actually represents a lifelong state? Given how many times most adults have misunderstood themselves, might it not be reasonable for them to wonder whether the kid who was deep in a "goth phase" two months ago, but totally preppy last summer, might not be more "questioning" than "certain"? When I read horror stories about CSA, it sounds reasonable to me to have a gender-affirming clinician gently ask whether "I'm not a girl" means "I'm so desperate to make him stop molesting me, that I'll even try living as a boy". But when you are trans, this doubtless feels like yet another layer of gatekeeping and rejection.

Insistent, persistent, and consistent is probably a notable subject. Maybe someone here would like to start it. WhatamIdoing (talk) 23:42, 14 April 2024 (UTC)

If you take the view that the roots of their gender questioning need to be understood, which may reveal they are depressed, possibly autistic and same-sex attracted and in a state of distress as a result of those factors The problem is, according to both the DSM-5TR and ICD-11, being depressed, possibly autistic, and/or same-sex attracted are neither exclusionary factors for being non-cisgender nor are they even related to a person's gender identity. Although the LGBT+ umbrella unites them, because of a shared struggle for acceptance, gender and sexuality are nonetheless separate concepts. Outside of an epidemiology study, a clinician doesn't need to know why a person is trans or gender diverse in order to provide them with the treatment and support they need to fully express their gender identity. Now in terms of what that treatment and support looks like, that obviously varies from person to person, some might be happy with nothing more than counselling to talk things through while they figure out how they want to express and present themselves, while others may want to take hormones and have certain surgeries to align their body with how they expect it to be. However in the current person-centered care model that we find ourselves in, the why isn't really important to that. Being gender diverse is not something you can definitively test for, there's no blood test, X-Ray, MRI, that can detect it, it's fundamentally something that a person expresses.

It's interesting that you bring up how we formerly treated homosexuality, because there are a lot of parallels there particularly with regards to pathologisation of something we now understand to be a normal variation of the human expression. If you go back to the 1980s and earlier, we treated homosexuality as something to be cured, under the mistaken belief that a homosexual person was actually a heterosexual person who had something wrong with them. As a result we as a society pathologised non-heterosexual sexualities. Now with regards to non-cisgender gender identities, we are currently in a transition state between pathologisation and acceptance. There are places in the world where we still pathologise non-cisgender gender identities, even for adults, and see it as something to be cured. But the mainstream medical view based on a century of research is that non-cisgender gender identities are a normal variation of the human condition, and that the best and most effective long term way to address the distress caused by the disconnect between the internal self and the external is to help the person transition their external self to be contiguous.

if you read the cass review and understand she is actually talking about mostly LGB kids with mental health issues See, this is in itself a highly controversial statement. Being non-cisgender is not a mental health issue, and hasn't been for over a decade now. The DSM-5 (released 2013) explicitly states that "gender non-conformity is not in itself a mental health disorder", and the ICD-11 (released 2019) re-classified gender incongruence as a sexual health issue. The idea that trans and non-binary kids are really LGB kids with mental health issues is woefully out of date, because gender and sexuality are two separate concepts. A trans person's sexuality usually doesn't change when they transition, someone who is attracted to men or women prior to transitioning will usually still be attracted to men or women after. All that sometimes changes is the label used to describe that sexuality (eg hetero -> gay/lesbian or vice versa). I say usually though because for some people it can be difficult to distinguish between gender envy (ie the desire to match another person's presentation) and sexual attraction. Post transition when the gender envy has either resolved or reduced, some trans people do realise that what they were experiencing was envy, and that actually they're attracted to someone else. Sideswipe9th (talk) 22:44, 13 April 2024 (UTC)

Just to clarify quickly - by "mostly LGB kids with mental health issues" I mean that statistically, a high rate are same sex attracted and with comorbid mental health issues, from depression to eating disorders. Void if removed (talk) 23:02, 13 April 2024 (UTC)

Ok, but that doesn't really change what I've said. If you look at the diagnostic criteria within the DSM and ICD, having depression, anxiety, an eating disorder, or whatever else aren't contraindications for being transgender. For the DSM in particular, having clinically significant distress or impairment, which can manifest as depression or anxiety like symptoms, is a pre-requisite for diagnosis for gender dysphoria in children, adolescents, and adults. The ICD meanwhile does not have the same requirement.

This is one of the areas where I personally think Cass has it wrong in her report. In paragraphs 10.36-40, Cass makes a recommendation that the youth gender clinics preform a full mental health assessment, however that's not their role. A gender clinic is not CAMHS, they shouldn't need to be trained in how to preform mental health assessments themselves. In my opinion, the only thing they need to be trained in is how to provide support and treatment for gender diverse youth specifically for issues relating to their gender identity. That's not to say however that the gender clinics don't have a role in this regard, merely that if there is a reasonable suspicion of a co-occurring mental health issue or if the patient outright says they are depressed, have severe anxiety or whatever else, they should simply make a side-referral on to CAMHS for that specific, non-exclusionary issue. CAMHS are in a much better position to provide that diagnosis, and treatment and support where it is indicated, especially with regards to neurodiversity where the CAMHS diagnosis->SEND statement->school support pipeline is both well defined and well known.

Conversely there is a real risk here that based on the recommendations Cass has provided, that clinicians in the GIDS replacement clinics will improperly use those side diagnoses to delay or outright refuse treatment and support for the patient's gender identity issues. That is something that has happened historically within the UK, both for trans youth and adults, and something that currently happens within Northern Ireland's trans youth clinic Knowing Our Identity, despite that action being explicitly contraindicated by accepted diagnostic and treatment guidelines. Sideswipe9th (talk) 00:13, 14 April 2024 (UTC)

I don't think that this modern atomization of care (regardless of whether that's three different psychologists separately managing gender vs anxiety vs chronic pain or three different physicians separately managing liver, kidney, and heart disease) is a model that works very well. Having to schedule three separate appointments for interrelated problems is the opposite of patient-centered care, and it not infrequently leads to contradictory advice: the liver doc wants a low-fat diet but doesn't mind if you eat lots of carbs, and the kidney doc wants a low-carb diet and doesn't mind if you eat lots of fat; the gender clinician suggests giving yourself more privacy during transition, and the anxiety specialist recommends more social interaction. It therefore does not surprise me that a coordinated, integrated approach is recommended. Coordinated, team-based care is seen as the best system in the rest of medicine.

(Also, I doubt that any clinician would want to be surprised by an undiagnosed mental or serious physical problem during transition. If a person has sensory issues, you probably want to know that before suggesting, e.g., a chest binder, and if they have difficulty with emotional regulation, it'd be well to know that before starting cross-sex hormones.) WhatamIdoing (talk) 00:47, 14 April 2024 (UTC)

I honestly don't quite know what to make of what Cass is saying when review says some think the clinical approach should be based on a social justice model. The weird thing is, she says it her foreword and in the summary in paragraph 5, but she never actually elaborates upon the meaning of it in the report's body, at least in the same terms. In enwiki terms, it's like she's added content to the article lead without also including it in the body. Although given there's close to 400 pages, it's possible she has, and I've just missed it. If she has, and you know the page and paragraph number could you share it? If I was to guess though, I would maybe say that's aimed at the gender-affirming care model, although if it is I would say that it's at best it's a misunderstanding of what gender-affirming care actually is. But that's a really rough guess and may be way off the mark.

I don't think the controversy surrounding the review is primarily because it's came from TERF Island, though it almost certainly hasn't helped. While there are certainly those lay people who see it in those terms, the issue being expressed by academics and the handful of MEDORGS who have released statements on it is that the review and the systematic reviews commissioned by it seem to widely diverge from what is (or was) the previously accepted norm, and the resulting controversy is because of the divergence. It may be that Cass and the academics at University of York are in the right here, but it may also be that they're wrong. Of course we only really care about verifiability and not the truth, however there is seemingly a major controversy surrounding this publication. WP:NPOV tells us that Wikipedia's purpose is to describe disputes and not engage in them, and in these circumstances my reading of it leads me to believe that right now basing the content of an article like puberty blockers would see actively engaging in the dispute while the dispute is ongoing.

Right now in terms of international bodies we have some early statements from WPATH affiliates like PATHA, and we also have statements from some human rights NGOs like Amnesty International. I assume, given the review's content, larger bodies like WPATH are formulating a more in depth response. What happens if the mainstream American medical organisations like the APA or AMA criticise the report's findings? What happens if the WHO criticise it? What if, as the early indications show, the forthcoming German, Austrian and Swiss guidelines wholly contradict Cass' report? Can we even base substantive article content on an article like puberty blockers on the systematic reviews commissioned by Cass if those are widely condemned and outright contradicted by another set of clinical guidelines released just a few weeks later?

How even does MEDRS advise us to proceed if we find ourselves in the situation where we have two, equally high quality guidelines, produced by two equally well respect medical bodies, that come to contradictory views about the exact same evidence base? WP:MEDDATE tells us to prefer the most up to date research, but we may just be about to find ourselves in a situation where there are going to be two equally high quality reviews, released within a few weeks of each other, that come to the opposite set of conclusions about the same evidence base. Have we ever had to even consider that sort of scenario before in a medical article? These are all the questions I find myself asking right now, and why I think we need to be cautious while this is playing out. Sideswipe9th (talk) 23:33, 13 April 2024 (UTC)

Well I was hoping one of you guys would say that "social justice model" is a well defined term in the trans debate. I wonder then why she would invent language. Perhaps she tried all the other ways of defining one side and felt they were all too contentious, and came up with their own euphemism.

I do get the sense from both of you that one model's priority is not the treatment of a mental health issue (or a collection of issues), even though the pathway in all countries AFAIK is to the mental health departments, but the (option to) use drug and surgical treatments to transform a body to align with an identity which is accepted at face value just as we accept someone's sexual identity. But that doesn't really answer my question of why WPATH and others still argue about the evidence wrt mental health outcomes.

I think this area is also why it is vital that we separate criticism of the Cass Review from criticism of the systematic reviews. You can for sure say the systematic reviews were measuring the wrong thing, if alleviating gender-related distress and improving mental and psychosocial health (e.g., self harm, suicidal, school/work/social life) are not one's primary aim, and possible negative outcomes on cognitive development, cardiometabolic risk, fertility, bone density and height are not one's primary concern. If ones primary aim is alignment of a body with a gender identity as a worthy goal in and of itself, and everything else is secondary. But what one can't really do is criticise the systematic reviews for doing their job, since they are an algorithm, and Sideswipe9th knows all about those. They are open for criticism if they chose the wrong selection criteria or a bad assessment model or even "had bugs" and made mistakes, but hopefully those would come out at peer-review and editorial assessment, and be obvious for attack subsequently. I haven't seen anyone suggesting this. It should be entirely possible for another team to do that review and come up with nearly the same conclusions. And those conclusions didn't surprise and confirmed what previous systematic reviews did. So when I read that folk are saying these reviews contradict MEDORG I disagree. The Cass Review may well contradict MEDORG, but those systematic reviews do not. I find it frustrating then when the two kinds of reviews are confused. It's like the systematic reviews are like the facts, such as census results or health or education statistics, and the Cass review is like an expert, of a particular flavour perhaps, who then makes recommendations about improving the nation's health or teaching provision. Sensible people of different flavours will disagree on what to do with those facts, or even to dismiss them as irrelevant, but they are separate from the facts themselves.

So I'm trying to see if our articles can say that if XYZ are prioritised then there is no good evidence making any recommendations to treat ABC, there is weak evidence to help DEF and moderate evidence of harm with GHI. But if TUV are prioritised then MEDORGS 123 all recommend them for ... That basically the two teams have different belief systems that underpins their views on what assessments should be done and what to prioritise as a treatment goal. But what we get away from is our article repeating misinformation about these systematic reviews.

As I noted earlier, comparisons of trans with gay only take us so far, as all sides in this battle see an enormous role for healthcare to provide, which is not the case for being gay. Plus, historically the role of healthcare in "treating" homosexuality was linked with then-criminality in adults.

As an aside, wrt CAMHS, I think one issue was that historically, when a child identified as trans, they got referred to GIDS and then taken off the CAMHS waiting list, with the assumption that GIDS would deal with the self harm and the suicide attempts and the possible undiagnosed autism. And when they arrived at GIDS, the only thing they were assessed for and treated for was gender related distress. So those other issues were never looked at by anyone. Add to that the fact that mental health has never had equality with physical health in the NHS and fallen even further behind under this government, both waiting lists are unacceptably enormous. So we do need someone to figure out how to holistically deal with the chid, and whether Cass's recommendation is wise or ideologically unsound is an argument for another day. The current system very much wasn't working.

Colin Colin°^Talk 10:13, 14 April 2024 (UTC)

I wonder then why she would invent language. From what I've seen, you're not the only person to be asking that question. I wish I had an answer for you, or that Cass had addressed what she meant by it in the report.

But that doesn't really answer my question of why WPATH and others still argue about the evidence wrt mental health outcomes. The short answer is, it's complicated. Gender incongruence can cause dysphoria, which itself can manifest in a multitude of symptoms from depression and/or anxiety all the way up to suicidality. Transitioning typically helps alleviate those issues which is why WPATH and others have a large focus on the impact of mental health outcomes from the different treatment modalities. However mental health issues are often multifactorial, or can interact with and play off of each other. For example, helping a trans person of any age transition won't address the cause of a person's depression if another part of that cause is a traumatic event in their past, or they have undiagnosed and unsupported autism or ADHD, or because they have been masking for years or decades. But transitioning does often make it easier to address those issues, because it eases part of the mental burden being dysphoric causes.

The issue here is, providing a trans person the support they need to transition, and providing them with support for trauma or autism or ADHD (or whatever else) are two different, if interrelated, disciplines. A counsellor who can provide a safe space for someone to explore their gender expression has a different skill set and training than one who can provide a safe space for someone to explore issues arising from being autistic in a neurotypical aligned world. Yes you could theoretically combine them under one roof, but given the sheer diversity of the trans and non-binary population, that one roof will rather quickly become a monolith.

But what one can't really do is criticise the systematic reviews for doing their job, since they are an algorithm, and Sideswipe9th knows all about those. It's not that simplistic. An algorithm is only as good as its input parameters, and Garbage in, garbage out is a rule with any algorithm. For example it is entirely possible to conduct a systematic review, and through the manipulation of the various parameters exclude evidence that goes against whatever your pre-supposed conclusion is. If someone wants to do that however, the difficulty is usually in doing it in a manner that is not blatantly obvious. Now obviously, I'm not saying that happened here, I'm speaking purely in hypotheticals. But I am aware of a 2009 paper in the American Journal of Gastroenterology that goes into detail about some of the ways a systematic review can come to the wrong conclusions about an evidence base.

With respect to the systematic reviews commissioned by Cass, there are academics I know of who have said the reviews are flawed, and there is at least one group, who unlike the academics Cass commissioned have published previously in this field, are currently writing a commentary for submission to the BMJ about the flaws compromising their results. Whether that gets accepted by the BMJ, or rejected and published elsewhere, and what exactly this commentary states remains to be seen. But I would say that it's a potential flaw in our processes to consider all systematic reviews as being beyond reproach simply because they have passed peer-review and been published.

but hopefully those would come out at peer-review and editorial assessment Peer-review is far from perfect. I've published two papers (not going to cite them but they are on algorithms, you don't need to know my name :P) and I know first hand how the peer-review process can be abused. For one of my two papers, I had an anonymous reviewer complain about why I hadn't cited a couple of other papers in my literature review and as comparisons for my results. For my part, I looked at the papers they wanted me to cite and they weren't relevant at all to my own work, nor were they valid comparators against my results so I consulted with my PhD supervisors. After talking with them, we were able to figure out both why the reviewer wanted these papers cited and who the reviewer was, as they were research published either by himself or his research group. My supervisors were not at all surprised by this, nor were any others I discretely talked to at conferences. And this wasn't for some low quality, low impact factor journal mind. I was submitting my papers to high impact-factor journals published by Springer and IEEE.

As for editorial assessment, journal editors do almost nothing. In my own experience the only things they ever look at are typesetting issues. Interestingly enough there was a rather large example of a journal editor not catching both bad science and unethical science, in transgender research last year. The Diaz and Bailey article on ROGD was published in Archives of Sexual Behavior, and subsequently it was heavily criticised due to fundamental and fatal flaws in its methodology and for a lack of required ethical approval by hundreds of other academics in the field. In the end, it was retracted, but only after both the IASR and Springer themselves stepped in.

It should be entirely possible for another team to do that review and come up with nearly the same conclusions. Only assuming they use the exact same parameters as the researchers commissioned by Cass. As soon as you change one of the parameters, you'll get a different set of results. As I've said both here and on the Cass Review talk page, early indications based on a press conference from the guideline authors are that the forthcoming German, Austrian and Swiss guidelines have looked at the exact same research that the Cass commissioned academics did, and have come to completely the opposite result. How they've come to that conclusion, and why it is so different from Cass' remains to be seen.

Also, the Cass commissioned systematic reviews don't appear to be fully replicable at this time. The review on puberty blockers states that they carried out searches on MEDLINE, EMBASE and PsycINFO through OVID, CINAHL Complete through EBSCO, and Web of Science (Social Science Citation Index), however they've only provided the search strings for their MEDLINE search. What strings and parameters they used for EMBASE, PsycINFO, CINHAL Complete, and Web of Science aren't stated.

It's like the systematic reviews are like the facts No, that's not quite right. Systematic reviews are only as reliable as the data they consume and the parameters used when assessing that data. As I said before, if you give them bad inputs you'll get bad outputs; garbage in, garbage out. Some of the academic criticisms I've seen on this are along GIGO lines, though none are published yet in reliable sources as they are still being written.

they got referred to GIDS and then taken off the CAMHS waiting list, with the assumption that GIDS would deal with the self harm and the suicide attempts and the possible undiagnosed autism That's both a mistake, but also one that isn't universal across the United Kingdom. In terms of the mistake, where the child is expressing suicidality and exhibiting self-harm behaviours, they shouldn't have been removed from the CAMHS lists. CAMHS is in a much better position to support that child, especially if those issues have other causes alongside gender incongruence related distress.

As for it not being universal, the only pathway for a trans youth to get referred to KOI is through CAMHS or the learning disability service. Where this becomes a problem is that KOI use engagement with CAMHS as kind of a stick, and will remove services from that youth if they don't engage with CAMHS. Now you may well ask, why is this a problem? Well, not every trans person has co-occurring mental health issues that are separate from gender incongruence related distress. There are quite a lot of trans youth who don't need any additional mental health support, once they have been supported through transitioning. However KOI force the youth to engage with CAMHS in order to get that support, even when it is wholly contraindicated and neither the child nor their family feel it is needed or wanted.

When looked at together, these are both two extremes of how different regions of the UK (England and Northern Ireland) have got the wrong approach when it comes the involvement of CAMHS for trans and non-binary youth. The correct approach is somewhere in the middle, where CAMHS is neither a required nor prohibited step in accessing health care through a gender clinic, but is instead an option available for (and only for) those youth who actually need it.

The current system very much wasn't working. On this, I think we can all agree. Sideswipe9th (talk) 00:42, 15 April 2024 (UTC)

Cass didn't just invent the language:

• "Gender Justice L.A. is a grassroots social justice organization led by and for gender non-conforming, two spirit, Black, Indigenous, and trans people of color in Los Angeles" [1]
• "Trans People of Color Coalition is ...the only national social justice organization that promotes the interest of Trans People of Color" [2]
• "Transfinite is a first-of-its-kind collective social justice project..." [3]
• "Galaei is a Queer and Trans, Black, Indigenous, and People of Color (QTBIPOC) radical social justice organization" [4]

WhatamIdoing (talk) 00:43, 15 April 2024 (UTC)

I don't think that's quite what Colin, and it's definitely not what I meant here. The term social justice goes back 200 years. I don't think anyone is questioning that. The issue is what does Cass mean when she says the Although some think the clinical approach should be based on a social justice model, the NHS works in an evidence-based way. She uses that phrase once, in paragraph 5, page 20, and never again in the rest of the report. In the context of the report, what does she mean by the social justice model? What is the social justice model of health care? It's not a term I'm familiar with, nor any of the rest of us in this discussion it seems. Sideswipe9th (talk) 00:52, 15 April 2024 (UTC)

Presumably, when she says "I have faced criticism for engaging with groups and individuals who take a social justice approach" she means "I have faced criticism for engaging with trans rights groups that self-identify as social justice organizations". WhatamIdoing (talk) 00:55, 15 April 2024 (UTC)

Sure, but that's not the only statement she makes about social justice, nor is it the one I was talking about. Sideswipe9th (talk) 01:12, 15 April 2024 (UTC)

There have been several discussions at WT:MED about the flaws of peer review, editorial selection, fraudulent papers, which in turn screw up the reviews that hoover them up. I wouldn't be over concerned about selection strings other then medline: do you really think there would be a good quality relevant study that wasn't on PubMed? Anyway, we are not really encouraged to our own peer or editorial review of such works. We just have to respect the hierarchy of evidence and trust that any wrongs get righted without ourselves thinking we know better than the editors of the BMJ or whatever.

The kind of thing on that page where a systematic review in the BMJ is being juxtaposed with some random doctor in Australia via a daily newspaper saying they missed out four studies that would have said different is not how MEDRS works.

Are the German, Austrian and Swiss guidelines going to publish a better systematic review or are they simply going to do, what it appears to me WPATH are doing, and include the low quality "evidence" in their opinion making.

I get your comment that mental health improvement assessment is made difficult by all the comorbids. But it doesn't change the fact that the best evidence repeatedly says he mental health improvements haven't been found by moderate or high quality studies. But that's not the same as saying that moderate and high quality studies have found negative effects, just that this particular reason-for-doing-it isn't evidence based. As WAID mentioned elsewhere, lots of Cochrane reviews on other things report that NO good quality research exists and NO evidence-based conclusions can be made, and yet doctors then still decide whether to use or not use a therapy. They just have to admit that at present their choice is not evidential, or is based on other factors.

I note that your criticism on the limited worth of peer-review is not being repeated at the discussion of the merits of Cal Horton's paper. I think that talk page could do with some knowledgeable reality, rather than puffery about thematic analysis and peer reviewed journals. And I think it is also worth thinking that what if Hal Corton (Cal's evil nemesis) published a gender-critical thematic analysis that said the Cass Review was the best thing since sliced bread, published in a similarly modest journal, would all the editors on that page be jumping up and down to include someone who'd recently completed a phd in gender-critical-feminism? I find turning these things around is helpful to spot bias. I don't think anyone would be going "ooh, peer review" or "ooh, thematic analysis" or be at all happy to state their opinion in Wikivoice. -- Colin°^Talk 10:54, 15 April 2024 (UTC)

How they've come to that conclusion, and why it is so different from Cass' remains to be seen.

Cass explains how WPATH's commissioned systematic review came to a different conclusion to the NICE one - by including low quality research. If the upcoming Swiss review does the same, then we'll be in the same position, ie findings that are not robust when you filter out low quality inputs, which ought to be a cause for concern. Which is more likely to be GIGO? The one with more, or less garbage? Void if removed (talk) 08:09, 15 April 2024 (UTC)

Yes, it isn't established language and my best interpretation is that it is an attempt to sever the gordian knot of the differing approaches, and the inflamed debate over affirmation/exploration/conversion.

She's tried to move away from the specifics of the approach, to the basic justifications - because evidence will (or should) govern the specifics.

I don't think it will work, because this sort of thing has been tried before, and any new attempt at neutral language is branded a dogwhistle.

Indeed, it hasn't worked given that WPATH etc are accusing the Cass Review of endorsing conversion therapy. Void if removed (talk) 08:02, 15 April 2024 (UTC)