Talk:Puberty blocker

Vaginoplasty

The claim that the puberty blocker does not leave enough material to perform vaginoplasty is misleading. Cessation of the puberty blocker without continuing with HRT will allow puberty to continue as per the assigned sex at birth, including increased penis length - It is therefore not the puberty blocker alone that causes the loss of penis shaft material. However, modern techniques of vaginoplasty in trans women no longer require penis shaft length but instead use peritoneum pull through technique that has been used in cis women who were born without a vaginal canal for over 60 years. After 9 months in cis girls the peritoneal tissue is indistinguishable from vaginal tissue under a microscope. The method SRS-PPV Penile Peritoneal Vaginoplasty results in a self-lubricating and elastic vagina that unlike older techniques does not require a lifetime of dilation (https://www.kamolhospital.com/en/service/SRS-PPV/).

Systematic reviews

@Snokalok, re your edit summary: Directed contradicted by numerous recent systemic reviews listed in the article, I assume you are saying that the conclusions drawn in Zepf (2004) have been directly contradicted by more recent, or higher quality, systematic reviews? In which case which ones are you referring to? Barnards.tar.gz (talk) 15:43, 13 March 2024 (UTC)

"Current evidence doesn’t suggest that GD symptoms and mental health significantly improve when PB or CSH are used in minors with GD." -Zepf

Puberty blockers:

"Positive outcomes were decreased suicidality in adulthood, improved affect and psychological functioning, and improved social life." [1]

"Numerous studies, primarily of short- and medium-term duration (up to 6 years), demonstrate the clearly beneficial-even lifesaving-mental health impact of gender-affirming medical care in TGD youth." The page on puberty blockers came to this conclusion, but in the summary statement they say gender affirming care in general because they're also evaluating HRT and I didn't think it'd be nice to you to copy and paste the entire page. [2]

And under WP:MEDORG, International medical org position statements are give equal or greater weight than reviews, so here's two international orgs

Endocrine Society:

"Puberty blockers allow more time to explore gender identity, live in the experienced gender, and understand the medical and/or surgical options. They also avoid unwanted sexual development and, in later pubertal stages, stop periods and prevent further facial hair growth/voice deepening. Puberty-blocking medications are fully reversible."[3]

"Suppressing puberty is fully reversible, and it gives individuals experiencing gender incongruence more time to explore their options and to live out their gender identity before they undergo hormone or surgical treatment. Research has found puberty suppression in this population improves psychological functioning. Blocking pubertal hormones early in puberty also prevents a teenager from developing irreversible secondary sex characteristics, such as facial hair and breast growth."[4]

WPATH:

"when compared with baseline assessments, the data consistently demonstrate improved or stable psychological functioning, body image, and treatment satisfaction varying from three months to up to two years from the initiation of treatment." "At baseline, the transgender youth demonstrated lower psychological functioning compared with cisgender peers, whereas when undergoing puberty suppression, they demonstrated better functioning than their peers" "Longitudinal research demon-

strating the benefits of pubertal suppression and gender-affirming hormone treatment (GAHT) was carried out in a setting where an ongoing clinical relationship between the adolescents/families and the multidisciplinary team was maintained "[5]

Now let's look at the text of your edit:

"While some studies have shown benefits and improvement to psychological well-being, more recent systematic reviews have concluded the available evidence is very low certainty, and that the current studies have significant conceptual and methodological flaws, and show no clear clinical benefit."

I want to focus here on the reduction of the psychological outcomes, as well as use of "very low certainty" and "no clear clinical benefit" here, because for the former, all the NICE review concluded this based on was that there were no randomized controlled trials, which are impossible to perform for puberty blockers given that RCT's are double blind, and it's impossible to have a double blind study when the control group is visibly going through puberty while the other group isn't. As for "no clear clinical benefit", this is of course contradicted by the numerous reviews listed above, as well as the policy statements of the international orgs cited (plus numerous national orgs that I can pull if you want), AND your own words, as improvement to psychological wellbeing *is* a clinical benefit, as is halting puberty. Thus, at best this paragraph is WP:UNDUE weight for the summary, and at worst WP:NPOV.

At most I'd say you can toss this review into the section where all the other relevant sources and pieces of info are listed, but putting it in the summary and in particular giving it such strong weight, isn't at all beneficial to the article. Snokalok (talk) 17:36, 13 March 2024 (UTC)

Additionally, looking more closely at Zepf, its entire argument also appears to center around the lack of randomized controlled trials, which again, cannot be done for puberty blockers, flat out. So I'd say that even including it at all beyond "A later review echoed NICE's concerns" is dubious at best Snokalok (talk) 17:47, 13 March 2024 (UTC)

WP:MEDORG does not say International medical org position statements are give equal or greater weight than reviews.

Something that WP:MEDRS does say is The best evidence for efficacy of treatments and other health interventions comes mainly from meta-analyses of randomized controlled trials (RCTs). Systematic reviews of literature that include non-randomized studies are less reliable. Just because a treatment cannot be tested in a randomized controlled trial doesn't mean we have to uncritically accept whatever standard of evidence we can get. It means the highest levels of certainty are out of reach, and that we can't rule out things like confounding factors and reversion to the mean - and therefore that caution is warranted, which looks to be the conclusion reached by the most recent systematic reviews.

On top of the NICE study and the followup by Zepf, we have the reviews and position statements from Finland, Sweden, Norway, and France, all taking a cautious or skeptical tone. The AAP has commissioned its own systematic review of evidence[6], so presumbly its current policy statements are backed by something other than a systematic review of evidence.

It is no longer feasible to not mention this uncertainty in the lead.

AND your own words, as improvement to psychological wellbeing *is* a clinical benefit It is still true that those studies concluded there were psychological benefits, but it is also true that the later, more reliable systematic reviews have cast doubt on the reliability of such studies. Barnards.tar.gz (talk) 19:17, 13 March 2024 (UTC)

Okay

A:

They have a whole diagram there clearly showing International medical orgs as the highest ranked of MEDRS sources, so yes they do.

B:

"Just because a treatment cannot be tested in a randomized controlled trial doesn't mean we have to uncritically accept whatever standard of evidence we can get"

Except that the overwhelming majority of medications and medical procedures are without randomized controlled trials. Less than one in ten procedures have high quality GRADE ranking, and over 50% have low quality or very low quality.[7] And yet despite that, we don't have a paragraph on that in the summary of every wikipedia page on every treatment. So unless you want to start going through every medical article and adding a similar paragraph in its intro (which if you do, I'd happily assist), why are you intent on handling this treatment differently?

And even if a handful of countries, many of which have far more expansive bans on trans care already in place (Finland, Sweden, Norway) [8][9][10], or are so well known internationally for transphobia that they're often referred to as 'TERF Island'[11], or a whose medical apparatus has listed trans people as 'an epidemic' [12], don't find that level of evidence sufficient for this one specific, highly politicized medication, why are we privileging them over the consensus of the international medical community and the policies of far larger and far more consequential national organizations? It's still UNDUE and POV.

By your logic, we should start listing the opinions of Hungary, Russia, and Saudi Arabia as well.

C:

The sources listing psychological benefits *are* reviews, not studies. The fact that one review is saying "Nuh uh cus you don't have this type of study that's impossible to perform" does not discount or diminish that - the same way it doesn't discount or diminish it for the countless other medical treatments out there without RCT's.

D:

Putting the words of detractors in the evidence section with all the other reviews is one thing, but putting it in the lede, especially when it's a hotly disputed position with numerous more reliable national orgs as well as every major national org still saying otherwise, just becomes POV pushing. Snokalok (talk) 20:48, 13 March 2024 (UTC)

Please read the diagram again. It’s not contrasting medical org guidelines on the left hand side with studies or scientific reports or systematic reviews on the right hand side, it’s comparing gradations of different types of MEDORG guidelines. The preceding paragraphs make this clear: … can be the equal of the best reviews…. Can be. Not necessarily. And not “greater”.

If another treatment without RCTs was also subject to multiple independent reliable systematic reviews casting doubt on it, then yes, we absolutely should mention that in the lead of the article about those treatments. I suspect that most RCTless treatments do not attract this type of coverage because they are uncontroversial. In those hypothetical cases and this real one, we should be led by the sources. With such a large (and growing) body of scholarship reaching a verdict of uncertainty, it would be negligent for us not to mention that uncertainty in the lead. It’s already in the body.

Note that the proposed wording doesn’t claim puberty blockers are unsafe, or should never be used. It simply highlights that the evidence to date does not support the purported clinical benefits to a high level of certainty. Barnards.tar.gz (talk) 21:25, 13 March 2024 (UTC)

Except again, international medical consensus is still clearly established on this. If you want to read over the WPATH SOC8, it's linked above, and is very unequivocal on this matter. Prioritizing sources against that consensus in the summary simply because the treatment is politically controversial would be a tenuous proposal on a non-medical article, but we don't give such weight to views outside the medical mainstream, motivated heavily by political controversy, in the summary of a medical article. Otherwise imagine what the articles on abortion would look like.

If you want to add a dedicated criticism section to the gender affirming care subsection, go nuts, I'll even help, but as it stands, it's simply not enough to put it in the summary. Snokalok (talk) 21:36, 13 March 2024 (UTC)

No, it is not "clearly established", as demonstrated by the international medical disagreement about this. Again, there is no more recent systematic review than the Zepf one, and none of the sources you've offered are systematic reviews.

You've offered a literature review (which is not a systematic review) a review article, a couple of press releases and WPATH's position. None of those is sufficient to overrule this systematic review. Your edit comment removing this addition does not support the removal.

Also attaching a blog post as a critical response to a MEDRS like the NICE review is WP:FALSEBALANCE as you've done. Sure, SBM is a WP:RS but it is not equivalent and this is giving it WP:UNDUE weight. Void if removed (talk) 22:38, 13 March 2024 (UTC)

Okay

A. Being the most recent doesn't make it the best source, I don't know why you keep holding to the fact that was published in 2024 as making it the end all be all.

B. "International medical disagreement" Yes, and there is international medical disagreement about vaccinations. About abortion. About covid masks. About homosexuality. Many of which, have their own sets of doctors publishing their own reviews saying that abortion is murder or that vaccinations are the devil. Many of which, have entire countries whose system has fallen in line behind these ideas and none of which makes them at all take precedence over international consensus established by the international orgs centered around these issues.

And even if we take international orgs out of the equation, all of the countries listed above have less than half the combined population and number of doctors as the US and its orgs.

C. Press releases outlining the position of the Endocrine Society, the international org on hormone related care. Do not reduce them.

Ultimately again, by your logic we'd have to say that international consensus on things like abortion doesn't exist because the medical association of Iran or whatever is against it. Snokalok (talk) 22:47, 13 March 2024 (UTC)

And also, literature reviews are systematic reviews, so Snokalok (talk) 22:48, 13 March 2024 (UTC)

If Iran published reliable systematic reviews on this subject, then of course we would take those into consideration. Do they? Not that I’ve seen. Your comparison to abortion is also flawed because the people publishing against abortion are coming from a lay political/religious/ethical perspective, as opposed to formal scientific reports in reliable academic medical journals.

In contrast, we now have multiple independent systematic reviews coming out of respected academic and healthcare institutions of Europe. We have reliable sources confirming there is rising professional disagreement[13]. Our article already includes a substantial section detailing the contrasting positions. On what basis do you propose we ignore all of this in the lead?

It might have been true 3-4 years ago that an international medical consensus existed, but the field has moved on and our article is now out of date. Barnards.tar.gz (talk) 08:19, 14 March 2024 (UTC)

Because again, a handful of small countries going in a different direction because they have - at a time when it’s become a very politically contentious treatment - decided to apply a standard of evidence required to puberty blockers that no other medicine is held to, does not a consensus break. Consensus doesn’t mean unanimous. It warrants them a dissenting voice on the article, but in 2022 WPATH put out its SOC8 guidelines reaffirming the overall international medical community’s stance on the matter, and the Endocrine Society had repeated it emphatically similarly. The field still supports puberty blockers, as does every American medical org which represents far more doctors serving far more people than all of the countries you’ve listed combined.

Ultimately, all that the above review you’ve posted shows, is that a single digit number of professionals in Germany (the ones who wrote it, that is) disagree on the grounds that an impossible to perform type of study for the medication can’t be performed, and that for some reason this standard only applies to puberty blockers. But that does not an international consensus break. At most it earns it a sentence in the same. paragraph as the NICE review Snokalok (talk) 08:29, 14 March 2024 (UTC)

Addendum: It should also be noted, that all of the countries you listed, undertook these actions well before the WPATH SOC8 came out, and the only thing that has changed since then as far as I can tell, is a single digit number of people in Germany putting out a single review, which in the face of multiple international orgs, is not enough to reshape the article. Snokalok (talk) 08:43, 14 March 2024 (UTC)

Medical consensus isn't a headcount, and it certainly isn't a headcount of the population of different countries. Barnards.tar.gz (talk) 08:57, 14 March 2024 (UTC)

You’re right, it’s the recently stated words of the international medical orgs charged with providing and overseeing such care. Snokalok (talk) 14:20, 14 March 2024 (UTC)

Your reversion comment was [Directly] contradicted by numerous recent systemic reviews listed in the article, and thus not at all fit for the summary

AFAICT, you've offered one actual systematic review, and that is 3 years older than this one.

I don't think this is valid justification for the reversion. I don't think there are numerous recent systematic reviews that contradict this one, and this one builds on and strengthens the conclusions of the 2020 NICE review.

Country population and number of authors aren't valid reasons to discard a top-tier MEDRS. Void if removed (talk) 09:53, 14 March 2024 (UTC)

I mean A. I’ve listed two reviews, as we established in the thread below, B. That’s another word I keep hearing you use, “top tier”, but what actually makes it top tier? I remember you once describing the Cass Review as top tier despite the fact that it was incredibly opaque about its composition and methods. Is simply being affiliated with the state enough? C. You’re right, it’s not a reason to discard it, but it’s not enough to put it in the summary over the internationally established consensus, and certainly not worded in such a POV manner Snokalok (talk) 14:24, 14 March 2024 (UTC)

Do you have a suggestion for modifying the lead so that WP:LEADFOLLOWSBODY? Because it currently doesn't mention the systematic reviews at all, despite them forming a significant chunk of the body of the article. Barnards.tar.gz (talk) 15:19, 14 March 2024 (UTC)

Really I think we should be giving more weight to international consensus in general, considering all the reviews say the exact same thing - “no rct = no puberty blockers”. We’re not covering any new ground by listing how many reviews have made that their hill to die on, I think the entire area should be restructured into a single paragraph or subsection covering the lack of RCT’s Snokalok (talk) 15:37, 14 March 2024 (UTC)

You keep saying international consensus, but there just isn't any such thing any more. There is a sharp transatlantic divide between US-led institutions and European institutions.

Furthermore, it is not true that the systematic reviews amount to “no rct = no puberty blockers”. For a start, none of them conclude "no puberty blockers", they simply conclude that the evidence for their benefits is lacking. Secondly, have a read of Zepf. There are numerous shortcomings pointed out that are unrelated to a lack of RCTs, for example:

• With regard to the critical target variables “gender dysphoria”, “quality of life” and “body image” there were no significant effects, ie the PB administration did not cause any significant improvement.
• ... there was no difference between groups regarding the form of intervention “PB plus psychological support” vs. “psych support alone”.
• No valid statement can be made regarding the target variable “cognitive development/cognitive functions” based on only one study
• (Turban et al., 2020) is called out as poor quality, ...the authors of the study did not report the data for GnRH analogues separately from other interventions

Caveat: quotes above derived from a Google Translate version of the original.

Barnards.tar.gz (talk) 16:18, 14 March 2024 (UTC)

Again though, regardless of what a handful of the least populated countries in the world say, the international orgs responsible for this care - of which these countries are very much a part - have still agreed upon this. If it was guidance released 10, 15 years ago, in light of more recent opinions that'd be one thing, but this was released in 2022, after all of the above countries made their shifts rightward on trans care.

And all Zepf is, in the face of that, is the opinion of five or so doctors. A thoroughly-read opinion perhaps, but compare it to the depth of review done in the SOC8 (seriously do read it), by countless more doctors.

In summary. If three doctors in country A say "bad", five doctors in country B say "bad", and six doctors in country C say "bad", and then the international org responsible for handling such care worldwide says "good", the former doesn't mean nearly as much, because at the end of the day there are individual doctors with their own pet opinions on everything. There are doctors who believe that homosexuality can be cured with electroshock, for instance. There are doctors who believe the covid vaccine is a government conspiracy. The fact is, that the SOC8 released in 2022, and the Endocrine Society's continuing statements on the matter, as the international professional orgs representing the practitioners in this field, are quite clear on this, and that a handful of doctors distributed across Europe, simply do not command anywhere near the same weight for the purposes of this article. Again, if you want to put a "criticism" section outlining the criticisms, by all means, but there is a clearly stated international consensus that does hold. Snokalok (talk) 16:39, 14 March 2024 (UTC)

Addendum: I feel like you're deliberately to some degree sidestepping the fact that, the standard of evidence being applied is something that no other form of medicine has to go through. Because we have to ask, what does that suggest in terms of POV for the authors? Because anything without RCT's, which amounts to 90% of medicine, you can write a review and say the same things they said here. The fact that a few doctors have decided to make this determination over a highly politicized medication something to attach their names to, when you see none of such a thing being done for less controversial medicines, is something we need to interrogate for the purpose of weight and sourcing.

But regardless, the international orgs representing the global coalition of those providing such care, have made it clear in light of these opinions, that they do not agree, and that the evidence *is* there. That's an international consensus. Snokalok (talk) 16:56, 14 March 2024 (UTC)

what a handful of the least populated countries in the world say... - this continues to be an absurd line of analysis. There is nothing in WP:MEDRS that suggests we should be evaluating medical sources on the basis of how many people live in the country where the source was published. Characterising peer-reviewed systematic reviews published in reputable medical journals as the product of "a handful of doctors" is equally absurd.

Regarding "90%"... I don't know if that's the figure, but if it is it wouldn't surprise me. Are you aware that a huge, huge number of medical interventions have been found to be ineffective (or worse) when subject to the rigors of RCTs? Meta-Research: A comprehensive review of randomized clinical trials in three medical journals reveals 396 medical reversals

Why is this particular medical intervention being singled out for additional scrutiny? Yes, you're probably right that its controversial nature is a factor. Another factor is the rapid growth in GD presentation in the last 10-15 years. Another reason is the serious life-or-death narratives surrounding the intervention. For all these reasons, it's not unreasonable to want to make the best possible evaluation of the evidence. Hence, lots of people are doing evidence reviews and planning studies. There's nothing here to suggest a malign POV.

Are you aware that most members of WPATH are US based? And that the European nations in question now deviate from its standards of care? The claim that it represents the be-all and end-all of international consensus is... low certainty. Barnards.tar.gz (talk) 17:31, 14 March 2024 (UTC)

Are you aware that a huge, huge number of medical interventions have been found to be ineffective (or worse) when subject to the rigors of RCTs? Irrelevant, RCTs won't work for puberty blockers because the desired outcome, halting puberty, is not something you can miss. Here's an article[14] which succintly sums it up: Although RCTs are considered high-quality evidence because of their ability to control for unmeasured confounders, the impossibility of masking which participants receive gender-affirming interventions and the differential impact of unmasking on adherence, withdrawal, response bias, and generalizability compromises the value of RCTs for adolescent gender-affirming care.

TLDR, if you take a group of trans kids who want to pause their natal puberty, tell them you're pausing it, and then half of them don't experience a paused puberty while the other half do, 1) the youth will know if they received the blockers or a placebo, 2) the researchers will know the same, 3) the youth will not continue taking a placebo when they're trying to stop their puberty, 4) you're forcing kids to go through a puberty against their will despite all the evidence that's harmful. Per 1 and 2, a double blinded trial is impossible, per 3, up to half your participants will probably drop out, and per 4, you're mistreating the youth and forcing them through irreversible changes against their will. IE, any DBRCT on puberty blockers is unethical and doomed to failure from the start.

This is actually covered even in Randomized control trial#Blinding, which says An RCT may be blinded, (also called "masked") by "procedures that prevent study participants, caregivers, or outcome assessors from knowing which intervention was received." Unlike allocation concealment, blinding is sometimes inappropriate or impossible to perform in an RCT; for example, if an RCT involves a treatment in which active participation of the patient is necessary (e.g., physical therapy), participants cannot be blinded to the intervention. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 17:57, 14 March 2024 (UTC)

I’m quite aware of why you can’t do an RCT for such interventions. That doesn’t create a free pass for the intervention - it means evidence for its efficacy can never be high certainty. Barnards.tar.gz (talk) 18:11, 14 March 2024 (UTC)

When it's that handful vs the orgs responsible for overseeing that care worldwide, then yeah, it is just a handful. That's how source analysis works. Systematic review doesn't mean infallible end all be all, it means an ideal place to look. It's like RSP sources on the rest of the wiki; if a neo nazi publishes an article in the NYT saying the holocaust never happened, we don't say that because it's in the NYT we have to give it weight, we analyze everything surrounding that, including that, overwhelming historical consensus is that the holocaust did happen.

This is no different. A handful - yes, a handful - of doctors said "no", the rest of the international community all emphatically said yes.

I'm going to need a citation for that bit about most WPATH members living in the US. Snokalok (talk) 18:30, 14 March 2024 (UTC)

That about 75-80% of the membership is in the US isn't a secret. The WPATH membership directory is open. There's about 2500 members total (at the moment) and about 1900 in the US. The membership fluctuates regularly but the ratios don't change much. Void if removed (talk) 21:05, 14 March 2024 (UTC)

The exact numbers at this time are 1,933 that have the United States as their country out of 2,554 total membership. That puts the US membership at 75.7%. Zeno27 (talk) 21:19, 14 March 2024 (UTC)

Right, in that case that brings me to my next point:

As of 2022, the year the guidelines were published, there were 65 dedicated trans youth clinics alone in the United States, to say nothing of all of the regular hospitals and doctors that provide care for both adults and youth. [15]

Compare that to one in the UK (Tavistock, as I think we've all well established by this point).

One in Norway. [16]

Three in Sweden. [17]

Two in Finland. [18]

And four in France. [19]

That's 65 in the US and 11 in the combined dissenting countries. A total of 76, or, 85.5% US. Meaning that if anything, the United States is underrepresented at WPATH, and that it being majority American is not out of line with the state of the international field. And again, that 65 is just the ones that have singled themselves out as being dedicated to trans youth care specifically, something which is illegal to do in many red states. I don't think it's controversial to say that the trans medical care field as a whole in the United States is significantly larger than that. Snokalok (talk) 05:42, 15 March 2024 (UTC)

There are several clinics in the UK. The Tavistock is run by NHS England and has a satelitte clinic in Leeds (does that count as a separate clinic?), but there are four in Scotland, two in Northern Irerland and one in Wales: Gender identity clinic#United Kingdom Certainly, the Sandyford Clinic in Glasgow has yet not announced it's dropping the WPATH guidelines: NHS clinic ‘follows discredited trans guidelines that encourage castration’ Zeno27 (talk) 06:07, 15 March 2024 (UTC)

Right but only NHS England has gone against puberty blockers, and all the source you're providing does is highlight how much media campaigning - and especially right wing sources like The Telegraph - is playing a role in creating pressure for that. Snokalok (talk) 06:13, 15 March 2024 (UTC)

I'm not sure the relevance of that statistic either way. It's not like medical knowledge is determined by counting countries. If WPATH is the big international trans organization, and it is, it doesn't matter where its members live. Probably the WHO doesn't have a lot of members living in Western Sahara and that's not an issue for its guidance, right? Loki (talk) 02:26, 15 March 2024 (UTC)

The initial question was to do with any bias in WPATH: the countries that seem to be dropping WPATH as an authority on treatmerntt are currenty European, which is underrepresented in terms of membership.

But that does raise the question of the two faces of WPATH: a trans advocacy group that produces treatment guidelines it would like to see adopted worldwide and a trade body with a list of thousands of members and their specialities (including law, chiropractic (bizarrely), electrolysis, scocial work, nurses, surgeons) advertising for business. Zeno27 (talk) 05:46, 15 March 2024 (UTC)

It's neither, and characterizing it as such is a pretty blatant POV. It's simply, the international medical org for setting the standard of trans-related healthcare. Until the 2010's they openly advocated conversion therapy. They're not an activist group or a trade organization, they're a medical org like any other, and to characterize them as otherwise simply because they take a supportive stance on trans healthcare is openly disingenuous. Snokalok (talk) 05:51, 15 March 2024 (UTC)

Where WPATH members come from does not matter. What matters is it is a credible and reputable medical organization of people who are experts in transgender healthcare. -TenorTwelve (talk) 07:24, 15 March 2024 (UTC)

I agree that we should focus more on international medical consensus. -TenorTwelve (talk) 07:17, 15 March 2024 (UTC)

The first is indeed a systematic review. The second is a narrative review, which sits further down the MEDRS scale.

Top tier just means it sits at the top of the MEDRS scale. Void if removed (talk) 16:57, 14 March 2024 (UTC)

Fair, but international orgs still sit above all of that. If this was the word of an international org published in 2010 vs everything in the last few years, I'd perhaps agree. But all of the comments by various dissenters amount to the same thing - "This standard of evidence that most medicine is not generally held to, is not satisfied here, despite it being impossible to satisfy for this medication for both practical and ethical reasons. Therefore there is no evidence" and in response, the international orgs representing broad consensus have said "No, there is plenty of evidence pointing to X, it just doesn't meet this arbitrarily established benchmark. But it's still more than enough to go on."

Because ultimately, a review is only the opinion of the handful of doctors that took part in it, whereas the opinions of WPATH and the Endocrine Society, are the broad consensus of the international field. Thus, the opinion of this handful should not be privileged over an international consensus. As I said to Barnard, if you want to make a "Criticism over no RCT" subsection, go for it, I'd honestly say it's overdue. But that is not enough to earn it a place in the summary, let alone the dominant weight it was given.

Actually, I might make that subsection if it's okay with you. Snokalok (talk) 17:07, 14 March 2024 (UTC)

international orgs still sit above all of that This is not true. Barnards.tar.gz (talk) 17:32, 14 March 2024 (UTC)

A few thoughts on RCTs, the GRADE scale, and puberty blockers

It is unethical to do a randomized control trial for puberty blockers because denying health care to a person for the sake of an experiment could lead to suicides.

Most medicines are not “high quality” on the GRADE scale and have not received this scrutiny for how it “ranks.”

The GRADE guidelines also warns against over-relying on randomized control trials in recommending treatments. “Although higher quality evidence is more likely to be associated with strong recommendations than lower quality evidence, a particular level of quality does not imply a particular strength of recommendation. Sometimes, low or very low quality evidence can lead to a strong recommendation” -TenorTwelve (talk) 08:06, 15 March 2024 (UTC) TenorTwelve (talk) 08:06, 15 March 2024 (UTC)

None of those links is a systematic review AFAICT. Void if removed (talk) 18:37, 13 March 2024 (UTC)

Did you miss the word "review" in the corner? Snokalok (talk) 22:33, 13 March 2024 (UTC)

Review, literature review and systematic review are different things. Void if removed (talk) 22:38, 13 March 2024 (UTC)

Review alone could mean something narrower, potentially, but literature review and systematic review mean the same thing. They are both reviews of multiple studies on a specific subject, a systematic review of the literature. Silverseren^C 22:46, 13 March 2024 (UTC)

They don't. But I see now the first is actually a PRISMA systematic review after all, so it is on a par with Zepf, but 3 years older.

For the distinction, see https://www.mmu.ac.uk/library/research-support/systematic-reviews/what-is-a-systematic-review Void if removed (talk) 00:04, 14 March 2024 (UTC)

The issue here is that systematic reviews are also called systematic literature reviews, which can cause confusion. Your link is correct, in that literature reviews in themselves are of a broad topic, which is what differentiates them. But you're not going to see something like that in this very narrow topic field. So they're all going to be systematic literature reviews. Silverseren^C 00:09, 14 March 2024 (UTC)

I fear this discussion has wandered wildly off topic.

The Zepf update to the NICE review is the most recent systematic review, and there's no good reason not to mention it in the lede. The removal of it was based on the comment that it was contradicted by multiple recent systematic reviews. This appears not to be the case, with only one cited systematic review which is 3 years older. I believe the mention of Zepf should be reinstated in the lede.

An endless discussion about bias and activism and right-wing media and number of researchers and the US focus of WPATH and the population of Germany vs the US and how many gender clinics it has seems to me to be a complete waste of time.

Zepf is a WP:MEDRS, building on and reinforcing an existing WP:MEDRS, both of the highest standard we are supposed to be using to build articles like this. No-one is saying WPATH's position should not be included. But WPATH's position should not be used to elide or downplay high quality sources that assess the evidence and find it lacking. Void if removed (talk) 09:37, 15 March 2024 (UTC)

That's the thing though, being the most recent doesn't grant it some unique privilege, nor does fitting MEDRS. It simply means it's one more data point that we can add to this article, but it's still at the end of the day only the viewpoint of the doctors that wrote it, and not one at all supported by international consensus. What that means is we can include it in the article, we can even give it its own criticism subsection, but putting it in the summary when recently restated international consensus is firmly against its conclusions, is - as I've said all this time - undue and POV.

If you wanna write that criticism section, go for it. Otherwise as I said before, I might. Snokalok (talk) 15:55, 15 March 2024 (UTC)

This seems all too similar to AYUSH articles, where editors push for organization statements to be given more credence than reviews. Either way if it's integrated into the article as a section it might as well be in the lead, that is how leads are supposed to be written. XeCyranium (talk) 22:43, 15 March 2024 (UTC)

I would argue there's a world of difference between internationally agreed upon best practice and Indian homeopathic remedies, but honestly I'm too tired and it's Friday so here, I offer a compromise:

"While few studies have examined the effects of puberty blockers for gender non-conforming and transgender adolescents, the studies that have been conducted generally indicate that these treatments are reasonably safe, are reversible, and can improve psychological well-being in these individuals, including reducing suicidality. Some reviews conducted agree with these findings, while others say that the certainty of evidence is not high enough to make a clear determination."

And in the body:

"A 2020 commissioned review published by the UK's National Institute for Health and Care Excellence concluded that the quality of evidence for puberty blocker outcomes (for mental health, quality of life and impact on gender dysphoria) was of very low certainty based on the GRADE scale, however this review has attracted criticism from some in the field, due to this rating being due to a lack of randomized controlled trials, which have been described as neither feasible nor ethical in the context of puberty suppression for this purpose."

I want the SBM source to be added back in (see the thread below), for the reason that, it is a valid, non-fringe criticism of the RCT line of thought, from a source editorial consensus has agreed upon as being reliable for exactly this topic, and WP:FALSEBALANCE applies based on views, not on their sources Snokalok (talk) 23:54, 15 March 2024 (UTC)

I just meant in the sense that a national organization endorsing a specific view doesn't mean that all quality research aligns with it. I think that summation for the lead is pretty good, but I feel like saying it as "some studies find..." followed by "some reviews of these studies..." is kind of redundant language. It could just lead with the discussion of reviews, since those are usually the highest quality sources for medicine and they're covering the studies anyway. XeCyranium (talk) 00:19, 16 March 2024 (UTC)

As an addendum I have no problem with science based medicine being used, it's a high quality source, though I wouldn't use it to argue against any high quality reviews unless it's specifically citing other systematic reviews. XeCyranium (talk) 00:22, 16 March 2024 (UTC)

Ah! Regarding national orgs, I fully agree, hence my point about the UK ruling X doesn't make it true the same way it wouldn't if Saudi Arabia weighed in. WPATH and Endocrine are international though, hence why I give them more weight.

Regardless, I don't want to think about this when I wake up tomorrow, so

"While few reviews have examined the effects of puberty blockers for gender non-conforming and transgender adolescents, the reviews that have been conducted primarily either indicate that these treatments are reasonably safe, are reversible, and can improve psychological well-being in these individuals, or that the certainty of evidence is not high enough to make a clear determination."

And then, with the SBM source below because again, it is relevant to the topic the same way the bit on off-label use is. Sound good? Snokalok (talk) 00:24, 16 March 2024 (UTC)

While I'm only one editor I think that would be fine. I would probably word it differently if I wrote it but I think the message would be the same either way. XeCyranium (talk) 01:15, 16 March 2024 (UTC)

@Barnards.tar.gz@LokiTheLiar@Silver seren@TenorTwelve@Your Friendly Neighborhood Sociologist@Void if removed Any issues? Snokalok (talk) 01:48, 16 March 2024 (UTC)

I disagree, because that is obfuscating and weighting the presentation in favour of safety and efficacy, when systematic reviews now lean toward caution and highlighting poor quality of evidence. It is better to lay out the actual reviews and their findings, since there have been so few. As for SBM, they might be a RS, but they are not MEDRS, and it seems wholly inappropriate to offset a systematic review from a UK institute as widely respected as NICE with what is essentially a US gender clinician's blogpost that approvingly quotes GenderGP(!) as a source. We should not be offsetting systematic reviews with this sort of opinion, any more than we should be citing a recent Times editorial describing puberty blockers as "quack medicine". I think you're opening the door for low-quality running commentary with this and I strongly advise sticking to MEDRS wherever possible on this most controversial of subjects. Void if removed (talk) 11:39, 16 March 2024 (UTC)

“because that is obfuscating and weighting the presentation in favour of safety and efficacy, when systematic reviews now lean toward caution”

Okay even if that was true, which is a tremendous if that I am in no way ceding, the handful of reviews you’re describing have still reached conclusions outside international consensus as found recently by WPATH and Endocrine; and the reviews in question have not made any new complains beyond “no RCT’s”, so five more doctors in Germany throwing their names into the “no RCT’s” bucket hardly merits reshaping the entire page.

The changes I’ve proposed are, honestly far beyond what I think is reasonable but I offered them anyway in the spirit of compromise. You meanwhile, have proposes no compromise of any sort, merely demanding that your view outside the medical mainstream be given complete dominance because you recently read one (1) more source that agreed with the same complaints already made by the others. I have already met you more than enough halfway, the proposed changes above are the limit of how far I am willing to meet you without any compromise on your part, and honestly it seems that, by reading the replies, neither side is satisfied with that anyway, so, in light of lack of editorial consensus, we revert to WP:STATUSQUO. Snokalok (talk) 14:53, 16 March 2024 (UTC)

I think should just describe the schism clearly:

The World Professional Association for Transgender Health endorses the use of puberty blockers as a medically necessary gender-affirming intervention. Some European countries have reduced such usage of puberty blockers following systematic reviews which have found the evidence of benefits to be low-certainty. Barnards.tar.gz (talk) 12:45, 16 March 2024 (UTC)

This works for me FWIW. Straightforward, doesn't overstate it in any direction. Void if removed (talk) 21:52, 16 March 2024 (UTC)

I would support keeping it at “While few studies have examined the effects of puberty blockers for gender non-conforming and transgender adolescents, the studies that have been conducted generally indicate that these treatments are reasonably safe, are reversible, and can improve psychological well-being in these individuals, including reducing suicidality.” This wording would avoid false balance. TenorTwelve (talk) 09:19, 16 March 2024 (UTC)

I support this wording. Loki (talk) 00:48, 17 March 2024 (UTC)

@TenorTwelve@LokiTheLiar@Barnards.tar.gz @Void if removed

I think these wordings both have advantages and disadvantages, so let’s combine them.

“While few studies have examined the effects of puberty blockers for gender non-conforming and transgender adolescents, the studies that have been conducted generally indicate that these treatments are reasonably safe, are reversible, and can improve psychological well-being in these individuals, including reducing suicidality. For this reason, the World Professional Association of Transgender Health and the Endocrine Society both endorse their use. However some European countries have reduced the use of puberty blockers after conducting reviews in which they found the evidence of benefits to be of low-certainty.”

Thoughts? I wanted to say conducting reviews instead of systemic reviews due to the reviews primarily being from government sources, and to avoid misleading the reader into thinking the detracting reviews are the only reviews. Snokalok (talk) 05:25, 17 March 2024 (UTC)

If you want it can be “conducting systematic reviews”, I’m not picky about the use of ‘systematic’ Snokalok (talk) 05:29, 17 March 2024 (UTC)

I also like this wording. Loki (talk) 06:42, 17 March 2024 (UTC)

My worry is that in elevating the European countries narrative, it could lead the reader to question the medical consensus that puberty blockers are safe and reversible. When it is framed as an unsettled question or debate, some will believe it to be unsafe and that’s why it was banned in many states. I’m not fully opposed to the wording, but I am worried about false balance TenorTwelve (talk) 06:43, 17 March 2024 (UTC)

How would you modify it? Snokalok (talk) 07:04, 17 March 2024 (UTC)

I broadly like this wording but have similar worries to TenorTwelve. I think the 3rd sentence should be more descriptive like Sweden and the United Kingdom restricted puberty blockers to clinical trials following independent systematic reviews which found the evidence of benefits to be of low-certainty^[footnote] with a footnote explaining the grade scale and unethical nature/infeasibility of RCTs and the role of medical ethics in creating guidelines when evidence is low. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 19:49, 17 March 2024 (UTC)

some will believe it to be unsafe and that’s why it was banned in many states

It is not our responsibility to worry about US politics.

It is our responsibility to accurately reflect what reliable sources say.

If it is an unsettled question then it should be presented as such. Void if removed (talk) 18:51, 17 March 2024 (UTC)

It is however our responsibility to not misrepresent the medical consensus. Some of the European reviews, like the 2020 NICE review from the UK have their deficiencies and have been criticised for that. If we're including those reviews then we're also going to have to include any criticisms that have due weight. For the NICE review that includes, at minimum, the joint WPATH/EPATH statement. Sideswipe9th (talk) 19:03, 17 March 2024 (UTC)

We would be safer not making any contested medical claims in the lead given the divergence of MEDRS views. Barnards.tar.gz (talk) 15:43, 17 March 2024 (UTC)

I just want to observe that recent edits have a) relegated some highest quality MEDRS to a "criticism" section which is inappropriate since they are not criticism, they are systematic reviews, and b) padded that criticism section with at least as many words criticising the criticism, sourced to lower-quality sources.

This is unbalanced. I'm for reverting all of this. Void if removed (talk) 13:48, 17 March 2024 (UTC)

a) I support moving the content on the NICE review to the U.K. section and the content on Finland to the Finland section.

b) If you're referring to the position statement by WPATH and EPATH criticizing the statement, it is absolutely due. If you're referring to SBM, the fact NICE is keeping quiet about the authors is non-medical information which is due and appropriately sourced. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 18:24, 17 March 2024 (UTC)

Again, moving some of the highest quality MEDRS further and further down the page, away from the section to which they have direct relevance to an uninformed reader, is unbalanced.

The "gender-affirming care" section as it was on March 12th - prior to NHS England's decision to halt routine prescription of them which preceded a flurry of renewed interest in this page - with the highest quality sources laid out chronologically, was absolutely fine. Void if removed (talk) 19:04, 17 March 2024 (UTC)

Science based medicine

@Void if removed You do realize that WP:FALSEBALANCE applies to the views themselves, not the sources, right? Like, SBM is an RSP green source, so it's considered reliable for this exact purpose, and it is a valid criticism not at all fringe within the field. Snokalok (talk) 16:21, 15 March 2024 (UTC)

@Barnards.tar.gz You removed the content In 2021, NICE denied a request to provide the names and qualifications of the authors of the review, Science-Based Medicine described this as "especially concerning given the emergence of trans health ‘experts’ who actively work to remove protections and support for trans people and an utterly unacceptable state of affairs for a review or report produced by a government agency." with the edit comment Not appropriate to counterpoint a MEDRS source with a non-MEDRS source. The following paragraph provides more authoritative criticism anyway.

We are not counterpointing any medical information, and as WP:MEDRS says This guideline supports the general sourcing policy with specific attention to what is appropriate for medical content in any Wikipedia article, including those on alternative medicine. Sourcing for all other types of content – including non-medical information in medicine-articles – is covered by the general guideline on identifying reliable sources.

The fact that NICE refused a FOIA request is non-medical information.

The fact there is a cottage industry of anti-trans "experts" like SEGM and co who are political activists rather than objective scientists is widely recognized and the fact they may have been the one to write the review is non-medical information. I'll also note, the WP:RSP entry for SBM notes they often cover FRINGE material and per WP:PARITY are often useful (Parity of sources may mean that certain fringe theories are only reliably and verifiably reported on, or criticized, in alternative venues from those that are typically considered reliable sources for scientific topics on Wikipedia..

As such, saying it's a non-WP:MEDRS source is not an applicable argument, so I ask you to please self-revert. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 18:15, 17 March 2024 (UTC)

If the purpose of that sentence is to attempt to undermine a MEDRS source because it may have been written by a baddie, that’s even worse. Barnards.tar.gz (talk) 18:27, 17 March 2024 (UTC)

NICE are specifically named on WP:MEDRS as an example of widely respected governmental and quasi-governmental health authorities. Your attempt to redefine this as WP:FRINGE is misplaced. Void if removed (talk) 18:56, 17 March 2024 (UTC)