Talk:Puberty blocker

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)

It is unethical to do a randomized control trial for puberty blockers: This is not true. Even if it were true, there are ethical ways to study the subject (e.g., with a waiting list control group: treat as many people as you can, and compare them against the people you couldn't treat).

Also, in re experiment could lead to suicides, last I heard, the evidence for suicide risk was low quality, and the risks are not evenly distributed (e.g., autistic trans people have a much higher suicide risk than non-autistic trans people). Trials can also be tailored to reduce risks (e.g., by excluding anyone with a history of suicide attempts, because these days, a prior attempt is the single biggest predictor of suicide – bigger even than a diagnosis of major depressive disorder). So one really need not worry that it's impossible to study these things; at most, it requires a little more effort to set it up properly. WhatamIdoing (talk) 16:56, 20 March 2024 (UTC)

I see the article states "randomized controlled trials are not regarded as feasible or ethical in the case of research for gender-affirming care". I think this should be rephrased to be an opinion, or at least attribute who "regards" them as not feasible or ethical. Whether they are or are not isn't really something that Wikipedians should be arguing among themselves about. But WAID is correct that RCTs have been performed in situations where experts strongly believed already that treatment was beneficial and even life saving, and for treatments where blinding is impossible, and so on. I'm familiar with one such RCT on the ketogenic diet that involved 145 children and which took advantage of the shortage of dieticians/support-staff/neurologists to meet the demand for this therapy (sound familiar?) to do the "waiting list control group" approach WAID mentions. It won't be able to study all aspects (for example, if the ketogenic diet leads to bone loss long term, but both groups eventually get it, then you don't have a control for that aspect). I don't think this view on RCTs on puberty blockers rises to the level of a hard fact, vs the opinion of some source author with good reason to want that opinion to be true. -- Colin°^Talk 10:20, 21 March 2024 (UTC)

It is true, it's been widely recognized for years as unethical and the infeasiiblity speaks for itself. Here's a review noting that[20], here's an article listing even more reviews and studies saying so[21]. Many refer to evidence of it's infeasibility in Mul et. al (2001 so this was proved 2 decades ago), where they couldn't have a control group when treating precocious puberty because the control group dropped out because, obviously, they were evidently still going through puberty. Here's a review article on RCTS for puberty blockers, which handily links to the extensive literaure on how they're not always feasible or appropriate.[22] Like, this is standard knowledge for clinicians investigating hormones that are known to treat certain conditions, here's a review on growth hormones for short stature from 2010 which notes Mul et al., and past ethics board decisions on RCTs, for why RCTs are infeasible and recommends PCTs instead[23]

Even if it were true, there are ethical ways to study the subject (e.g., with a waiting list control group: treat as many people as you can, and compare them against the people you couldn't treat), which are not RCTs (and still presupposes you have a large pool trans kids going through an incongruent puberty because you won't provide them timely care). Nobody, literally nobody, has said the effects of PB can't or shouldn't be studied. But there is a broad consensus in the field that RCTs are unethical in this situation and bringing up other types of studies doesn't detract from that.

Do neither of you see the obvious ethical and implementational challenges of randomly saying 50% of a population of trans kids should be forced to go through their natal puberty? Like, even if you ignore ethics of the the cronenbergian nature of what you're doing to them and the fact you're setting them up for expensive dangerous medical treatments later (most trans surgeries are related to undoing the secondary sexual characteristics) - why would the youth not drop out of the study when their puberty continues to progress?

P.S. Are there any sources saying RCTs for trans youth are ethical? There is an abundance of sources saying they're not, and neither of you have presented sources saying otherwise. I've personally only seen SEGM & Co saying they're necessary and free of ethical issues. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 16:08, 21 March 2024 (UTC)

Too much text for something we should not be discussing. We are not here to convince each other whether such RCTs are feasible or ethical. But, from a purely logic point of view, there exist, there really do absolutely exist RCTs where people had similar issues as presented here. It isn't for you or I to persuade anyone whether researchers might be able or willing to do those studies. Presumably right now lots of trans kids are going through puberty without these drugs, so your unethical control exists but isn't being studied in any trial. The NHS reports only about 100 children are currently on them in the UK. I get that the problems seem unsurmountable and if one is minded to argue that the current weak evidence is enough, that's a fairly persuasive argument for writing a paper on why better evidence is unethical or impossible.

But, regardless of the feasibility/ethics, one cannot escape the statistical reality that without a control, effects seen may be regression to the mean, or the normal changes expected for an age group growing up and so on. And this is what these reviews say. This matters because the reviews say the changes are statistically small, if they even rise above chance at all. This isn't like penicillin or a cataract op, where the effect is miraculous and so unlikely nobody would question it. -- Colin°^Talk 16:30, 21 March 2024 (UTC)

I see the article states "randomized controlled trials are not regarded as feasible or ethical in the case of research for gender-affirming care". I think this should be rephrased to be an opinion, or at least attribute who "regards" them as not feasible or ethical. - you said we should attribute it to opinion, I presented reasoning why it should continue to remain treated as a fact. Whether they are or are not isn't really something that Wikipedians should be arguing among themselves about - Exactly, RS say they aren't feasible/ethical, you say they are, but have presented no RS backing that up. If there is truly disagreement in RS about whether RCTs are ethical for puberty blockers, please present the evidence.

so your unethical control exists but isn't being studied in any trial. Yes, but again, that wouldn't be an RCT. Waiting list comparisons are not RCTs - they have some ethical issues sure, but they don't have the fundamental problems of RCTs here (impossibility of masking/blinding and control group retention). In a waiting list cohort, you aren't telling them you're giving them puberty blockers as you give them a placebo.

This matters because the reviews say the changes are statistically small - but acknowledges that may be evidence they're effective (they found GD levels did not change, but the purpose of blockers is to prevent it getting worse by blocking puberty). Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 17:10, 21 March 2024 (UTC)

Fair point. Though having several people on one side of an argument claim the same thing doesn't magically make that a fact. Ideas such as "Trickle-down economics" or the belief that any tax cut whatsoever is bound to stimulate the economy are frequently trotted out by right wing parties. Doesn't make it true. But I accept that at least in those cases there are rebuttals. We shall all see if someone actually does an RCT on this, though I suspect neither of us should hold our breath. Anything meaningful would take a long while to do and longer still to get published.

Waiting list comparisons are RCTs. It isn't that they are given a placebo (which is something that may have an effect). They are given "standard treatment" or "alternative treatment" or "watchful waiting" or whatever the trial wants to be a control. For the ketogenic diet, patients assigned to the six-month wait were given "usual care" which was to continue to take and adjust if necessary their AEDs.

One of your linked papers also seems to think RCTs are blinded (masking) and that participants would be disappointed when the find they grow breasts or facial hair. This makes me frustrated because that's a fairly basic thing to get wrong. -- Colin°^Talk 17:34, 21 March 2024 (UTC)

I feel like you two are talking past each other, because YFNS is talking about double-blinded RCTs (impossible to do ethically, gold-standard of medical research) while Colin is talking about unblinded RCTs (possible to do ethically, have obvious issues). Loki (talk) 19:59, 21 March 2024 (UTC)

Perhaps YFNS can confirm what they mean, but the article and what sources I've read all talk about the lack of RCTs or the supposed impossibility of doing RCTs. I've only seen one paper, so far, attacking the strawman of a blinded (masked) RCT. I'm not aware of anyone lamenting the lack of blinded RCTs or insisting on them, for very obvious reasons. And on that count, the parallel to ketogenic diet is similar (though there was once a pilot attempt at a blinded RCT for the KD which didn't work out). -- Colin°^Talk 08:30, 22 March 2024 (UTC)

I believe the key point of that paper was that RCTs are best when masked, so having a non-blinded RCT takes away one of the things that generally make RCTs actually useful in the first place. An even if unblinded and unmasked, the sources keep pointing out the basic issue that kids are not going to spent time on a waiting list for puberty blockers for 4 years of puberty - your control group won't stick around for you to data-collect (and those that do are most likely the ones who can't afford anything else but to be treated like a lab rat). The sources do not say these methodological concerns are the only ones, they also frequently highlight the unethical nature of denying people care, but even if you toss ethics to the wind the obvious issue is teens will not agree to be the control voluntarily.

And, for years, I'd only seen SEGM & co lament the loss of RCTs, but the NICE reviews (for hormones and blockers) both stated that the solution to the ethical issues of a "no treatment arm" (forcing kids to go through an incongruent puberty) may be giving them "close psychological support" (which will not alleviate any worsening dysphoria or future dysphoria from secondary sex characteristics) instead. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 23:14, 25 March 2024 (UTC)

This paper attacked blinded RCTs as a strawman; no other reason to do so. If no sources are demanding blinded ones, well, then you've got your answer as to whether that fatally diminishes their power. It doesn't. The sources would have demanded double-blind RCTs if they wanted the impossible. And the "denying people care" issues is one many other RCTs have overcome. It is widely documented that in the UK many thousands are on waiting lists for many years and they eventually become adults without ever being seen by child services. You can't claim scenarios are unethical so impossible if they already do actually exist in large numbers. It is simply an unavoidable statistical fact that without a control, it is highly likely that some or even all of the effects "seen" are due to other reasons. Please don't try to make this a "SEGEM & co" issue, because that's just basic science/maths.

I suspect we are in a place where some organisations don't want to admit an RCT would be possible and desirable because "giving an inch" in a fierce political war will be seized upon by the other side who are trying to ban the whole clinical field. That's why I think we should give weight to those bodies conducting systematic reviews of the evidence according to tried and tested criteria, rather than mere expert opinion that studies that would be considered "pilot size" in most fields, is convincing evidence. MEDRS emphasises such reviews for a reason. -- Colin°^Talk 13:09, 26 March 2024 (UTC)

You can't claim scenarios are unethical so impossible if they already do actually exist in large numbers. There is currently one private provider who prescribes puberty blockers to trans youth in the UK (and elsewhere); GenderGP, and both puberty blockers and feminising hormone therapy are available on the grey market. In a December 2022 article by Reuters, GenderGP said they had about 800 youth patients. Yes both of those options are heavily discouraged by the NHS and others, but they are nevertheless available.

I'm not sure how reliable or even feasible it would be to run a control group study when the participants who are in the control group due to waiting lists are able to source the medications through alternative means. It seems to me as though this would have the same type of problems that plague nutrition research studies, where adherence to the study protocols is not guaranteed outside of extremely tightly controlled situations (eg, keeping the study participants in a controlled environment for the duration of the study where they cannot access non-study-provided food), and self-reporting data is considered to be either of low quality or unreliable. And in an environment where being seen by a private provider can lead to the NHS refusing treatment and being immediately removed from lengthy waiting lists, a lot of patients and their families won't report that they're sourcing the medications through alternate means.

This type of control study for puberty blockers might have been possible fifteen or twenty years ago, when alternate sources for the medications in question were unavailable. But in the current environment where alternate sources are available I suspect there would be too many confounding factors for any data from a waiting list control group to be reliable. Sideswipe9th (talk) 20:39, 26 March 2024 (UTC)

That article mentions 8,000 young people awaiting any care, and 800 on this GenderGP's "book" but gives no indication of how many of those are on puberty blockers. I don't disagree with you that it is technically possible for some patients to access such private treatment at a cost. But it is also possible for someone to start their child on the ketogenic diet without neurological/dietician/nursing support and all you'd need are a scale to weigh food to 1g accuracy (as low as £5) and some ketostiks (a few quid). It would be quite irresponsible and dangerous, especially for children with special needs, but my point is that it is possible for armchair-doctors/activists to come up with reasons but, well, in other fields it was done.

None of this gets away from the MEDRS problem that systematic reviews are the highest form of evidence. And we have a discrepancy between what our article currently states, confidently, in wikivoice, about efficacy and safety, and what documents based on such reviews state, which is we don't know and we need to find out.

There's a line in that early Cass review publication that both sides look at the same weak or absent research and come to entirely different conclusions. -- Colin°^Talk 08:29, 27 March 2024 (UTC)

For completeness, here's a paper published last week titled "The gender-affirming model of care is incompatible with competent, ethical medical practice" containing such passages as:

The World Professional Association for Transgender Health (WPATH) endorses the leading international standards of care for treatment of gender diverse patients. They assert that ‘[g]ender diversity is a natural variation in people and is not inherently pathological’ (pS34). However, no evidence is presented and the supporting reference leads back through the previous version of the Guidelines to a statement by the WPATH Board of Directors. Not only do the guidelines rely on a circular reference to an evidence-free assertion of this core assumption of their model, GAMOC advocates reject the possibility of testing the model using randomised control trials as unethical.

and

Gender-affirming care is fundamentally incompatible with competent, ethical medical practice. It predicates a class of experiences which diverge from those of the vast majority of human beings, but refuses to describe normal experience or the patterns of divergence. It assumes there are no pathological aetiologies of gender diversity and protects this assumption by forbidding the assessment of pathology in individual patients, and by forbidding the evaluation of treatment outcomes by RCTs.

This takes the interesting position that the insistence that RCTs are unethical is, itself, unethical. Void if removed (talk) 10:32, 26 March 2024 (UTC)

So on one hand we have international consensus being trans is not a mental illness, and on the other we have a dude writing in a journal (that he's a deputy editor for) saying yes there's a consensus about this but that's just because of the "activists" - being trans could just be a mental illness, nobody has considered that because activists don't want us to (conveniently glossing over the past ~50 years of "trans people are probably just mentally ill" being the dominant model until evidence became too overwhelming that it was bullshit). Shocking nobody, the only people clamoring to agree are everybody's favorite conversion therapists "Gender Exploratory Therapists", Genspect and GETA (now Therapy First) [24][25]. His only other published work on trans people[26] was criticized because he based his whole argument on the original Bell v Tavistock case, and didn't mention how many findings he kept noting as gotchas were overturned in the appeal[27].

Those quotes add nothing to the conversation, not least of all because RCTs aren't actually necessary to evaluate treatment outcomes, there are other kinds of study... But analyzing the first, he states the core assumption of the gender affirming care model is [g]ender diversity is a natural variation in people and is not inherently pathological and that GAMOC advocates reject the possibility of testing the model using randomised control trials. Randomly denying people treatment because you believe that assumption incorrect and want to try out gender diversity is not a natural variation and is not inherently pathological is wildly unethical.

For context, just a little further down he says Unquestioning gender-affirming care is therefore unable to exclude the possibility that it is reinforcing the pathologies of some, most, or all of its patients - I feel ridiculous I have to type out that "what if all the trans people are just mentally ill" is WP:FRINGE nonsense and one person ranting about how gender diversity could be always pathological and "activists" in control of the health organizations around the world are suppressing science is not a particularly weighty source for anything, least of all the ethics of RCTs... Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 20:02, 26 March 2024 (UTC)

I agree this is little more than WP:RSOPINION. I fail to see how its any different to the currently cited criticism of Cass/NICE in that regard, which gets a whole paragraph of 3 sentences, in wikivoice. That is, after all, a piece by "some person", published in WPATH's journal, and I'm not sure how an "Inductive and deductive reflexive thematic analysis" with several spelling errors and reams of text complaining the Cass Review is cis-supremacist is any less opinion than this. Neither of these are high quality MEDRS, merely illustrating the spectrum of published opinion, yet one POV is heavily favoured in this article.

> didn't mention how many findings he kept noting as gotchas were overturned in the appeal

Just as an aside, that cited letter is wrong. It states that "he vast majority of children who take [puberty blockers] move on to take cross-sex hormones" was a factual finding overturned on appeal. It was not. What was overturned was the derivation from this uncontested fact to the statement therefore that s/he is on a pathway to much greater medical interventions. That remained in the realm of difference of expert opinion, and was thus why the appeal was successful. Void if removed (talk) 09:46, 27 March 2024 (UTC)

So I'm reading through that paper, checking some of its more outlandish claims and came across the following: The [depathologization] movement was instrumental in changing gender identity disorder to gender dysphoria in DSM-5, and categorising gender incongruence as a form of sexual health condition rather than a mental disorder in ICD-11., which is cited to two sources; a paper by Jack Drescher and the WHO announcement of the changes in the ICD-11. Not only does neither of those sources support the sentence, Drescher's paper refutes it by saying that the change in category away from gender incongruence being a mental health disorder was simply reflective of a change in thinking by the field of researchers, and not as a result of the influence of activists that Amos claims.

Then there's The driving principle of the GAMOC is that health care professionals cannot assess but must affirm patient-reported gender identity. which is cited to the WPATH SoC 8 and a peer-reviewed position statement from the European Society for Sexual Medicine. Not only is this a fundamental misunderstanding of what gender-affirming care actually is, once again neither of the cited sources actually support the sentence. The WPATH SoC has an extensive chapter on the assessment process for trans and gender-diverse adults, and separate chapters for the assessment of adolescents and children. And the ESSM position statement also has separate sections for the assessment of adults and youth.

I could go on, but I don't see this paper being reliable for anything but the misinformed and incorrect opinions of its author. If an editor tried to write this paper as a Wikipedia article, we would revert and rewrite it to actually reflect the cited sources. I would love to know what feedback the author received during the peer-review process, because if this is representative of the quality of other papers published in the journal I would have grave concerns about whether we could consider it a reliable source. Sideswipe9th (talk) 21:17, 26 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)

Editors generally find it easier talk about systematic and narrative reviews. Both are excellent types of sources. Which one is better depends on what you're trying to write. Choose a systematic review if you want to talk about numbers (e.g., drug efficacy, prevalence, survival rates). Choose a narrative review if you want to know about information affected by human reasoning and social factors (e.g., nosology, diagnostic process, ethics, research directions). WhatamIdoing (talk) 17:02, 20 March 2024 (UTC)

The issue is that a narrative review can end up being little more than the opinion of the author citing cherry picked studies that reinforce their opinions and glossing over failings in those studies or failing to mention other studies that would suggest another opinion, or that we simply don't know for sure. Systematic reviews are meant to avoid those traps. They can have their own problems (e.g. in areas where fraudulent research is published, as systematic review would hoover that up and be influenced until the fraud is found and dealt with). They often have a frustratingly high bar for what counts as good evidence. And some I have read seem to read almost like an computer generated results rather than taking into account the actual field they are researching and the difficulties it has. But this is where those writers/bodies using such reviews have the scope to go one way or another. NICE, for example, or some other body such as a consensus conference for a disorder/disease can decide there is little evidence for X but also no better options than X and accept it is still recommended practice.

What is different here to some other fields is that I don't see people waving around truly FRINGE-theory-pseudoscience studies looking at things that have no scientific explanation for how they might work and concluding we should all start using therapy X. People on all sides of this debate are looking at pretty much the same studies, in all their imperfect human but good faith scientific purpose, and reaching different conclusions. Nobody starts flinging FRINGE WP:UPPERCASE when NICE decides some cancer drug lacks evidence or is simply too expensive for the benefit it possibly offers, whereas in the US, it is available provided you have the cover/money. These are differences of medical approach, where rational intelligent people can come to different conclusions. So I object to editors flinging FRINGE at the NHS England position, as though they have started recommending yoga for treating cancer. -- Colin°^Talk 10:26, 27 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)

I don't think I'd have an objection to including a response to the review from WPATH . I'm not sure that's an accurate representation of what this is though - it is a response to the NHS consultation on puberty blockers policy. It is not criticising the review so much as arguing (in question 3, about the evidence base for that policy) that NHS policy should account for other factors, which they lay out in detail, mostly stating that the NHS should not place too much weight on a systematic review.

The only actual part that even looks like a criticism of the NICE review is this:

In subsequent stakeholder testing (2023), 8 stakeholders suggested 19 identifiable and unique references that might have been erroneously omitted from the evidence review or literature surveillance report, which were assessed to not fall within PICO and search methodology, with one exception: de Vries et al., 2014. It was concluded that the de Vries et al., 2014 study does fall within the PICO format and search methodology as set out by NICE. It indicates that use of GnRH analogues along with other interventions (e.g., multidisciplinary care) improves body image outcomes after gender affirming surgery. However, this evidence does not materially affect the conclusions of the existing evidence review.

Emphasis mine. They say that some papers "might" have been "erroneously" excluded. They don't identify these papers or address why. They name one paper apparently excluded (de Vries et al 2014) but that it doesn't change the result.

The stakeholder review they refer to is this one here. What it found was that, despite what the stakeholders said, none of these were actually erroneously excluded.

The de Vries et al study was excluded because:

It remained excluded from the final NICE evidence review as the relevant population and follow-up time points were included in the de Vries et al. (2011) study.

So none of this is even a criticism of the NICE review, actually, just a narrative description of a 2023 stakeholder review that found nothing wrong with the NICE review whatsoever.

I don't think this is WP:DUE, and the description and framing used in the current article would mislead a casual reader.

In fact, if you look at this citation of this submission, it describes it much better:

Trans healthcare professionals outside of the UK have critiqued the Cass review as well as critiquing healthcare policies inspired by the Cass Review such as the NHS’ 2023 draft service specification (WPATH et al.).

The way it has been included here is taking WPATH's broad, critical response to the NHS service specification and wrongly implying it is a response to the NICE review. Void if removed (talk) 15:39, 19 March 2024 (UTC)

I think you've elided two important other quotations from that paragraph. The first sentence; The selected studies by NICE only focused on the effects of puberty blockers, therefore studies that evaluated a combination of blockers, hormones, and/or surgeries were excluded., which to me reads as a criticism of the scope of the review, and last sentence There are additional studies that are of relevance and should be considered to be incorporated within the NICE review, which to me reads as though it were a list of articles erroneously excluded from the review.

As far as I can tell from reviewing the documents released on 12 March, those additional papers in the October 2023 WPATH/EPATH response continued to be excluded from the review when it was used for the current policy. At least one of those papers, van der Miesen et al. is listed in the consultation document from 11 March as being included in the original review, however there is no corresponding citation to it in either of the evidence reviews nor can I find discussion of it in any of the other documents released on 12 March. Sideswipe9th (talk) 23:51, 20 March 2024 (UTC)

• criticism of the scope of the review

But that is not criticism of the review, that is just describing the scope of the review in the context of this submission response. WPATH's entire response here is directed not at NICE, but at the NHS service specification, and what they are saying is that the service specification should be informed by more evidence than the NICE puberty blockers review encompassed. They are responding to the consultation question whether all relevant evidence has been considered.

This is the problem of using a consultation response and framing it as a critical response to the NICE review, when it is not.

• which to me reads as though it were a list of articles erroneously excluded from the review

No, what they are arguing is that these additional studies are either more recent or cover combinations of therapies (eg blockers plus hormones) which they believe will give a more favourable result to their preferred approach if taken into account. None of these were in the scope of the review. None have been erroneously excluded. Most weren't even published at the time, and some of those listed studies were actually in the separate review into GAH.

Eg. the very first one:

There are additional studies that are of relevance and should be considered to be incorporated within the NICE review: Kuper, L. E., Stewart, S., Preston, S., Lau, M., & Lopez, X. (2020). Body Dissatisfaction and Mental Health Outcomes of Youth on Gender-Affirming Hormone Therapy. Pediatrics, 145(4), e20193006. https://doi.org/10.1542/peds.2019-3006

Is mentioned dozens of times in the second 2020 NICE review, "Gender-affirming hormones for children and adolescents with gender dysphoria".

WPATH don't believe that the NICE review which focused solely on puberty blockers sufficiently informs NHSE's service spec on puberty blockers. That is the extent of this response. That's not a criticism of the NICE review, least of all a methodological one, that is a request to NHSE to look beyond the narrow focus of the review in considering its service specification. This response does not establish that any papers were erroneously excluded.

• At least one of those papers, van der Miesen et al. is listed in the consultation document from 11 March as being included in the original review

What it says is already identified as part of the evidence review, literature surveillance report or stakeholder testing

It turns out it wasn't part of the original review, but was raised by stakeholders, and classified in the stakeholder report as New evidence identified by stakeholders that does not fall within PICO and search methodology. Void if removed (talk) 13:35, 21 March 2024 (UTC)

Please familiarize yourself with WP:RIGHTGREATWRONGS, fears that readers will draw the "wrong" conclusion based on an accurate reflection of the medical research as it stands is not an appropriate reason for obfuscating our portrayal of the situation. XeCyranium (talk) 22:35, 20 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)

So, just to be clear, the problem here is that it verges on attempting a meta-meta-analysis of competing MEDRS sources which reach different conclusions. This risks SYNTH. When we have multiple diverging sources of apparently equal quality and weight (as defined by MEDRS), we can't synthesise these into a single wikivoice conclusion. "Studies indicate safe/effective/etc." is not a valid summary of all the available sources - it's a summary of some of the available sources, and is contradicted by other available sources of (at least) equal quality and weight.

There's an endless rabbit hole available where we effectively become medical researchers and statisticians and start work on that meta-meta-analysis, but that is undoubtedly original research.

The encyclopedic point here, at summary level, is that we have two contrasting stances. We should just state what those stances are, and who is taking them.

Hence:

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.

This puts both stances alongside each other, in their own terms, with no synthesis needed. Barnards.tar.gz (talk) 14:09, 19 March 2024 (UTC)

What? Evaluating the relative strength of sources is not WP:SYNTH or WP:OR, it's the basics of how Wikipedia works. Not evaluating the relative strength of sources is WP:FALSEBALANCE. The whole thing WP:MEDRS does, and in fact the very concept of a reliable source in the first place, is evaluate the relative strength of sources.

Right now, we have the primary international medical organization in this area and most national medical organizations on one side, along with relevant research, and on the other side there are a few but not all national medical organizations in Europe, and this one study. That doesn't sound "at least equal" to me, that sounds like the WPATH side clearly outweighs the Europe side. Loki (talk) 16:07, 19 March 2024 (UTC)

It’s not one study, it’s three systematic reviews from three independent groups of researchers in three countries. WPATH is influential for sure, but it’s not primarily a scientific research outfit, and it’s no longer the only game in town. The scientific literature which reaches different conclusions is substantial and growing. There is no longer a single medical consensus, there are multiple competing consensuses, and trying to pick a winner is way beyond the scope of evaluating source weight. Barnards.tar.gz (talk) 22:08, 19 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)

And again, a review is a good source, it’s not due more weight than the (very well cited) findings of every relevant international medical org, and even if it was, there are reviews finding the opposite conclusion as well. Your sources as they stand simply aren’t enough to reshape the summary so drastically. At this point, WP:DROPTHESTICK. Snokalok (talk) 17:38, 19 March 2024 (UTC)

Medical reviews are actually due more weight than the public statements of professional associations, that is exactly how it works. XeCyranium (talk) 22:37, 20 March 2024 (UTC)

The idea that SBM is a "lower quality source" is absolutely false. It's used in WP:MEDRS articles all the time, and is a particular valuable source for debunking BS, because it tends to cover fake or dubious science while clearly stating what's wrong with it in ways that is otherwise uncommon for scientific sources. Loki (talk) 06:24, 18 March 2024 (UTC)

SBM is not a MEDRS-ideal source. It is acceptable for Wikipedia:Fringe theories when no higher-quality alternatives are available. WhatamIdoing (talk) 17:35, 19 March 2024 (UTC)

References

Overall article structure

This article doesn't follow the suggested form at Wikipedia:Manual of Style/Medicine-related articles#Drugs, treatments, and devices and I think the end result is that we're missing a lot of information. The suggested order is written with individual drugs in mind (e.g., for Fluoxetine (Prozac), not for Antidepressant or Selective serotonin reuptake inhibitor), but I think it is still useful as a sort of checklist that should be consulted and adapted to the needs of each subject.

Here's a comparison of this article vs the others. This is a political hot button in some parts of the world, but so are other drugs (e.g., opioid crisis, SSRIs in children, etc.). I think that if we make this article's structure look somewhat more like a normal drug-class article, we'll end up with an article that is more informative about the substances themselves.

Comparison of article structures

Puberty blocker	Analgesic	Antacid	Anticonvulsant	Antidepressant	MEDMOS suggestion
1 Medical uses 1.1 Gender-affirming care 1.1.1 Criticism 1.2 Adverse effects 1.3 Available forms 2 Legal and political challenges 3 Stances of medical organizations 3.1 Australia 3.2 Finland 3.3 France 3.4 Norway 3.5 Sweden 3.6 United Kingdom 3.7 United States 4 Public opinion	1 Etymology 2 Classification 2.1 Paracetamol (acetaminophen) 2.2 NSAIDs 2.2.1 COX-2 inhibitors 2.3 Opioids 2.4 Alcohol 2.5 Cannabis 2.6 Combinations 2.7 Alternative medicine 2.8 Other drugs 2.9 Adjuvants 2.10 Other uses 3 Uses 4 List of drugs with comparison 5 Research 6 See also 7 References	1 Medical uses 2 Side effects 3 Properties of antacids 4 Interactions 5 Formulations 5.1 Liquids 5.2 Tablets 5.2.1 Chewable tablets 5.2.2 Effervescent tablets 6 Brand names 7 References 8 External links	1 Terminology 2 Approval 3 Drugs 3.1 Aldehydes 3.2 Aromatic allylic alcohols 3.3 Barbiturates 3.4 Benzodiazepines 3.5 Bromides 3.6 Carbamates 3.7 Carboxamides 3.8 Fatty acids 3.9 Fructose derivatives 3.10 Gabapentinoids 3.11 Hydantoins 3.12 Oxazolidinediones 3.13 Propionates 3.14 Pyrimidinediones 3.15 Pyrrolidines 3.16 Succinimides 3.17 Sulfonamides 3.18 Triazines 3.19 Ureas 3.20 Valproylamides 3.21 Other 4 Non-pharmaceutical anticonvulsants 5 Treatment guidelines 6 History 6.1 Marketing approval history 7 Pregnancy 8 Research 9 References 10 Further reading 11 External links	1 Medical uses 1.1 Major depressive disorder 1.2 Anxiety disorders 1.3 Eating disorders 1.4 Pain 1.5 Other uses 1.6 Limitations and strategies 1.7 Switching antidepressants 1.8 Augmentation and combination 1.9 Long-term use and stopping 2 Adverse effects 2.1 Pregnancy 2.2 Antidepressant-induced mania 2.3 Suicide 2.4 Sexual dysfunction 2.5 Emotional blunting 2.6 Changes in weight 2.7 Bone loss 2.8 Risk of death 2.9 Discontinuation syndrome 3 Pharmacology 4 Types 4.1 Selective serotonin reuptake inhibitors 4.2 Serotonin–norepinephrine reuptake inhibitors 4.3 Serotonin modulators and stimulators 4.4 Serotonin antagonists and reuptake inhibitors 4.5 Tricyclic antidepressants 4.6 Tetracyclic antidepressants 4.7 Monoamine oxidase inhibitors 4.8 NMDA receptor antagonists 4.9 Others 5 Adjuncts 5.1 Less common adjuncts 6 History 6.1 Isoniazid, iproniazid, and imipramine 6.2 Second-generation antidepressants 6.3 Rapid-acting antidepressants 6.4 Publication bias and aged research 7 Society and culture 7.1 Prescription trends 7.2 Adherence 7.3 Social science perspective 7.4 Environmental impacts 8 See also 9 References 10 Further reading 11 External links	Medical uses or Uses Contraindications Adverse effects Overdose Drug interactions or Interactions Pharmacology (e.g., Mechanism of action, Pharmacodynamics, Pharmacokinetics, Pharmacomicrobiomics) Chemistry (e.g., Synthesis and Detection in body fluids) Manufacturing History Society and culture (e.g., Legal status, Recreational use, Economics, Brand names) Research Veterinary use or other animals

If you look through this and it doesn't feel like a fit at all, then we might want to talk about whether the subject of the article is actually puberty blockers, or if perhaps you'd prefer to have an article on Delaying puberty in trans children. WhatamIdoing (talk) 23:46, 20 March 2024 (UTC)

An article scoped along the lines of use of puberty blockers in trans adolescents does seem like it would be a notable topic separate from this article. The use of puberty blockers for precocious puberty is pretty non-controversial and we're not really doing that justice in the current structure of the article. As far as I can recall, there are some known adverse effects for their use in precocious puberty that we don't really cover in this article at present, with the current section on adverse effects almost exclusively focusing on their adverse effects from use on trans youth.

We already have articles on feminising hormone therapy and masculinising hormone therapy, so creating a specific article to summarise the use and politics surrounding the use of puberty blockers in trans youth wouldn't be unreasonable in my opinion. If we did create one, we should leave a summary style blurb and section behind pointing towards that specific article while restructuring this one. What we'd call that article I don't know though, though I'm not sure "trans children" is correct. This type of medication is typically prescribed at Tanner 2, so "trans adolescents" might be more appropriate. Is there anything more concise than Delaying puberty in trans adolescents? Sideswipe9th (talk) 00:18, 21 March 2024 (UTC)

I think such a split might well be useful. Combining the two is a bit like the issue we have at ketogenic diet where the article is about an epilepsy therapy that is nearly exclusively used in children, but people want to talk about the weight loss fad diet in overweight adults (which currently sits at Low carbohydrate diet). They have similarities but the population groups are totally different, the proportions of food kinds (i.e. dose) is different, and the side effects and intended effects are different. What similarities there are has to come from sources explicitly noting similarities. -- Colin°^Talk 11:47, 21 March 2024 (UTC)

If this gets split out, I think as far as naming I'd suggest separating out the current section that's taken over this page, so something like Puberty Blockers (Gender-affirming Care). Anything else is going to be subject to value judgements about tanner stages, age limits, terminology used in RSs and so on. Void if removed (talk) 13:57, 21 March 2024 (UTC)

What I worry about with this wording is that it risks leading a passive observer to think of the two as entirely different treatments, when really this is one treatment being used for multiple purposes.

Perhaps “Use of Puberty Blockers in Gender Affirming Care” Snokalok (talk) 14:33, 21 March 2024 (UTC)

No, it is two entirely different treatments, even if the same drug is used. There are quite a lot of drugs used to treat entirely different things. Like epilepsy drugs for neuropathic pain. Precocious puberty has totally separate causes, treatment intention and age when stopped.

This article currently is a weird one. It isn't a drug article like Triptorelin and it isn't a drug-class article like Gonadotropin-releasing hormone agonist. Those drugs could be used for prostate cancer, say, and nobody is blocking puberty in a 70-year-old man.

Is "gender affirming care" quite right? The puberty blocking is "to temporarily halt the development of secondary sex characteristics" and "allow patients more time to solidify their gender identity, without developing secondary sex characteristics, and give transgender youth a smoother transition into their desired gender identity as an adult". I'm not aware that anyone is affirming agender/immature as an body option, where the child remains forever pre-pubertal? Are they? It facilitates a later gender affirming stage, which is either to go on to sex hormones or to affirm that assigned-at-birth?

The "gender affirming" use of these drugs isn't "puberty blocking" but to reduce testosterone in trans women, say, who are also taking female hormones.

So I'm wondering if reliable sources talk about these being pre gender affirming care, or something like that? -- Colin°^Talk 17:56, 21 March 2024 (UTC)

Your understanding is actually incorrect, puberty blockers are administered to trans children in the exact same manner as they are to cis children with precocious puberty. They’re not used concurrently with estrogen to block testosterone, those are medications like cyproacetate. Puberty blockers are used prior to estrogen to buy time to decide since puberty is a time sensitive matter. Snokalok (talk) 23:45, 21 March 2024 (UTC)

Regardless, the common medical parlance is to refer to them as gender affirming Snokalok (talk) 23:47, 21 March 2024 (UTC)

I suspect we disagree on what "exact same manner" means. If you look at the clinical guidelines for PP and what the clinician has to test for, consider, the range of possible treatments, the issues to monitor, when to start, when to stop, not forgetting the biggie of age-group, there's nothing the same about it other than what's in the medicine and its administrative route. I don't think we should conflate two different treatments, which each have entirely separate clinical guidelines, licencing (or lack of), eligibility criteria, causes, aims, and so on. -- 08:55, 22 March 2024 (UTC) Colin°^Talk 08:55, 22 March 2024 (UTC)

This sort of thing is why I suggested just using what's there now as the least bad/most likely consensus. Getting into the whys and wherefores and age groups and terminological conflicts is gnarly. Frankly, when medical bodies are at odds over what the purpose even is or who it applies to, any title will inevitably pick sides on that disagreement.

I think it is clearest to use the language of the NICE reviews and NHS clinical commissioning ("children and adolescents with gender dysphoria/incongruence") but this is language WPATH etc are moving away from as pathologising so comes with its own set of conflicts. "Gender-affirming care" while not IMO as clinically bland and explanatory, does have the advantage of longstanding consensus on this page, and in the interests of avoiding yet another source-counting debate over who is or is not FRINGE I'd just stick to what's there right now, personally. Void if removed (talk) 09:30, 22 March 2024 (UTC)

@Sideswipe9th, I think "children" is fine, because Tanner II is usually around age 10 or 11 these days. In biological terms, they may be pubertal adolescents, but in social and legal terms, they're still children.

If we split the article, would it make sense to split by sex (male/female) or gender (trans boy/girl/non-binary) as well? The considerations (e.g., effects of endogenous testosterone on facial structure) do not apply equally to all body types or life goals. WhatamIdoing (talk) 17:13, 21 March 2024 (UTC)

On children vs adolescents; I'm pretty sure the reliable literature on this topic use either adolescent or youth, not children. The treatment protocols for trans children (pre-pubertal) are basically just social transition (ie name and pronoun changes, allowing the child to chose their own clothing and hair style, etc). Pubertal suppression really doesn't start until Tanner 2, at which case most sources I'm familiar with consider the individual an adolescent.

On splitting by sex or gender; No, I don't think we need a split on gender or sex here. There'd be a large amount of repetitive content between the two/three articles, as the treatment protocol itself is the same; same medications, same dose, same dose schedule. The differences in effects on secondary sex characteristics could be handled I think by separate subsections for male and female. Sideswipe9th (talk) 18:09, 21 March 2024 (UTC)

Just realised the argument on children vs adolescents in the title would be stronger with sources. WPATH SoC 8 has separate chapters for children, adolescents, and adults, and doesn't discuss puberty blockers until the adolescent chapter. The Endocrine Society guidelines also start their guidelines on puberty blockers in the "treatment of adolescents" chapter. The Australian SoC for trans and gender diverse children and adolescents don't give any guidance on puberty blockers until their adolescent chapter. The American Psychological Association's guidelines only briefly discuss puberty suppression in the context of adolescents.

The only major English language guideline (not searched other languages due to language barrier) that I've found that deviates from discussing puberty blockers solely in the context of adolescence is the NHS England guidelines and the 2020 NICE evidence review that has been subject to extensive discussion above. Both of those discuss puberty blockers for both childhood and adolescence. However the majority of the studies within the NICE evidence review use adolescents when referring to their respective cohorts. Sideswipe9th (talk) 18:32, 21 March 2024 (UTC)

The medical guidelines are talking about adolescents. Shall we prioritize the medical viewpoint over other viewpoints?

The options look like this:

• Medical viewpoint: The patient is 11 years old and Tanner stage 2, so "adolescent".
• Social viewpoint: The 11-year-old next door is a great kid.
• Legal viewpoint: 11 year olds are children.

Wikipedians have a tendency towards overmedicalization. Is that a tendency that we want to embrace here, or to resist? WhatamIdoing (talk) 01:22, 31 March 2024 (UTC)

I don’t support separating this as it is the same medicine. I will also note that sources will often talk about precocious puberty and transgender children in the same article in reference to each other. Also “Delaying puberty in trans children” is not a neutral wording as it gives the impression this is an experiment on trans kids, which it is not. -TenorTwelve (talk) 07:23, 23 March 2024 (UTC)

@TenorTwelve, what makes you think that delaying puberty is treating trans kids like guinea pigs? Presumably the goal of giving puberty blockers to trans kids is to delay puberty, so "delaying puberty" sounds like a pretty simple, factual description to me. WhatamIdoing (talk) 02:04, 13 April 2024 (UTC)

I am not comparing children’s health care to an experiment and if I gave that impression, I apologize. I’m looking at this from multiple angles. “Delaying puberty” is factually correct. My worry is that it could be misinterpreted in a way to question the motives of the administration of health care. Though that wasn’t my point. I wrote this to oppose separating the article into precocious puberty and trans care because they are the same medicine and the two are often mentioned jointly in reliable sources.-TenorTwelve (talk) 09:27, 13 April 2024 (UTC)

I wonder if it's really true that the two are often mentioned jointly in reliable sources, or if it's instead more true that sources about trans kids mention precocious puberty (e.g., as a way of indicating that it is a medical treatment that's been successfully used for years in a condition that isn't socially controversial). It could be that the trans sources mention PP but the PP sources don't mention trans. WhatamIdoing (talk) 00:25, 17 April 2024 (UTC)

I've done a little literature search on PubMed. Here's what I've found. The term "puberty blocker" is not used in the literature to refer to treatment for precocious puberty. There are a number of treatments for precocious puberty and "GnRH analogues" or "GnRH analog" are the terms that those dealing with precocious puberty used to refer to the treatment it shares with trans kids and we have an article on them: Gonadotropin-releasing hormone agonist. If you try searching for "puberty blocker" and "precocious puberty" together you will find nothing. Whereas searching for "puberty blocker" or "puberty blockers" uncovers only trans topics. If you search for "GnRH analogues" and similar words and for individual drugs, you find that they get used for precocious puberty but also for treating female and male cancers that are hormone encouraged, and other random stuff. And nobody says to a 60 year old with prostate cancer that we're going to put you on puberty blockers.

The term "puberty blocker" is a trans-therapy term. I think that's a killer blow for the the idea that this article is about precocious puberty at all, or about any other uses of these drugs such as cancer treatment. And I suspect there's a good reason people choose to link this to the treatment for precocious puberty rather than breast cancer as "Around 10% of the patients taking XYZ die of breast cancer within five years" doesn't sound so great.

If you look in the history, you see the first version of this article was talking about treating trans kids and the mention of precocious puberty is explicitly talking about an earlier use of such drugs, but not this one.

The very fact that such drugs are not licenced for treating trans kids means that even articles on the individual drugs will suffer generally from a weakness of literature on their use for that, since the manufacturer never ran trials on that group. So I think the literature on the drugs themselves and the literature on precocious puberty will not generally mention treating trans kids other than as an aside.

In contrast of course there is motivation in the trans literature to refer to the earlier, safe, licenced treatment for an entirely different patient group. In that regard, it is similar to how e.g. an article on migraine treatments might mention that some of the drugs are also used to treat other conditions, but just as aside.

Rather than split the article, I suggest the article titled Puberty blocker focus entirely on the therapy for trans kids, mentioning precocious puberty as an aside, as that is exactly what the literature does with that term. -- Colin°^Talk 08:17, 17 April 2024 (UTC)

All excellent points, @Colin Zeno27 (talk) 09:53, 17 April 2024 (UTC)

Proposal for fixing the lead

I've come back to see that after various side-quests in the discussions above, we are no closer to actually fixing the lead. I think I detect rough consensus that the conclusions of the systematic reviews should be mentioned in some capacity. They are currently not mentioned at all.

These are the problematic paragraphs:

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.

The use of puberty blockers in transgender youth is supported by twelve major American medical associations, including the American Medical Association, the American Psychological Association, the American Academy of Pediatrics, along with four Australian medical organizations, the Endocrine Society, and the World Professional Association for Transgender Health (WPATH)

As well as the lack of any mention of the other main POV in the first of these, there is an overly Americentric laundry list in the second.

As I proposed a couple of times in the previous discussion, I think we should replace both of the above with the following:

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.

Things we shouldn't be including:

• Specific medical claims about risks or benefits. The highest quality scientific sources tell us the matter is not settled, so we cannot present these as settled.
• Any attempt at picking a winner in wikivoice between the two sides.
• Excessive detail. There's plenty in the article body.
• Carve-outs undermining either POV, per WP:MEDRS: Remember to avoid WP:original research by only using the best possible sources, and avoid weasel words and phrases by tying together separate statements with "however", "this is not supported by", etc.

I see there is also a proposal for splitting the article in two. All of the above would apply equally well to a potential separate article focusing on the gender-related usage of this treatment. Barnards.tar.gz (talk) 18:40, 22 March 2024 (UTC)

Right, and as I’m sure you saw, there’s an entire other half of the editors on this page who disagree entirely with your proposal, hence why I’ve countered already with a proposal to combine their wordings and yours. Re-pasteing here

“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.” Snokalok (talk) 19:11, 22 March 2024 (UTC)

I prefer the first two sentences of Snokalok's version to Barnards.

I object to any broad statement about "European countries" in either proposal. Various ones have had very different positions. Finland released new guidelines which all Finnish sources agree were meant to strengthen access to blockers, the only sources framing it as a reduction of puberty blockers tend to lead back to a SEGM translation and 90% unreliable sources directly quoting them. Norway supports the use of blockers, this article was written to make it look like that changed but it never did (issue since fixed). Sweden makes it clear they don't mean RCTs when they said trials, their guideline is a caution rather than rule, and blockers are still being routinely prescribed.

The only national health service which has in any way reduced use of blockers after a review is the UK. Not some European countries, one. Homogenizing all those situations as a cohesive alternative position to WPATH and the Endocrine Society (when most countries listed lean closer to those standards than the NHS ones) strikes a false balance. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 23:49, 25 March 2024 (UTC)

You are reading way way too much into very terse sources. I think we need to get better sources than to argue what Sweden/Norway/Finland/France meant by words like "on an experimental basis" or "the greatest reservation" and "it is important to recall the recent decision (May 2021) of Karolinska University Hospital in Stockholm to now ban the use of hormone blockers." For example, "Ukom recommends that puberty blockers and hormonal and surgical gender confirmation treatment for children and young people are defined as experimental treatment" could well mean "Only available as part of a clinical trial" which is a heavy restriction. Do we have a source saying what the effect of this really is? They say "Our findings show that the knowledge base is deficient" which at odds with our lead, which repeats the US line that despite the lack of studies, there is evidence of various beneficial effects, and here's a bunch of US organisations who have written position statements.

The underlined statement above has no sources to back it up. That's the problem with saying confidently something about dozens of countries, bases on a few newspaper articles. If you've got a big spreadsheet someone with numbers of puberty blocker prescriptions in all 44 European countries over the last 20 years then I'll stand corrected. I think actually what is lacking is information about most European countries and the fact that perhaps in many of them this sort of care simply has never been available. Full stop. The solution is to find some better sources. -- Colin°^Talk 13:26, 26 March 2024 (UTC)

Analyzing the European Countries' Positions:

• UK: Did a systematic review with members of SEGM on the working group[28][29](found out it was confirmed this morning, shocking...), concluded the evidence was low certainty by modified grade (ignoring many useful metrics and ignoring GRADEs own guidance), and as a result the NHS restricted puberty blockers to clinical trials only.
• Finland: The phrase prioritise psychotherapy over medical transition comes from a SEGM translation. Prior to that guideline, they did not actually have a guideline on GD. It was not based on a review. This guideline was about moving away from centralized gender clinics and expanding access to care for youth hampered by those centralized clinics. The author's note that psychic evaluation is by no means meant to heal [gender dysphoria] - they are calling for availability of mental health services not "treating GD with pyschotherapy". Calling their first guideline on treating trans youth somehow "reducing puberty blockers" is nonsensical.
• France: A single statement by a single organization saying "use caution". Not based on a review. Not binding at all.
• Norway: In 2020, the Norwegian health service said "puberty blockers good for GD in youth". In 2023, an NGO said "there isn't evidence puberty blockers or hormones help trans kids". The actual health service said "lol nope", but misinformation was spread far and wide that the NGO's recommendations were actually binding.
• Sweden: A private health provider announced it would not provide PBs to those under 16 outside clinical trials. After a review, the national health board issued guidance supporting restricting the use of PB to clinical trials (while, for the record, noting that doesn't mean RCTs due to the ethical issues). But, PB's are still provided by the health service, and doctors can still prescribe them.

In short, the NHS restricted puberty blockers after a review, and the Swedish Health Board said, in a non-binding manner, they should be restricted after a review, but there does not seem to be evidence it has been restricted.

The phrase [X has] reduced such usage of puberty blockers following systematic reviews which have found the evidence of benefits to be low-certainty. is not true when you replace X with Finland, France, or Norway. Same with Sweden (where they called for blockers to be restricted, but did not restrict them). It's only true for the UK. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 17:19, 29 March 2024 (UTC)

One of the key guidelines at MEDRS is that Wikipedia respects the level of evidence (and accurately reports this, where relevant) and editors are not permitted to disregard high levels (such as systematic review) because of their own opinions, or as here, personal attacks about who may or may not have attended a zoom meeting. I don't know why you think posting such text has any place on Wikipedia? Do you think that's how it works? That I go, oh, since a working group had some zoom participants who Believed The Wrong Thing^TM then, yes, let's ignore the bit in MEDRS about respecting the evidence quality and the bits on WP:RIGHTGREATWRONGS about thinking Wikipedia is the place to argue about the merits of a NICE systematic review. As for the other countries, I asked for better sources, not for a biased opinion. -- Colin°^Talk 16:08, 31 March 2024 (UTC)

Firstly, if there is a need for better sources find them. If at the moment we are unsure about the usage of puberty blockers in the countries due to lack of sources then we can not say anything about them reducing usage of puberty blockers, this mean instead of "some European countries" it would have to be "In the UK". Secondly whilst I am certainly no expert on MEDRS, if there is reasonable doubt (presumably this would have to be from a high level source) that a review that was meant to be systematic was in fact not done systemically and in fact was biased due to fringe influences, we as editors should be able to disregard it. LunaHasArrived (talk) 10:18, 1 April 2024 (UTC)

1) As for the other countries, I asked for better sources, not for a biased opinion The onus is on you to provide sources that [X has] reduced such usage of puberty blockers following systematic reviews which have found the evidence of benefits to be low-certainty is true for any other country than the UK. You can't say something is true, and then when I point out "the sources in the article don't support that" insist I'm the one who needs to provide sources - that's ridiculously backward. Of the 5 countries I listed one, which was my summation actually incorrect for?

2) editors are not permitted to disregard high levels (such as systematic review) because of their own opinions, where did I do this? All I've pointed out is the UK is the only country that reduced such usage of puberty blockers following systematic reviews which have found the evidence of benefits to be low-certainty. Please don't put words in my mouth.

3) as here, personal attacks about who may or may not have attended a zoom meeting. I stated the UK Did a systematic review with members of SEGM on the working group[29][30](found out it was confirmed this morning, shocking.. Where is the personal attack? The Society for Evidence-Based Gender Medicine is 1) undeniably a WP:FRINGE group known for pushing misinformation about transgender healthcare and 2) was involved in the review. I didn't even mention the first part... Please don't accuse me of personal attacks that don't exist.

4) A systematic review (heavily criticized for ignoring relevant studies, calling for unethical trials, ignoring the GRADE approach's recommendations, and not even properly tracking the outcomes they should) does not outweigh the consensus of WP:MEDORGS on how to interpret it. We can and should include it and its results, but we also must include what MEDORGS say about the evidence base. Nobody is calling for it to be ignored, but it does not have the "trump all" ability you seem to think it does. WP:RIGHTGREATWRONGS is arguing that we as editors should take 1 review saying as the end all be all source above all the medical organizations saying "we support X according to the evidence base of the field as a whole including that review".

We are trying to discuss the statement [X has] reduced such usage of puberty blockers following systematic reviews which have found the evidence of benefits to be low-certainty by way of analyzing which European countries it's true for - please stay on topic. This is not a discussion of how to weigh the NICE review so the majority of your response was completely off-topic in addition to misrepresenting me. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 17:31, 1 April 2024 (UTC)

Em, you are the one filling this talk page with stuff like "France. A single statement by a single organization saying "use caution". Not based on a review. Not binding at all." or "UK Did a systematic review with members of SEGM on the working group" and casting aspersions about how NHS England arrived at its conclusions. This isn't a forum for what YFNS thinks each country's position is. Nor is it a forum for Wikipedians to make comments about a systematic review based on gossip. The "heavily criticized for ignoring relevant studies, calling for unethical trials, ignoring the GRADE approach's recommendations, and not even properly tracking the outcomes they should" is one set of opinions, written largely by activists. For example, a SBM blog post doesn't override a systematic review in MEDRS. -- Colin°^Talk 09:36, 3 April 2024 (UTC)

This wikipedia article currently has the text In 2022, France's Académie Nationale de Médecine recommended the "greatest reserve" when considering puberty blockers due to potential side effects, including "impact on growth, bone weakening, [and] risk of infertility".[30]

The source for that says the Académie Nationale de Médecine in February 2022 recommended the “greatest reserve” when considering puberty blockers or hormone treatments due to possible side effects such as “impact on growth, bone weakening, risk of infertility” and others, according to a translation. (The "others" being social contagion/ROGD)

The Academy's statement[31] is In the event of a persistent desire for transition, a careful decision about medical treatment with hormone blockers or hormones of the opposite sex within the framework of Multi-disciplinary Consultation Meetings;

This is what WPATH supports by the way, they don't say "give blockers out like candy", they say "have a multi-disciplinary team go over the known and unknown effects with the family", which include the "impact on growth, bone weakening, risk of infertility".

How does Politco summarize the situation in France?[32] But French doctors offering transgender care said the guidelines aren’t impeding access. Children are eligible for hormone treatments with parental permission at any age... The academy recommended that doctors get parents’ consent and use caution in prescribing those remedies, given possible side effects including weakened bones and sterility. The guidelines also urge the involvement of a team of doctors in relevant specialties, psychological care for the patient and clear disclosure of the ramifications of irreversible surgeries. “It has not changed anything as we were already providing multidisciplinary care,” Martinerie said.

My point is this: per MOS:LEAD and WP:RS, does this article and reliable sources support the statement France reduced such usage of puberty blockers following systematic reviews which have found the evidence of benefits to be low-certainty? Why are some insisting we say "some European countries" in a statement that only applies to 2?

And please: This isn't a forum for what YFNS thinks each country's position is - I am trying to have a discussion about what the sources in the article say, what the article says, and how to write the lead based on it. The "heavily criticized for ignoring relevant studies, calling for unethical trials, ignoring the GRADE approach's recommendations, and not even properly tracking the outcomes they should" is one set of opinions, written largely by activists. - Only applies if you define WPATH and the leading peer-reviewed journal on transgender healthcare as "activists" - which you shouldn't be doing. Please, focus on the discussion at hand. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 21:26, 5 April 2024 (UTC)

The statement from the Academy actually goes way beyond just expressing caution. The language of “greatest reserve” and the supporting list of reasons for that reserve (a list of side-effects, the risk of misdiagnosis, the growing number of detransitioners, and the possibility of “transient” dysphoria), plus the recommendation to extend the psychological care phase as long as possible, is a profoundly different stance from what WPATH promotes. Barnards.tar.gz (talk) 22:01, 5 April 2024 (UTC)

To quote myself: "per MOS:LEAD and WP:RS, does this article and reliable sources support the statement France reduced such usage of puberty blockers"? As Politico states Children are eligible for hormone treatments with parental permission at any age... The academy recommended that doctors get parents’ consent and use caution in prescribing those remedies, given possible side effects including weakened bones and sterility. As the Academy stated Although, in France, the use of hormone blockers or hormones of the opposite sex is possible with parental authorization at any age, the greatest reserve is required in their use, given the side effects such as... A position statement saying "this should be done" does not mean "it was done" - expressing caution and/or making a recommendation is not a concrete change in treatment policy, no matter how strong the language is or reasons they list, which they themselves acknowledge. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 22:21, 5 April 2024 (UTC)

The purpose here is to summarise the stance of the country’s medical authority. The level of compliance with that stance is a different matter. See the subthread below on alternatives to the word “reduced” if that’s the problem. But the material point here is that the stance is different to that of WPATH. Barnards.tar.gz (talk) 22:58, 5 April 2024 (UTC)

I'm with YFNS here: the tone of the statement is different from how WPATH would say it but the actual concrete recommendations are not. So it's not materially different, so we shouldn't report it as a disagreement with WPATH.

Or in other words, rather than say In 2022, France's Académie Nationale de Médecine recommended the "greatest reserve" when considering puberty blockers due to potential side effects, including "impact on growth, bone weakening, [and] risk of infertility", we should say something like While recommending the "greatest reserve" when considering puberty blockers or HRT in children due to potential side effects, France's Académie Nationale de Médecine does endorse their use "in the event of a persistent desire for transition". The bottom line is an important part of the recommendation here, and not listing the bottom line creates a misleading impression that these recommendations are more different from the medical consensus than they actually are. Loki (talk) 06:26, 6 April 2024 (UTC)

The concrete recommendation is to prioritise psychotherapy (is this what some would call conversion therapy?) for as long as possible, which is a huge divergence from WPATH. Never mind all the reliable sources that characterise France as having diverged from WPATH. Where are the reliable sources saying their position is not materially different? Barnards.tar.gz (talk) 07:28, 6 April 2024 (UTC)

Loki and YFNS are just interpreting sources statements of mere a few words according to their own meaning. I just see YFNS continue to fill this page with their own interpretations of what a couple of words means. And Politico is not a MEDRS source. And this is an (self-described) activist. The whole thing is messed up also with American politics which makes all sides incapable of giving an inch and agreeing with anything an "opponent" says.

The thing about things like systematic reviews and NICE guidelines and similar is that often the only vocal comments on them are .... from people who hate what they say. Some of those haters will be wise learned folk who may have a point, but a lot of them are cranks or activists or just well paid US doctors with a private practise to defend. So while you think you have "heavily criticised" as a counter to such, Wikipedia doesn't think agree. Wikipedia regards this as opinions and has to weigh whether those opinions matter to be worth mentioning as opinions (WPATH yes, activist blogging in SBM no). But what they are not is they are not superior MEDRS sources for evidence of benefit/harm.

Nobody ever in the history of medicine has written a letter to the editors of the Lancet or a newspaper saying what a fine job XYZ has just done and how great it is we have such intelligent wise people looking into it for us. The closest one might get is a glowing editorial in the journal edition that features such a review or guidelines. Criticism of what some big review or committee came up with is entirely normal and usually does not mean those are fatally flawed to quite the degree that letter-writers make out.

Editors here may feel strongly that some of these first class reviews and first class quasi-government recommendations are wrong, and agree with the criticism of them, but it is WP:RIGHTGREATWRONGS to bang on about this criticism, without having a superior source. Where's the WPATH systematic review of the evidence that is superior to the NICE one? -- Colin°^Talk 19:40, 6 April 2024 (UTC)

I just see YFNS continue to fill this page with their own interpretations of what a couple of words means. - I am quoting the sources so we stick to them and represent them properly - you are the one who leaves paragraph upon paragraph without any reference to any sources.

Wrt And this is an (self-described) activist & And this is an (self-described) activist. - You are the only one referring to SBM in this thread...

Where's the WPATH systematic review of the evidence that is superior to the NICE one? - The WPATH Standards of Care 8 was created through systematic reviews. And there are additional systematic reviews in this article supporting the use of blockers. Finally, the NICE review was a single review, of a small subset of studies, which said "evidence this makes mental health or gender dysphoria worse is low certainty, but that might be a good sign as GD is expected to get worse untreated". A review saying "the condition doesn't improve on this treatment, but hey it is prescribed to prevent it worsening" does not somehow overturn international medical consensus "this treatment prevents the condition getting worse." They are not as mutually exclusive as you seem to think they are.

To be completely honest, I have no idea what point you're trying to make about improving the article. You keep on attacking the strawman of SBM (which I'm not bringing up...), start tangents about how it's wrong to note as an aside that known FRINGE groups were involved in something, and accuse me of filling the talk page when I try and analyze by country what the positions are since we're trying to figure out how to address the countries in the lead. None of your comments in this thread have been about the topic of this thread: what should we write in the lead. So please, can you tell me what you want the lead to say and why (with references to the body and reliable sources currently in this article)? Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 01:32, 9 April 2024 (UTC)

The WPATH Standards of Care 8 was created through systematic reviews.

No it wasn't in this area. It says that systematic reviews were conducted where appropriate.

Chapter Members developed possible statements and with the support of the evidence review team the decision is made as to whether a systematic review for the draft statements were required.

The chapter on adolescent care says:

Despite the slowly growing body of evidence supporting the effectiveness of early medical intervention, the number of studies is still low, and there are few outcome studies that follow youth into adulthood. Therefore, a systematic review regarding outcomes of treatment in adolescents is not possible. A short narrative review is provided instead.

And there are additional systematic reviews in this article supporting the use of blockers.

I've seen only two reviews offered, only one of which is a systematic review (this). That review has been criticised, yet we don't mention that (here), despite how much space is given to criticism of the NICE review.

The other review is a narrative review, and - while relevant - a lesser MEDRS.

So by my count we have at least 3 systematic reviews in Europe going one way, one systematic review and two narrative ones in the US (or mostly the US, WRT WPATH) going the other way.

The Cass Review is finally being published at midnight tonight, at which point we will have another source of info. Void if removed (talk) 08:14, 9 April 2024 (UTC)

WPATH is still the international org, I don't know how many times you need to hear this, it has been well established that the US is actually underrepresented there. Snokalok (talk) 08:24, 9 April 2024 (UTC)

The criticism of The Rew et al review you linked had heavy acknowledgements to SEGM, saying that the experts SEGM provided helped shape the commentary. I don't think I should have to explain why this is a problem. SEGM also provided the money to make the criticism open access. As well as this the criticism is mostly centered on the inclusion and description of one study and that is far from the only study in the review showing positive effects on puberty blockers LunaHasArrived (talk) 08:49, 9 April 2024 (UTC)

YFNS, all I asked for were better sources on the Europe issue, because people (yourself very much included) were rambling on this talk page about their OWN interpretations of various countries, and making claims like only the UK has restricted anything. You cite a Politico article that is 8 months old and, well, entirely wrong about the UK (doesn't even get it right that it is just E&W) as E&W has now heavily restricted access and their entire point is that Europe hasn't. And their spin on research is positive whereas everyone here is banging on about how the research requirement is an impossible restriction. So that's not a useful source for us in April 2024.

I think some here don't understand what a systematic review is. I wonder if there is a good encyclopaedia anyone could link to where they could learn more?

If you read about sham surgery and particularly of arthroscopic surgery for osteoarthritis. For years surgeons said there was no ethical way of studying this in a controlled trial, never mind one with blinding. And all the US professional bodies said they had "evidence" their procedures were helping patients. But then bright people figured out how to do such sham surgery and wouldn't you know it, a mega million pound medical industry in the US is no better than homeopathy, but with all the risks of stroke and infection and dying on the operating table as with any other surgery under GA. And for years afterwards those same professional bodies still bang on about their "evidence" for helping patients and insurance companies still pay for these worthless procedures to be done. It took and still takes a long time for bright financially-motivated people to accept they are not only wrong, but have been getting paid to do their patients harm. Now, I'm not saying WPATH is the same, but a self-appointed organisation of professionals who perform therapy X for a living are not always the best at assessing these things. We can give weight to their OPINIONS because their opinions have weight, but let's not pretend to our readers that they have EVIDENCE. Please, show me the systematic reviews that say puberty blockers for treating trans adolescents are safe and effective. -- Colin°^Talk 12:26, 9 April 2024 (UTC)

this review Certainly says they are effective and says that whilst not necessarily safe, there were no adverse psychological effects. LunaHasArrived (talk) 12:54, 9 April 2024 (UTC)

The idea that SEGM is "undeniably" fringe and anyone who touches them in any way is also fringe is eh... in much the same way that the Cass Review is "fringe" and that the NHS service specifications are "conversion therapy". Also completely irrelevant to the NICE review and the subject at hand. The question is: is the statement "Some European countries have reduced such usage of puberty blockers following systematic reviews which have found the evidence of benefits to be low-certainty." supportable.

I think the most contentious parts are:

1. "following systematic reviews"

2. "reduced"

3. "evidence of benefits to be low-certainty".

I believe that for a minimum England and Sweden, 1 and 3 are definitely true. The French statement is based on the Swedish one ("A cet égard, il est important de rappeler la décision récente (mai 2021) de l’hôpital universitaire Karolinska de Stockholm d’interdire désormais l’usage des bloqueurs d’hormones.") so you have the same chain of reasoning, but not as clear an impact on policy.

The Norwegian model is to emphasise psychotherapeutic gatekeeping (ie, minimum 2 years of persistence and exploration of comorbid conditions), which is the sort of thing WPATH regards as "conversion therapy". They note the low certainty and poor evidence base.

I personally think the main sticking point is "reduced", as most of these are sounding caution, mandating extra safeguards or restricting to clinical trials.

Perhaps as a compromise instead of "reduced" it could be "sought to restrict"? Or "taken a more cautious approach"? Void if removed (talk) 10:45, 3 April 2024 (UTC)

I mean, gender exploratory therapy has been well established as a form of conversion therapy, and SEGM has been well established in the field as a conservative medical activist group similar to ACPeds. Neither is controversial. Snokalok (talk) 21:08, 4 April 2024 (UTC)

"reduced" could be changed to "restricted or expressed caution regarding". The key point is the emergence of a separate, independent POV on the matter. Barnards.tar.gz (talk) 16:15, 5 April 2024 (UTC)

How about:

Few studies have examined the effects of puberty blockers for gender non-conforming and transgender adolescents. The World Professional Association of Transgender Health and the Endocrine Society both endorse the use of puberty blockers as a medically necessary gender-affirming intervention. However, systematic reviews have found the evidence of benefits to be of low-certainty, and some European countries have subsequently restricted or expressed caution regarding the use of puberty blockers. Void if removed (talk) 16:37, 5 April 2024 (UTC)

Works for me. Barnards.tar.gz (talk) 16:50, 5 April 2024 (UTC)

We shouldn't say "systematic reviews" if we mean, as I think we do, "a systematic review". Loki (talk) 17:17, 5 April 2024 (UTC)

We do mean plural, as Sweden performed their own separate review, and the latest German update to the NICE review was by independent researchers. Barnards.tar.gz (talk) 17:25, 5 April 2024 (UTC)

I appreciate the direction this proposal takes but I do have a few minor qualms:

1) expressed caution regarding the use of puberty blockers applies to WPATH and the Endocrine Society too. They don't say give them out like candy, by default, or anything like that. They note the possible effects and unknowns. It feels a false dichotomy to conflate (A) countries restricting PBs and (B) countries expressing caution about PBs as a unified position against (C) WPATH/the Endocrine society saying they are appropriate for GD while acknowledging the risks, unknowns, and reasons for caution. B and C are much closer positions than A and B.

2) Building on that, some European countries is problematic. Not only does it conflate two positions per the above, it hides the fact that the number of European countries which have restricted care is only 2.

3) However, systematic reviews have found the evidence of benefits to be of low-certainty has 2 issues

3.1) some systematic reviews. Others referenced in the article have concluded otherwise. Systematic reviews have had differing conclusions, not a single one. If we're mentioning what systematic reviews said, we should summarize all of them.

3.2) It sidesteps all the issues over which data was actually tracked and how. Prominent medical bodies and peer reviewed literature have identified multiple concerns with that. If we're mentioning the reviews finding the evidence was of low certainty, we should mention 1) that RCTs are widely considered unethical in trans healthcare and 2) their extended conclusion that "though these studies didn't show GD got better on PBs, PBs are prescribed to prevent GD worsening so the lack of change could be the PBs working". Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 22:03, 5 April 2024 (UTC)

Perhaps “moved towards restricting” is better? That encompasses various stages of restriction. Some countries are further along that path than others but the direction of travel is very clear.

Just a note on Norway’s position… above you called Ukom a NGO, but it is actually a government agency with significant influence on the national guidelines, somewhat like the Cass review. And sure enough, here comes the update to the national guidelines in line with the Ukom report’s recommendations: [33]. Barnards.tar.gz (talk) 09:12, 6 April 2024 (UTC)

And again, WPATH and The Endocrine Society are global orgs, not American ones Snokalok (talk) 19:11, 22 March 2024 (UTC)

So leave in the last two and cut out the American and Australian mentions. I'll just do that actually since I think anybody could see only including two of the countries in the lead is silly. XeCyranium (talk) 19:35, 22 March 2024 (UTC)

If we're going to mention a handful of European countries than clearly we should also mention America and Australia, right? Loki (talk) 03:30, 23 March 2024 (UTC)

No, we shouldn't mention either until there's consensus for their inclusion. XeCyranium (talk) 17:51, 23 March 2024 (UTC)

What I haven’t seen is a good counter argument to my bullet point number 1 (this is the part where your proposal and mine differ most materially). How can we include your first sentence in wikivoice when the weightier (on the MEDRS scale) sources tell us to be cautious of such studies? Barnards.tar.gz (talk) 20:00, 22 March 2024 (UTC)

We’ve been going back and forth for over a week now, I don’t think we’re going to get each other to budge anymore, and if you want a change from the WP:STATUSQUO, you have to learn to compromise with other editors. This wording has everything you wanted to mention, and everything the other side wanted to mention. Take the win, some change is better than none, and without a compromise here, you don’t have consensus. Snokalok (talk) 00:08, 23 March 2024 (UTC)

How about: Few studies have examined the effects of puberty blockers for gender non-conforming and transgender adolescents. The World Professional Association of Transgender Health and the Endocrine Society both endorse the use of puberty blockers as a medically necessary gender-affirming intervention. 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. Void if removed (talk) 10:52, 26 March 2024 (UTC)

Do the weightier sources tell us to be cautious of such studies? By my read of the situation the weightiest sources are the international WP:MEDORG sources, and those endorse that conclusion forthrightly.

I frankly disagree the lead needs to be "fixed", and I see the attempt to "fix" it as an attempt to insert WP:FALSEBALANCE. Like, we're talking about "Europe" here but in fact it's not even most of Europe that is recommending against puberty blockers. Most major medical organizations in Europe still recommend puberty blockers, and it's just that we have problems finding those sources because they're often not in English and don't get picked up in major English news sources (unlike the handful of cases like the NHS where some place does become more skeptical, which get widely reported). Just look at Trans Rights Map and you'll see lots of countries that have "LGR procedures exist for minors" checked. Loki (talk) 04:03, 23 March 2024 (UTC)

Taking these out would be a major NPOV problem. I also think the “American/Australian” consensus is notable enough for the lead. -TenorTwelve (talk) 07:12, 23 March 2024 (UTC)

If it's notable enough to be the only two countries mentioned in the lead then it should be the majority of the prose in the section it's included in. It's not even close to that. I don't think a breakdown by country is even necessary for the lead, but it's patently obvious that only including two countries seemingly selected out of a hat from the many that are listed makes no sense. XeCyranium (talk) 18:03, 23 March 2024 (UTC)

I mean, personally I think that it should be the majority of the prose of the section it's included in, and the only reason that's not the case is that this article isn't sure whether it wants to be a WP:MEDRS-compliant article about the actual treatment itself or a non-WP:MEDRS-compliant article about the political controversy around it.

Those American medical organizations' support are sourced to ten separate sources, all of which are WP:MEDRS-quality. If each of those sources had the same amount of text devoted to it that the Karolinska Institute or the NHS has, it would easily be the majority of the prose in that section. Especially if we also removed text sourced to non-WP:MEDRS sources. Loki (talk) 18:54, 23 March 2024 (UTC)

I think it'd be fair to increase the prose about the USA, but I disagree the majority of the section should be about one country. There will almost always be more English sources available about how the USA does something but the article should still be a global overview. As to whether there should be two articles I don't know. I feel like most of the sources used in the article are valid for what they're being used to support. We shouldn't be using news sources to back up any medical statements but I don't know if the article does that. XeCyranium (talk) 23:46, 23 March 2024 (UTC)

I do agree that the article should be a global overview, but a really global overview, not just about the European countries that have news articles about restricting puberty blockers. That's, IMO, worse than making it just about American medical organizations, because in addition to still failing to have a global perspective it introduces serious WP:POV concerns. Loki (talk) 00:16, 24 March 2024 (UTC)

That's fine, there could always be more countries. This could be helpful for Italy: [34] [35] XeCyranium (talk) 01:06, 24 March 2024 (UTC)

I don't think your second paragraph is a useful way of thinking about this. Your so-called MEDRS quality sources for those American organisations are in fact political press releases objecting to laws being introduced in some states. Not one of them is a set of evidence-based clinical guidelines from that body. And at least one of the sources notes they made a joint declaration. So this is more that these various organisations have decided to take a united stand against government interference over their clinical judgements and threats to criminalise care. It isn't really anything at all like "We conducted some systematic reviews and widespread consultations and here are our new official guidelines for the treatment of X, giving the degree of evidential support or lack for each of the recommendations" that one might expect to see in evidence-based clinical guidelines. I wonder which of those organisations actually did that and whether all the others are just saying "I agree with Nick". That's my suspicion. Can someone point me at the US equivalent document, which systematically grades evidence to reach a clinical recommendation. The WPATH citation turns out to be a USPATH document that is also just a position statement released it seems to point-by-point attack some Florida legislation. This isn't MEDRS stuff, it's just politics. Where's the MEDRS stuff? -- Colin°^Talk 11:59, 24 March 2024 (UTC)

While I understand your point that these are not clinical guidelines, and do wish we had more of those in here, that doesn't mean that they're not WP:MEDRS sources. They are not just against the laws in question on general anti-regulation grounds but specifically official statements from WP:MEDORGs that gender-affirming for trans kids is evidence-based and medically necessary, which is a clinical recommendation.

For some actual clinical guidelines:

• Here's WPATH Standards of Care version 8, which endorses the use of puberty blockers in several places.
• Here's the Endocrine Society's Gender Dysphoria/Gender Incongruence Guideline, which also endorses the use of puberty blockers in adolescents.
• Here's the Canadian Pediatric Society (which I don't think we have on here) endorsing puberty blockers and referring to the previous two guidelines.
• Here's the American Academy of Pediatrics, doing similar.
• There's something here but I can't get past the paywall.

Other than that, what I'm seeing mostly is that medical organizations often endorse the WPATH and Endocrine Society guidelines (or generally agree that puberty blockers are evidence-based treatment) but don't specifically put out their own guideline where it's not directly relevant to their specialty. So for instance, here's an article by the American Psychiatric Association that endorses those guidelines but isn't itself a clinical guideline. We may want to search more for organizations of endocrinologists and pediatricians. Loki (talk) 18:05, 24 March 2024 (UTC)

So this is where this article needs to decide if it is a medical article or an article about politics. Those sources currently in the article are politics. You haven't really got six organisations all coming up with evidence based guidelines using a systematic approach. The WPATH guidelines, correct me if I'm wrong, appear to be "We looked at the evidence and made some consensus decisions which we will call evidence-based" and is therefore closer to a narrative review than a systematic review. I accept there's likely a lot of consensus around something like WPATH, which strengthens things, but it still seems to be to be "expert opinion, influenced by some studies someone did" than the sort of algorithmic systematic reviews that organisations like NICE or Cochrane do. My point is really you are comparing apples with oranges if you think six press releases that are all "Back off. Clinical decisions are our job, not yours, you bigoted ignoramuses" are six times as important as the NHS England decision, from a medical POV. If you want to write a political article then go for it, but please don't cite press releases or "position statements responding to proposed/actual laws" and claim that's a perfect MEDRS source. It has value for sure, but it is more "evidence of consensus among experts" than "evidence of therapeutic value". -- Colin°^Talk 18:37, 24 March 2024 (UTC)

Loki, https://edhub.ama-assn.org/ is a Continuing medical education website. In MEDRS terms, it's the equivalent of WebMD or a similar health information website. WhatamIdoing (talk) 01:44, 31 March 2024 (UTC)

"Gender-affirming care" for children necessarily includes puberty blockers

@XeCyranium: I would hope this was clear from other sources, but when a medical organization says that they oppose any laws and regulations that discriminate against transgender and gender-diverse individuals specifying explicitly that that includes children and adolescents, or that it strongly opposes any legislation or policy action that places restrictions on transgender health care and that criminalizes gender-affirming care, again specifying explicitly that it includes children, that is in fact necessarily support for puberty blockers even if they don't say so explicitly.

Now, I wouldn't be opposed to more explanatory text being devoted to each of these organizations explaining exactly what their positions are. I agree that it's relevant that many of these organizations are expressing a political opposition to restrictions on trans healthcare (and not, for instance, publishing medical recommendations on when puberty blockers are or aren't indicated). But don't just remove them! You're doing the equivalent of removing proofs about rectangles from the article on squares. Loki (talk) 01:31, 24 March 2024 (UTC)

I'm sorry but I disagree with the part where it needn't be explicit. It'd be like saying "the XYZ association supports the use of chelation therapy to treat mercury poisoning" but with a statement that only says "XYZ objects to legislation which would interfere with the treatment of mercury poisoning". But if you'd like to include it with a I'd understand. I mostly removed since I'd been surprised by the mention of a nursing association and thought it odd they would endorse a specific drug and then saw that their statement contained no such endorsement. XeCyranium (talk) 01:40, 24 March 2024 (UTC)

I did find an explicit source for the American College of Physicians here: [36] XeCyranium (talk) 01:56, 24 March 2024 (UTC)

And here's a source for the American Academy of Family Physicians: [37]. XeCyranium (talk) 02:20, 24 March 2024 (UTC)

This document from the American College of Obstetricians and Gynaecologists says that for the treatment of adolescents reference should be made to WPATH and Endocrine Society provisions so essentially supports it: [38]. XeCyranium (talk) 02:28, 24 March 2024 (UTC)

And I'm giving up on the American Osteopathic Association, they have the worst website layout imaginable on mobile, at least for me. If anybody is able to access it from another device it can be found at osteopathic.org. XeCyranium (talk) 02:35, 24 March 2024 (UTC)

Well, no, it's like an organization opposing laws against proper treatment of cancer and you removing that from the article on chemotherapy because they don't explicitly mention the word "chemotherapy". Puberty blockers are widely regarded to be the standard of care, so even if an organization doesn't mention them by name, if they talk about the standard of care in this area it does include puberty blockers.

I do agree that this is again a weird artifact of this being simultaneously a WP:MEDRS page and a page about a political controversy, but despite these most directly being statements about the political controversy they are also WP:MEDRS-quality sources about the treatment. Loki (talk) 02:04, 24 March 2024 (UTC)

I did find sources for three of the five organizations. To clarify what I mean with it needing to be near-explicit: I'm sure every medical body listed in this article would probably provide a statement to the effect of "we oppose any legislation that would seek to restrict treatment for transgender youth", but some of those same organizations don't endorse puberty blockers. Ergo I think an explicit endorsement is best. XeCyranium (talk) 21:51, 24 March 2024 (UTC)

LokiTheLiar please don't reinsert content with WP:VERIFIABILITY concerns unless you're going to use sources that actually support the statement you're including. If you're at a loss for sources I've posted some here in this very section. Please adhere to policy, if there are sources which actually support the content in question, which there are, use those. XeCyranium (talk) 21:28, 29 March 2024 (UTC)

The sources that were already there supported the statement I re-added. You looked at a bunch of sources that verified the claims, said they "failed verification" when they didn't, and then removed the claims for failing verification.

Feel free to add new sources but I dispute your removal in the first place or the idea the existing sources were in any way subpar. Loki (talk) 21:31, 29 March 2024 (UTC)

I would also like to get some extra eyes on this to avoid an edit war, so pinging past participants in similar discussions Snokalok, Your Friendly Neighborhood Sociologist, Barnards.tar.gz, Colin, TenorTwelve, WhatamIdoing and Sideswipe9th. Loki (talk) 23:03, 29 March 2024 (UTC)

I checked the page, it no longer exists. Could we get an archive or something? Snokalok (talk) 04:00, 30 March 2024 (UTC)

The disputed diff is this one and a few others like it going back and forth.

The TL;DR explanation of why there's a dispute is that I think sources saying an organization supports gender-affirming care for trans kids is sufficient to say that organization supports the use of puberty blockers (because puberty blockers are standard of care). XeCyranium thinks that a source must specifically say the organization supports puberty blockers. Loki (talk) 00:52, 31 March 2024 (UTC)

Loki, I'm sure you've got the facts right in practice, but I'd like you to think for a moment about the precedent here. If an organization says "We oppose laws against treating trans kids", there's a big difference between "supporting mainstream medical care, such as family counseling and puberty blockers in 10 year olds" and "supporting conversion therapy" (or "going straight to gender-affirming hormone treatment in 10 year olds" at the other end of the spectrum). We really do need sources that provide specificity. Fortunately, it looks like those sources are available. It'll just require some work to dig them up.

@XeCyranium, I don't think that AOA has an official organizational statement about puberty blockers on their website. They provide general information (e.g., https://findado.osteopathic.org/raising-a-transgender-child ) but no official statement. Such a statement might not exist, or it might be published in a medical journal instead of on their website. WhatamIdoing (talk) 02:02, 31 March 2024 (UTC)

Thank you for looking into the osteopathic association. XeCyranium (talk) 02:58, 31 March 2024 (UTC)

I appreciate you inviting more editors but I feel I should reiterate what I said in my edit summary, WP:VERIFY isn't subject to editor consensus on a talk page, whether the source says something or not isn't up for debate. I don't object to three of the orgs assuming the sources I've found are useable. But the source you're insisting on simply doesn't say what you're attaching it to. XeCyranium (talk) 03:19, 31 March 2024 (UTC)

The policy itself isn't but how to interpret it and, crucially here, whether the sources actually support the claim or not absolutely is. I've already explained why I believe the sources in question do in fact source those claims. Loki (talk) 03:21, 31 March 2024 (UTC)

I think it is reasonable for editors to discuss and agree on whether X => Y and can be assumed. I'm not sure Loki has done his case any favours by arguing for different reasons why X => Y. There are various statements mentioned above that are proposed as implicitly meaning support for puberty blockers but I don't think most of them would find consensus here. Some examples:

1. oppose any laws and regulations that discriminate against transgender and gender-diverse individuals, including children and adolescents
2. strongly opposes any legislation or policy action that places restrictions on transgender health care and that criminalizes gender-affirming care, again specifying explicitly that it includes children
3. opposition to restrictions on trans healthcare
4. opposing laws against proper treatment
5. Puberty blockers are widely regarded to be the standard of care, so even if an organization doesn't mention them by name, if they talk about the standard of care in this area...
6. an organization supports gender-affirming care for trans kids
7. oppose laws against treating trans kids

Even countries or organisations that agree on the use of puberty blockers for trans children might have quite different guidelines around their use. Even when they were more routinely used in NHS England (if "routinely" is an appropriate adjective for the tiny minority of referred patients who reached the end of the waiting list) I don't believe they were ever licenced for such use (correct me if I'm wrong) which is itself a negative (though not a fatal one: many epilepsy medicines are not licenced in children but yet used if an expert feels appropriate). I don't think "support/don't support" binary is appropriate for what is a nuanced medical decision.

What those US organisations are really saying is where the government can go stick itself, interfering with clinical choices for political ends, and that is ultimately are more binary argument that what the consensus is on the evidence for any one particular therapy. Wikipedia is not a political football, so I'm not particularly impressed by "Press release in response to Senator Stupid's latest law proposal" as any kind of MEDRS source. It is a political source. -- Colin°^Talk 16:37, 31 March 2024 (UTC)

I know your perspective but I feel like you have to consider that a statement to the effect of "it would be wrong to legislate against treatment of a condition" isn't the same as an endorsement of a specific common component of said treatment. If the source just mentioned puberty blockers I'd have no problem, and again I don't think the statement is even wrong. Would it be a fair compromise to include three organizations for which I found sources, assuming you don't object to them, and include the other two with a tag for a given period? XeCyranium (talk) 01:20, 2 April 2024 (UTC)

I'd be okay with that if you included them with a tag instead. Loki (talk) 02:35, 2 April 2024 (UTC)

I included the ACOG and ACP sources but upon further looking into the AAFP I'm not sure if they actually do have practice guidelines on puberty blockers. The source I previously provided was only their coverage of the Endocrine Society's recommendations, but carries a disclaimer that it is not an endorsement from the AAFP. XeCyranium (talk) 23:46, 9 April 2024 (UTC)

The lead and highlighting countries

Since there is dispute over removing it, I figure we should strike the current mention of the American and Australian medical bodies from the lead. My main reason for this is that we have multiple other countries that are included in the relevant section which we don't mention in the lead. Now one might say the solution is to add every country to the lead but at that point I think it becomes less a lead and more just a retreading of the section in question. XeCyranium (talk) 01:34, 24 March 2024 (UTC)

I feel I should also bring up [39] which I originally assumed was reverted by mistake to also reinsert the lead as it was. user:LokiTheLiar did you mean to continue to revert this edit? It seems like blatant WP:SYNTH to me, the source makes zero mention of Finland. XeCyranium (talk) 01:44, 24 March 2024 (UTC)

That was indeed a mistake. I agree the AAP source there is WP:SYNTH but not "On the other hand," as the source for the Finnish Ministry explicitly makes the comparison. Loki (talk) 01:49, 24 March 2024 (UTC)

I'd have no problem with saying that, the language itself didn't bother me it was the random American tidbit. XeCyranium (talk) 01:53, 24 March 2024 (UTC)

I'm not really sure where else to put this, but I'll attach this to concerns about naming individual, country-specific organizations and laws in the lead.

MEDORG doesn't actually talk about "international organizations". What the rest of the guideline means when it talks about "national and international expert bodies" is pretty much:

• the World Health Organization,
• government agencies (like the US FDA), and
• subject-specific expert bodies (like the Médecins Sans Frontières for disaster medicine).

WPATH and Endocrine would fall under that last point. So would most (but not all) of the organizations listed in https://glaad.org/medical-association-statements-supporting-trans-youth-healthcare-and-against-discriminatory/ We usually understand "expert" as excluding political and outright quack organizations.

But: Just because we could create a laundry list of organizations that support caring for trans kids, or even that specifically mention support for using puberty blockers (e.g., the Pediatric Endocrine Society) doesn't mean that we actually should have such a list in this article at all (cf. Joe Biden presidential campaign endorsements vs Joe Biden), or that we should name-drop our favorites at the top of the article.

If we are treating this as primarily a medical article, the lead should usually contain straightforward factual statements on points such as:

• what it is (e.g., drug class and how many different ones there are),
• what it's used for,
• how it works,
• what the side effects or other problems are, and
• what the history is (e.g., discovery, regulatory approval, availability).

For example: Antibiotics are drugs used for bacterial infections, they kill or at least stop further growth of bacteria, you might end up with diarrhea or other problems, we're all a bit worried about antibiotic resistance, and the discovery of antibiotics has literally saved millions of lives.

When I look at the lead that we have for puberty blockers now, I don't see the subject of this article being treated like a normal medical treatment. I see a strenuous "marketing" effort that leaves me with the feeling that there's something suspicious here. I'm being told that all the cool organizations endorse this treatment, and that we're under attack in all these states. (Oh, and those kids with precocious puberty don't matter, even though there are probably more kids with PP than kids taking puberty blockers as part of trans care, which is doubtless doubly discouraging for anyone trying to help a Kindergartner manage her menstrual period.) WhatamIdoing (talk) 03:09, 31 March 2024 (UTC)

Do we have any stats on how many are using these drugs for precocious puberty vs gender affirming? This page is not handling well the different uses of these drugs. For example, the page mentions this source wrt "women who took Lupron in order to grow taller" which appears to be an off label use. And I don't think our article reports this non-MEDRS source correctly, as the adverse effect reports are for the drug full stop, not one particular use. I think there is a danger we report on effects/side-effects for one patient group (e.g. v young children) or another (adolescents) and confuse the reader about which is relevant. And I suspect historically that's been the intention in this field, in that the safety profile for precocious puberty has been assumed for teenagers.

I agree the page is overloaded with legal and political stuff which are NEWS and less encyclopaedic than the medical aspects. -- Colin°^Talk 09:54, 3 April 2024 (UTC)

This sentence: The NICE review has been criticized by WPATH and EPATH for excluding studies combining puberty blockers and hormone replacement therapy and by parents of transgender youth for excluding evidence of its safety when used by cisgender youth undergoing precocious puberty. performs exactly that conflation. Precocious puberty lacks the psychological element that is the centrepiece of gender dysphoria, and the concern of Cass is the "unknown impacts on development, maturation and cognition if a child or young person is not exposed to the physical, psychological, physiological, neurochemical and sexual changes that accompany adolescent hormone surges".[40]

Precocious puberty is a separate condition, with a separate treatment regimen, and it cannot be assumed that safety and efficacy in one treatment context transfers to the other. Barnards.tar.gz (talk) 16:49, 5 April 2024 (UTC)

Efficacy, definitely, since the desired treatment outcome is different. (Or rather, the studies that say GnRH blockers work to prevent puberty are transferable but can't be taken to say that preventing puberty in trans kids improves outcomes.) But that's not what the quote you're talking about criticizes.

For safety, though, it doesn't make any sense to say someone is going to have more bone problems because they're trans. It's the same medication in very similar patients. Loki (talk) 20:26, 5 April 2024 (UTC)

The patients may be physically very similar but they are certainly not psychologically very similar, and the concerns raised by Cass and others are around the impact on cognitive development. Is the treatment really safe if it blocks psychosexual development, which is intertwined with identity development? This is not an issue in cases of precocious puberty, but it’s the very heart of the issue in cases of gender dysphoria. Then there’s the issue of blocking the development of mature decision-making abilities which are relied upon once the “time to think” is up.

So, it does not follow that the treatment being safe for precocious puberty makes it safe for use in children with radically different psychological symptoms.

Barnards.tar.gz (talk) 22:46, 5 April 2024 (UTC)

This sort of suggests that you (or Cass) would agree with YFNS that instead of puberty blockers, doctors should just directly prescribe HRT. But I at least very much doubt that Cass would agree with that, which suggests that what they say about just being concerned about delaying puberty at all is not really the issue.

I would say I don't have a source for this opinion, but I kind of do, since this is more-or-less what WPATH means by The selected studies by NICE only focused on the effects of puberty blockers, therefore studies that evaluated a combination of blockers, hormones, and/or surgeries were excluded. Loki (talk) 06:41, 6 April 2024 (UTC)

I’m very confused as to why you would think that I or Cass would come to that conclusion. What I’m saying is that assuming the effects of a drug on one population will be seen in a different population is invalid. Barnards.tar.gz (talk) 07:34, 6 April 2024 (UTC)

Looking at it from general principles, the main "physical" differences are likely to be due to the length of time on the drugs and the developmental stage the brain's in. Taking any hormone starting at age 3, and staying on it for 7 years, is likely to produce different effects than taking that same hormone starting at age 10 or 11, and staying on it for 12 to 24 months. Usually, you'd expect cumulative damage (e.g., bone loss) to be worse the longer you take a drug, but some effects only appear if the drug is taken during particular developmental stages or in combination with some other event (e.g., another drug or a comorbidity). We can't be certain that the drug side effects will be the same in these two groups, but IMO it's not entirely reasonable to write the article from the POV that, because it's unknown, then short-term use in older kids has a significant probability of having worse side effects than long-term use in little kids.

For this article, therefore, I suggest that we give the facts (e.g., the research is mostly done in younger kids with PP instead of older kids with TGD) without overemphasizing uncertainty or research limitations. WhatamIdoing (talk) 00:54, 13 April 2024 (UTC)

Cass Review

The final Cass Review has now been published and it includes not only yet another systematic review of blockers saying they lack evidence efficacy or safety (so that's 4 now), but also a separate systematic review into international guidelines, which is critical of many of the positions currently considered MEDRS (ACP, APA, WPATH etc, see table 6). How do we handle this? Void if removed (talk) 07:41, 10 April 2024 (UTC)

Link to the various studies supporting the review.

This review in particular is informative:

Two international guidelines (World Professional Association for Transgender Health and Endocrine Society) formed the basis for most other guidance, influencing their development and recommendations. - This validates the notion that stuffing the lead with mentions of lots of different orgs is misleading, if the ultimate source of the guidelines is actually WPATH and the Endocrine Society.

Conclusions Most clinical guidance for managing children/adolescents experiencing gender dysphoria/incongruence lacks an independent and evidence-based approach and information about how recommendations were developed. - MEDRS is clear that we should prefer independent and evidence-based sources, but we still need to report the WPATH/Endocrine Society position, as they clearly remain influential. We're not trying to pick a winner of the two POVs, but to accurately summarise what the two POVs are.

Overall, the review seems to further strengthen the MEDRS credentials of the "European caution" camp, so I think the following remains the best second paragraph for the article:

Few studies have examined the effects of puberty blockers for gender non-conforming and transgender adolescents. The World Professional Association of Transgender Health and the Endocrine Society both endorse the use of puberty blockers as a medically necessary gender-affirming intervention. However, systematic reviews have found the evidence of benefits to be of low-certainty, and some European countries have subsequently moved towards restricting the use of puberty blockers.

Barnards.tar.gz (talk) 10:36, 10 April 2024 (UTC)

"Few studies have examined the effects of puberty blockers for gender non-conforming and transgender adolescents."

This is directly contradicted by the Cass Report, which examined over 50 studies on that exact topic. It simply threw out all but one, and while I'm not commenting on that decision here, I am saying that we can't say "few studies" based on the Cass Report Snokalok (talk) 11:16, 10 April 2024 (UTC)

How about Few high quality studies have examined the effects of puberty blockers for gender non-conforming and transgender adolescents Void if removed (talk) 11:21, 10 April 2024 (UTC)

Better, but I feel high quality on its own has been well established as misleading to a reader. Perhaps, "Few studies using randomized controlled trial (...) outside of that, the studies there are indicate XYZ (...) Endoresement by world orgs (...) however systemic reviews have found low certainty due to the aforementioned lack of randomized controlled trials" Snokalok (talk) 11:24, 10 April 2024 (UTC)

The quality assessment is nothing to do with RCTs. Void if removed (talk) 11:29, 10 April 2024 (UTC)

By all means, tell me where in the paper I can find the methodology of quality assessment. I had difficulty finding reference to anything outside of RCT's myself. Snokalok (talk) 11:59, 10 April 2024 (UTC)

See the systematic review into puberty blockers here: https://adc.bmj.com/content/early/2024/04/09/archdischild-2023-326669

An adapted version of the Newcastle-Ottawa Scale for cohort studies was used to appraise study quality. Only moderate-quality and high-quality studies were synthesised.

This is "The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses".

They assessed:

11 cohort, 8 cross-sectional and 31 pre-post studies were included (n50). One cross-sectional study was high quality, 25 studies were moderate quality (including 5 cohort studies) and 24 were low quality.

Void if removed (talk) 13:10, 10 April 2024 (UTC)

I’m not ignoring this, it just takes time to read through on my breaks. Snokalok (talk) 07:18, 11 April 2024 (UTC)

Right, after having read up, this still requires an external control, which of course raises well documented ethical issues. Additionally, ascertainment of exposure requires blind interviews, but its again impossible to do a blind anything for puberty blockers, because puberty is very visible. Snokalok (talk) 09:58, 12 April 2024 (UTC)

The ethical issues with a control group are the same as any ethical issue with a control group, ie, they might be denied useful treatment. But until you do the study, you don't know. It might be you make them worse. Without a control you don't know, that's the point.

And studies were marked down for other reasons, like having atrocious dropout rates. If 70% are lost to followup how can you have any confidence in the results? Adding together bad data doesn't give you good data, it just gives you more bad data.

It is clearly possible to attain a high quality study design, since one was included. Void if removed (talk) 13:53, 12 April 2024 (UTC)

Anyway, if we're resurrecting this, we should bring in all the names.

@Sideswipe9th @LokiTheLiar @XeCyranium @Your Friendly Neighborhood Sociologist @TenorTwelve @Colin Snokalok (talk) 11:22, 10 April 2024 (UTC)

Also - they didn't "throw out" all but one - they assessed their quality, and found only one was high, with the rest moderate or low. That doesn't mean they disregarded the others. See https://adc.bmj.com/content/early/2024/04/09/archdischild-2023-326669

Eg,

Regarding psychological health, one recent systematic review reported some evidence of benefit while others have not. The results in this review found no consistent evidence of benefit. Inclusion of only moderate-quality to high-quality studies may explain this difference, as 8 of the 12 studies reporting psychological outcomes were rated as low-quality.

The conclusion:

There are no high-quality studies using an appropriate study design that assess outcomes of puberty suppression in adolescents experiencing gender dysphoria/incongruence. No conclusions can be drawn about the effect on gender-related outcomes, psychological and psychosocial health, cognitive development or fertility. Bone health and height may be compromised during treatment. High-quality research and agreement on the core outcomes of puberty suppression are needed.

Void if removed (talk) 11:27, 10 April 2024 (UTC)

Perhaps that first sentence isn’t needed at all. Considering this is the lead, mention of what studies have been done and how many and of what quality, is arguably detail subsumed by the recommendations of the main players. Discussion of studies and quality can be covered in the body. Barnards.tar.gz (talk) 12:23, 10 April 2024 (UTC)

I'm preliminarily against any change here, and agree with Snokalok's criticisms of taking this too seriously.

I would like to wait a little bit to give other organizations (like WPATH) a chance to respond to this. Loki (talk) 13:37, 10 April 2024 (UTC)

What are you hoping a statement from WPATH will do? Unless they capitulate entirely, there will still be two POVs of comparable weight that need to be covered in the article lead, which is currently completely lacking one of them. Barnards.tar.gz (talk) 18:00, 10 April 2024 (UTC)

I still find "of comparable weight" dubious. But regardless, the point here is that the Cass Review being released should not by itself change our coverage of this topic until we have a firmer idea of where it falls within the broader scholarship. Loki (talk) 18:51, 10 April 2024 (UTC)

A new systematic review is MEDRS, why would we wait to see if WPATH agree with it? This is the broader scholarship. Void if removed (talk) 19:49, 10 April 2024 (UTC)

I think that highlights the real issue. It's not that the Cass Review is a game-changer for this article. Rather, the situation remains where we're seeing medical academia and organisations split between a "pro" camp and a "European caution" camp, but only the former of the two is currently represented in the lede. Snokalok's earlier suggestion comes across to me as the best starting point on what to add to the lede. Anywikiuser (talk) 22:20, 10 April 2024 (UTC)

I disagree with the characterization of “European caution camp”, primarily because as the article says, it’s not all of Europe or even Western Europe, it’s a handful of countries within Europe compared to many more that still actively recommend puberty blockers. Snokalok (talk) 07:14, 11 April 2024 (UTC)

The proposed change doesn't use the phrase "European caution camp", that's just an air-quoted shortcut for the purpose of this discussion. The proposed change is to use the word some which is true even if not all European countries reach the same conclusion. Barnards.tar.gz (talk) 07:56, 11 April 2024 (UTC)

Not sure if a review only including one study in its actual evaluation can be considered a systematic review. At best, it would be a "need more data to make conclusions" type of report. Any conclusions made beyond that would be incongruous with the review itself and imply the authors pushing a stance not fitting with the data. Sounds like we'll need to wait for both more studies and probably also reviews of the Cass Review itself. I expect critical responses from scientific review of it to occur due to the Cass Review making the claim of the studies it threw out lacking double blinded control groups, when puberty blockers is one area (of which there are many in medicine) that such forms of studies are impossible for both ethical and logistical reasons. So the Cass Review using that aspect as a component to throw out a bunch of studies is going to be highly suspect when the academic community ends up properly analyzing it and giving responses. Silverseren^C 20:34, 10 April 2024 (UTC)

including one study in its actual evaluation

I would like to know where this particular myth has come from because that's simply not true. I've linked the review above. Only one study was high quality, but they included studies that were high and moderate quality in the synthesis. Void if removed (talk) 21:02, 10 April 2024 (UTC)

Though I can't be sure, it likely comes from a very poorly worded press release from Cass published alongside the review. PATHA and AusPATH then made a joint statement saying that In one review, 101 out of 103 studies were discarded.

Honestly we're best waiting for a few days/weeks for things to settle here before considering integrating substantive content from or about the Cass Review, whether it be in this article or any other. The early indications from other relevant medical bodies outside the UK is that this review is highly controversial, and seemingly out of step with international best practices. Rob Agnew, the chair of the British Psychological Society's Section of Sexualities has said on his LinkedIn that he "and many other clinicians, will be having a look at the final Cass Review in detail and trying to answer the question 'Why was Cass unable to find the research needed to provide trans youth with vital medical approaches that other countries found?'" Given the length of the report, the linked series of papers in the BMJ, and that seemingly no-one outside of certain elements of the UK press were given advance copy of the report's findings, it will take some time for the review and its content to be properly analysed and contextualised for our own purposes.

I know from my own skimming of the content, there are some real oddities present. I found Cass' opinion that the WPATH guidelines "lack developmental rigour and transparency" to be particularly galling, given how her own review has been conducted under a veil of secrecy, with the names and qualifications of the review panel members being withheld both earlier in the process and seemingly now post-publication with the panel members not being named in the report. This may even be outright false, given that WPATH were very open about both the methodology and list of contributing members behind the SoC 8. Sideswipe9th (talk) 01:35, 11 April 2024 (UTC)

I'll put my name down as in support of waiting. Alpha3031 (t • c) 11:04, 11 April 2024 (UTC)

It will also be interesting to see if reliable sources compare Cass' findings against the forthcoming joint German, Austrian, and Swiss guidelines that are due to be published shortly. There was a press briefing about those guidelines at the end of March, and the takeaways from that is that the German lead guideline seems to be diametrically opposed to what the Cass Review has found, particularly with regards to the prescription of puberty blockers at a Tanner stage appropriate time. Sideswipe9th (talk) 02:05, 11 April 2024 (UTC)

it likely comes from a very poorly worded press release from Cass published alongside the review

I see - people are confusing the research on hormones with the research on blockers. The systematic review on blockers is separate, so this particular objection (which has come up twice on this talk) is, aside from anything else, incorrect.

I found Cass' opinion that the WPATH guidelines

This is not Cass' opinion - this is the results of an independent analysis: https://adc.bmj.com/content/early/2024/04/09/archdischild-2023-326499

Table 6 in the review lays this out quite clearly.

It will also be interesting to see

It will - but right now we have one systematic review and WPATH saying one thing, and four systematic reviews saying another. The balance in the lede is way off, and continually bringing up the same old blogposts from partisan activists doesn't change that. Void if removed (talk) 08:04, 11 April 2024 (UTC)

The Cass review includes wild speculation, insinuating that porn might make kids trans and that therapists should ask about their porn viewing? It cites an anti-pornography educator who claims that 50% of porn is violent, which is just bogus. Zenomonoz (talk) 09:12, 11 April 2024 (UTC)

The Cass Report is more nuanced on the subject, but this is a digression. Anywikiuser (talk) 11:01, 11 April 2024 (UTC)

Cass cites a Nadrowski paper which claims that FtMs are "fleeing womanhood" to escape male sexual violence and porn. Very scientific. Edit: sorry yeah this is off topic for puberty blocker. We can strike or remove these three comments. Zenomonoz (talk) 11:54, 11 April 2024 (UTC)

Correct my if I'm wrong, but the relevant systematic review of puberty blockers is PMID 38594047 and is titled "Interventions to suppress puberty in adolescents experiencing gender dysphoria or incongruence: a systematic review" and written by Jo Taylor, Alex Mitchell, Ruth Hall, Claire Heathcote, Trilby Langton, Lorna Fraser and Catherine Elizabeth Hewitt, and published in the BMJ. There seems to be some confusion, which this section heading doesn't help, that the systematic review is the Cass Review or that Cass authored this systematic review. They commissioned it, and use it as part of their overall review for NHS England. Let's not confused the controversy about Cass's own recommendations with a systematic review in the BMJ.

Further, there seems to be a lot of nonsense about them doing a systematic review on 1 paper (throwing out all the others from 50). Snokalok, I think you should strike what you wrote. As Void quoted, they studied 50 papers. The sort of quality selection going on here is very much entirely normal. Some people the press interview seem to think and write about this as though there was some kind of exclusion of quality studies just because their findings were inconvenient. There is a level below which a study is not in fact adding knowledge to humanity. Loads of small scale flawed studies are published in medicine all the time. Some of them are explicitly pilots that accept their limited value but many are not, and their existence does not suddenly e.g. make homeopath work or herbal teas cure cancer.

As per any other medical therapy, we should be taking this top tier systematic review in a top tier medical journal and writing something like ""While there is good evidence that puberty blockers are effective at suppressing puberty in adolescents, as of January 2024 the lack of high-quality research in this area means no conclusions can be drawn about their effectiveness in treating gender dysphoria, their effect on mental and psychosocial health or cognitive development. There is evidence that bone health and height may be reduced." That is the MEDRS aspect to "do they work and are they safe". The efficacy aspect is done and dusted by this systematic review, and per MEDRS, can't be trumped unless someone does a better one.

The second question about what various bodies recommend and countries licence is where WPATH and NHS England and so on come in. And we also have a first class source to write about those: PMID 38594049 and PMID 38594048 which are titled ""Clinical guidelines for children and adolescents experiencing gender dysphoria or incongruence: a systematic review of recommendations" (parts 1 and 2). These are by Jo Taylor, Ruth Hall, Claire Heathcote, Catherine Elizabeth Hewitt, Trilby Langton and Lorna Fraser. You will notice that this systematic review is also not the "Cass Review" and also not authored by Cass. If we are to write about the various guidelines for the use of puberty blockers, I cannot think of a better source. What's the alternative? Twitter? The Telegraph? Pink News? This is a review in the BMJ for goodness sake, not some opinion piece or press release. And they are pretty damning about WPATH. Their conclusions like ""Most clinical guidance for managing children/adolescents experiencing gender dysphoria/incongruence lacks an independent and evidence-based approach and information about how recommendations were developed" and ""Few guidelines systematically reviewed empirical evidence, and links between evidence and recommendations were often unclear" should hugely determine what we say about guidelines like WPATH's, for example. Wikipedia loves secondary sources, and loves the very best secondary sources.

These various reviews, which are not to be confused with "The Cass Review", are top MEDRS sources we should be incorporating right now. There will be a lot of chatter in the coming days about "The Cass Review" but mostly about their conclusions about NHS England's strategy for adolescent care, and whether there's any realistic chance they will be implemented. There will be bodies, as Sideswipe quotes above, writing utter nonsense about this, like the claims about discarding 101 studies, and many will want to muddy the waters by calling the Cass Review controversial. But the BMJ systematic reviews I link to above are not Cass and very much not surprising: they did what systematic reviews do all the time, and the activist voices complaining about studies being rejected is also not surprising because that's a common refrain too. The homeopaths and the herbalists do that all the time. This is routine stuff and not any reason to hold back on incorporating the evidence findings. Really, the debate and controversy is about what people do with the evidence (or lack). And rational wise people will differ on this, with some being (over) cautious and some falling back on their own "expert" opinion and carrying on regardless. But Wikipedia cannot pretend to our readers that just about the only thing we have solid statistical evidence for is that puberty blockers supress puberty in adolescents, who may then end up shorter or with weaker bones. -- Colin°^Talk 18:51, 11 April 2024 (UTC)

But the BMJ systematic reviews I link to above are not Cass and very much not surprising: they did what systematic reviews do all the time, and the activist voices complaining about studies being rejected is also not surprising because that's a common refrain too. The homeopaths and the herbalists do that all the time.

It is inappropriate and unnecessary to be comparing the LGBT community to fringe homeopathy. Yo could have just left the majority of your final paragraph out. Silverseren^C 20:42, 12 April 2024 (UTC)

He's not saying it's the whole LGBT community, or even the whole trans community. Let's not take this out of proportion. Anywikiuser (talk) 19:40, 13 April 2024 (UTC)

I'm not even remotely comparing the LGBT community to fringe homeopathy. I'm talking about some of their arguments. That they make the same flawed and dim arguments. Try to spot them and you'll become a better editor. -- Colin°^Talk 19:54, 13 April 2024 (UTC)

I think even that is dubious and that your choice of comparison is seriously flawed. If you wanted to say they were making unscientific arguments, there's lots of better comparison points than total quacks.

But we should probably drop this, because I don't think it's going to go anywhere productive. Loki (talk) 20:08, 13 April 2024 (UTC)

I'm not just saying they are making unscientific arguments. They really are spreading disinformation in support of their cause. Which is bad, no matter how noble the cause. The very discussion on this page is a classic "a lie can travel halfway around the world while the truth is still putting on its shoes" -- Colin°^Talk 20:12, 13 April 2024 (UTC)

I'm also finding the idea that someone can "do a systematic review on one study" to be evidence that people (and the sources they're relying on) don't know what they're talking about. This is unfortunate, as I believe that most of the editors on this page are capable of writing systematic reviews.

Typically, a systematic review is done on "the entire contents of the PubMed database", so if you start one today, you're doing it "on" 38.6 million publications. Then you start filtering: Maybe you only want studies from the last 20 years. Only certain types of publications (e.g., excluding letters to the editor). Only studies that contain certain keywords. Only studies that include specific populations.

That process apparently got them down to 50 relevant studies, which they then assessed manually according to a pre-chosen, scientifically accepted, industry-standard rubric (they chose the Newcastle–Ottawa scale). This step isn't difficult; it's mostly tedious and occasionally expensive (if you have to buy a lot of paywalled studies). The results of that assessment determines which studies they read for content. In this case, they accepted 26 out of 50 (55%) for evaluation. (This, by the way, is not a bad acceptance rate; I've seen many systematic reviews from the famous Cochrane Collaboration that accept zero studies. The write-up is short and simple: "No good evidence, Further research is needed, good luck treating your patients between now and then".)

With the accepted studies in hand, the interesting part begins: You read the papers and figure out what their results are. Does it say anything about ____? Does it give any subgroup information (e.g., race, sex, age)? Does it reach a statistically significant result? Wait, I thought there were articles saying there were improvements to psychological functioning – oh, interesting, all of the ones reporting big improvements are low-quality papers.

I would be surprised if we didn't see special pleading in social media about why low-quality studies with the Right™ results needed to be included anyway, so that the report would have ended up with the Right™ results – after all, that happens all the time, and the motivations are perfectly understandable and usually noble – but I do hope that Wikipedia editors can avoid repeating errors like "systematic review on one paper", and I hope that we can improve this article by being clear about facts that are settled. For example, it may not be clear whether delaying pubertal development has long-term positive outcomes compared to other treatment alternatives, but it is clear that a year of puberty blockers results in a delay in pubertal development. Let's say that, clearly and directly. WhatamIdoing (talk) 01:53, 13 April 2024 (UTC)

I think in including this it should be noted for the puberty blockers review that the evidence was taken from April 2022 and earlier. I know it is obvious to people with familiarity I'm systematic reviews that they have to lag behind by a couple of years but I think making this explicitly obvious helps the common reader. LunaHasArrived (talk) 09:12, 14 April 2024 (UTC)

The April 2022 date was used to gather studies for synthesis but they do spend five paragraphs individually discussing the research since then until January 2024, and consider whether those studies change their conclusions or add information, and their answer is no. So I don't think it would be fair at all to claim this review was two years old already, as they seem to have gone out of their way to make it especially up-to-date. -- Colin°^Talk 15:22, 14 April 2024 (UTC)

Consensus-based vs evidence-based

Regarding Cass's review of international guidelines... we are talking about section 9 of the report (p126). Some key callouts:

1. There are two primary guidelines that have influenced nearly all the others, and which are not independent of each other:

9.22 The circularity of this approach may explain why there has been an apparent consensus on key areas of practice despite the evidence being poor.

2. The current international guidelines have some shortcomings, to say the least:

9.24 The guideline appraisal raises serious questions about the reliability of current guidelines. Most guidelines have not followed the international standards for guideline development...

9.28 The WPATH 8 narrative on gender-affirming medical treatment for adolescents does not reference its own systematic review...

9.29 Within the narrative account the guideline authors cite some of the studies that were already deemed as low quality, with short follow-up periods and variable outcomes...

9.32 Clinical consensus is a valid approach to guideline recommendations where the research evidence is inadequate. However, instead of stating that some of its recommendations are based on clinical consensus, WPATH 8 overstates the strength of the evidence in making these recommendations.

3. From the Taylor/Hewitt systematic review of guidelines[41]:

Most clinical guidance for managing children/adolescents experiencing gender dysphoria/incongruence lacks an independent and evidence-based approach and information about how recommendations were developed.

Therefore when assessing weight and MEDRS evidence quality for Wikipedia article purposes, we can not treat WPATH guidelines as a gold-standard source of biomedical information on puberty blockers. This is not to say that they should be ignored - far from it, they remain hugely influential and much of their non-PB content may still be valid. But we cannot adopt WPATH-derived positions on puberty blockers into wikivoice as if they were uncontested facts.

It is now absurdly overdue to update the lead to make clear that there is a divergence of recommendations between professional organisations using a consensus-based approach and scientific research using an evidence-based approach. Barnards.tar.gz (talk) 11:26, 17 April 2024 (UTC)

We should not ignore international consensus on this issue because of one study complaining about it. Loki (talk) 15:12, 17 April 2024 (UTC)

There is no international consensus, there are a multiplicity of viewpoints, with the centre of gravity of one cluster being WPATH and the centre of gravity of the other cluster being the European nations detailed already in the article. When we have a study (of the highest quality) suggesting that "the international consensus" is only "apparent consensus" due to circular reasoning, and that it is not as evidence-based as it claims, we cannot treat it as the only game in town. Barnards.tar.gz (talk) 16:16, 17 April 2024 (UTC)

It's not on the basis of one study complaining about it, though their complaints are entirely consistent with the reason MEDRS gives low weight to non-evidence-based opinions. The highest form of evidence for efficacy and safety comes from systematic reviews. Expert opinion is one of the lowest forms. In wiki voice we absolutely should state what these reviews have found, wrt what evidence there is and isn't. We need to say that some organisations disagree but we can only put their opinions as opinions. The lead currently gives enormous weight to spelling out which US organisations have published press releases, even if many of those organisations are not themselves involved in creating such guidelines and so are merely affirming "what he said".

We have first class sources saying that some organisations guidelines are non-evidence based. Which is fine if that's the approach they want to take. But we can't invent facts just because we wish it were otherwise. There are aspects of puberty blockers for which there is no good evidence they help, in wikivoice, and there are aspects for which there is modest evidence they harm. Claims by some organisations that they think there is evidence need to be backed up with their own systematic review that says so, because press releases don't trump that.

Per WP:MEDSAY we shouldn't restrict the wiki-voice facts about puberty blocker evidence to be "Cass Review stated that". For example, when we have systematic reviews that a drug is effective for focal epilepsy but not effective for migraine, we simply state that, without reference to where or how that information was arrived at. Time we did the same for puberty blockers. That isn't to say we ignore the controversy. -- Colin°^Talk 11:37, 20 April 2024 (UTC)

There's one thing above systematic reviews in (one of) the pyramids in WP:MEDASSESS and that's "clinical practice guidelines". Clinical practice guidelines have not changed because of the Cass Review outside of the UK, and international clinical practice guidelines are not likely to change.

Furthermore, WP:MEDSCI says we should summarize scientific consensus and so far the scientific consensus on puberty blockers does not appear to be changing.

I agree it's strange that a series of major systematic reviews do not appear to be changing the overall scientific consensus on puberty blockers yet. But it's ultimately the consensus that we cover here, not any individual study, no matter how strong it may appear to us. And it's not like this would be the only time this has happened, either. In our article on masking for COVID we mention that Cochrane review that didn't find evidence of effectiveness... as one line, and then follow up with a line criticizing it. (Admittedly, this is partly because there are tons of systematic reviews in this area, but still.) Loki (talk) 03:03, 21 April 2024 (UTC)

Also from WP:MEDORG: Guidelines do not always correspond to best evidence, but instead of omitting them, reference the scientific literature and explain how it may differ from the guidelines.

Which is exactly what we should be doing here: not omitting the WPATH guidelines, but also explaining how they differ from the scientific literature.

Also, the phrase the overall scientific consensus is problematic here.

• Firstly, there is no gold-standard source telling us what the (singular) overall scientific consensus is.
• Secondly, I am guessing you are treating the WPATH (and WPATH-derived) guidelines as the yardstick of consensus - but we have now seen numerous reasons why that consensus may be flawed or illusory.
• Thirdly, "consensus" and "evidence" and "science" are distinct terms of art in this context, which must not be conflated. As an illustration, the new German guidelines under development[42] are an "S2k-level" guideline. What does that mean? It's a German (AWMF) schema for positioning guideline reliability:[43]

S2K guidelines: S2K guidelines are developed by a committee of specialists in the medical field in question. The recommendations made are consensus-based. Because medical information isn’t systematically collected and assessed here either, the information that the recommendations are based on isn’t very reliable.

Figure 1 in this article explains the difference between consensus-based guidelines and evidence-based guidelines - the latter being needed to reach the higher level of an S3 guideline.

Needless to say, just because a group of doctors have reached consensus on a position, that doesn't mean (a) that all doctors agree with that position, or (b) that the position is based on scientific evidence. Medical reversal is a thing. In fact, WPATH is not primarily a scientific organization. It is a professional association. No doubt many of their members do conduct and publish scientific research, but as an organization it also seeks to further the interests of its own members, meaning it has one foot outside the domain of science. Therefore, even if WPATH represented universal medical consensus amongst doctors (it does not), this would not translate directly to scientific consensus. Barnards.tar.gz (talk) 09:12, 21 April 2024 (UTC)

Loki, what happens to a pyramid when the blocks below are removed? It falls down. The pyramid on the left, with clinical guidelines above meta-analysis and systematic reviews is drawn on the assumption that those guidelines are built on top of them. We now have a serious review of those guidelines PMID 38594049 and PMID 38594048 which clearly exposes that they are not. It's a pyramid for a reason, Loki.

There are three separate issues here. What the science says about the evidence, and what various groups declare to be recommended practice and what in fact occurs in the field (which sometimes is discovered to be way below standard). For the first, a systematic review, looking at all the studies in that area, grading them, and producing a scientifically sound conclusion is our best source. Often the evidence and the guidelines are gloriously in sync but here they are not and that isn't just editor opinion but something we also have the highest possible source for.

For example, in the UK our healthcare uses different metrics than the US to recommend for very expensive treatments (like the latest drugs). This can mean different treatments are recommended than in the US and that affects our clinical guidelines. Or the US may take a more "don't want to get sued" approach which means their guidelines include far more tests "just in case" then in the UK where wasting money is a concern. So guidelines can differ from the evidence base for various reasons. Sadly also sometimes professional or supposedly grass-roots bodies can come under the influence of those who do not care for the evidence but have other priorities. -- Colin°^Talk 09:56, 21 April 2024 (UTC)

Updates to UK section

I don’t want to get involved in editing a medical article. But I think the UK section of this article should be updated to say (a) that private clinics may have trouble with the regulator if they prescribe puberty blockers [44], and (b) that the Scottish Sandyford Clinic has announced that it has ‘paused’ prescribing puberty blockers [45]. Sweet6970 (talk) 16:56, 18 April 2024 (UTC)

Agreed. — The Anome (talk) 12:11, 20 April 2024 (UTC)

Culture wars, article split suggestion

This article is now about two things: medical matters, and the current culture war regarding this, with both sides treating this as a clear matter of good vs. evil (with themselves, of course, on the side of good), and each viewing the other as some kind of lunatic fringe. We should probably try to structure the article accordingly, and maybe even break out the culture war material into its own article:

I've suggested Puberty blockers political controversy as a name for this. The "Legal and political challenges" section from this article would probably be a good place to start.

In particular, we should be careful not to conflate reasonable disagreement within the medical community with the political agendas of culture warriors on each side, something which is made more difficult by the appropriation of the former by the latter. — The Anome (talk) 12:11, 20 April 2024 (UTC)

I agree. I think it may be beneficial to create a separate article for puberty blockers in trans minors in general (sth along the lines of Puberty blockers in transgender healthcare), because most of the article is now about their application in gender-affirming medicine, instead of summarising this and the other uses they currently have. Cixous (talk) 18:11, 20 April 2024 (UTC)

I think you mean well but I believe that would be highly likely to turn into a WP:POVFORK, and even if not just means two difficult pages to deal with instead of one. Here's how: One article would contain only MEDRS and have a balance of POVs that reflects the views of different medical bodies around the world, whereas the other would, over time, get loaded up with newspaper and magazine thinkpieces, disproportionately from Americans, and reflecting mostly just the views of American journalists, and new ones constantly being written every time some American state proposes some legislation or other.

Better too to keep the amount of 'culture war' text under control. It's sufficient to say what the LGBT advocates say and why they say it, and same for the other side, with some detail to mention legal status by location, but not with excessive detail or falling into the trap of re-reporting the same reactions in every state. To be NPOV, all of this should be closely contextualized with the MEDRS in the same article, and vice versa. Crossroads ^-talk- 23:32, 20 April 2024 (UTC)

The political aspects of the topic are intertwined with the medical and scientific aspects, so a split would probably act to de-contextualize the two from each other. It would be better to keep this as an article primarily about the medical treatment, and keep a lid on the political statements with reference to WP:NOTEVERYTHING. Barnards.tar.gz (talk) 10:03, 21 April 2024 (UTC)