Talk:Puberty blocker - Misplaced Pages

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Vaginoplasty

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

Systematic reviews

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

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

Puberty blockers:

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

"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.

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."

"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."

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 "

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, 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

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

"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. 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) , or are so well known internationally for transphobia that they're often referred to as 'TERF Island', or a whose medical apparatus has listed trans people as 'an epidemic' , 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.

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.

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. 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 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 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.

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

One in Norway.

Three in Sweden.

Two in Finland.

And four in France.

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° 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, here's an article listing even more reviews and studies saying so. 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. 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

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° 16:30, 21 March 2024 (UTC)

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° 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° 08:30, 22 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. Silver seren 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. Silver seren 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)

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 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:

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 Misplaced Pages 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 Misplaced Pages:Fringe theories when no higher-quality alternatives are available. WhatamIdoing (talk) 17:35, 19 March 2024 (UTC)

References

https://www.jclinepi.com/article/S0895-4356(10)00332-X/fulltext#:~:text=Although%20higher%20quality%20evidence%20is,lead%20to%20a%20strong%20recommendation.&text=Waldman%20R.J.

Science based medicine

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

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

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

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

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

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

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

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

Neither of you are providing a compelling reason why readers should not be informed that a FOIA act about the authors was denied.

SEGM & co are undeniably WP:FRINGE. SBM are known for reporting on FRINGE groups, so raising concerns they were involved is well within their established wheelhouse in terms of our sourcing policy.

And, to be clear, as with all sourcing on Misplaced Pages, context matters. If we would not treat a review by the Russian equivalent of NICE finding homosexuality to be infectious or etc to be infallible, then we shouldn't give a lot of weight to a review by anonymous authors criticized by leading international professional groups from a country a Council of Europe report found to have a human rights problem due mass vilification of trans people, rising anti-trans sentiment, and rollbacks and attacks on transgender civil liberties due to the rise in power of the gender-critical movement. The United Kingdom's abyssal treatment of trans people is internationally considered WP:FRINGE.

So please, 1) why should the fact the authors are anonymous be considered "medical information" instead of "non-medical information" as explicitly permitted by WP:MEDRS? And 2) why should the United Kingdom's recognized issues with trans rights and legislative capture not be taken into account when assessing evidence quality? Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 21:03, 17 March 2024 (UTC)

I'm begging editors to please stop inserting WP:FRINGE into every discussion on this talk page. None of these topics are covered by WP:FRINGE because as this very article attests there's no consensus from high quality research or organizational bodies. If somebody starts trying to put in sentences about homeopathic puberty blocking "drugs" then that would be covered by WP:FRINGE. This topic on the other hand is something where there are competing mainstream views with differing mainstream proponents and rationales, not one where the obvious answer has been found. XeCyranium (talk) 00:48, 18 March 2024 (UTC)

WP:FRINGE does not mean "pseudoscience". That's a common misconception. WP:FRINGE covers anything that's outside of the mainstream of its academic field. This of course includes pseudoscience, but it also explicitly includes questionable science and alternative theoretical formulations.

Despite the Council in Europe report and the NICE study, it's still pretty clear that the consensus of the field is set by WPATH. International medical organizations with guidance on this follow WPATH, as do American ones and Australian ones (as well as, frankly, still most of Europe.) The WHO doesn't have guidelines out yet but just looking at the panel of people they assembled to make their guidelines, they pretty clearly think WPATH is at least credible. And if the consensus of the field is set by WPATH, that would leave SEGM as very firmly WP:FRINGE. if your defense is just that some Europeans question the consensus, that's still WP:FRINGE. Loki (talk) 06:47, 18 March 2024 (UTC)

Why are you talking about SEGM? This is about:

- A top-of-the-pyramid MEDRS source (a systematic review by a highly respected institution)

- Which has been reinforced by a second, more recent systematic review, in Germany, in 2024

- Being "balanced" with a 2021 blogpost, which insinuates with no evidence whatsoever that because an FOI request for personal information made by GenderGP was legitimately refused - as confirmed on two appeals - the NICE review *might* have had people the author doesn't approve of associated with it in some unspecified way.

NICE are not fringe. The Cass review is not fringe. The NHS service specifications are not fringe. A German systematic review is not fringe. WPATH is not fringe. None of these are fringe.

some Europeans question the consensus, that's still WP:FRINGE

Fringe does not just mean "anyone who disagrees with WPATH", nor does it mean "anyone who disagrees with NICE", nor does it mean a significant minority position in a global debate over standards of care and evidence in the medical community.

The constant claims that completely mainstream sources are fringe in talks in these areas are way off base, can we please move on. Void if removed (talk) 10:31, 18 March 2024 (UTC)

Why are you talking about SEGM? That's who the source is referring to. SBM is known to be a RS on FRINGE groups. They list SEGM and the ADF, known FRINGE groups, as examples of fake experts who may have been involved due to the refusal of the FOI request. Again, is a FOI request for the authors was refused "medical information" or "non-medical information"? Because your MEDRS argument only applies if we use the source to comment on the former, not the latter as this does. To clarify, I'm mostly ambivalent though leaning towards include on "SBM stated xyz about this" due to their RSP status, but here I am referring solely to information about the FOI.

a systematic review by a highly respected institution - did you mean a systematic review by a quasi-governmental institution in a country that has received international criticism for it's treatment of trans people and lack of healthcare provided them? Because you haven't addressed my question about the UK's track record...

In that linked discussion and the original one it referred to, consensus found "Gender Exploratory Therapy" (a rebranding of conversion therapy, funny enough pushed by Genspect and SEGM & co) was, in fact, fringe (so not way off base). As I recall you left walls of text saying it wasn't fringe largely due to a progress update on a review you kept insisting should be treated with the weight of an actual review. That being said, please focus on the discussion at hand instead of bringing up (and misinterpreting) old ones.

We can't work towards consensus if you refuse to engage with my points, so I'll ask again:

1) why is "a FOI request was refused" "medical information" requiring MEDRS comparisons as opposed to "non-medical information" as is explicitly permitted by WP:MEDRS? By your argument it seems you think we can only mention that if a systematic review does

2) does the fact the UK have a recognized human rights problem with respect to trans healthcare and civil rights factor into this discussion, and if it doesn't, why not?

Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 17:09, 18 March 2024 (UTC)

1a) The "a FOI request was refused" sentence had the effect of poisoning the well of a MEDRS source, using a non-MEDRS source as justification. The way to challenge the credibility of a MEDRS source is with another MEDRS source.

1b) The suggestion that a MEDRS source should be discounted/downgraded/undermined because someone may have been involved (despite there being no evidence for this), is literally a conspiracy theory.

2) This is more well poisoning, and is far removed from the point when the conclusions of the UK study have been re-affirmed and strengthened by a German study. Does Germany also have a recognized human rights problem with respect to trans healthcare and civil rights? Barnards.tar.gz (talk) 12:13, 19 March 2024 (UTC)

To answer your second question: no, the country of origin of the researching body doesn't in any way have an impact on the quality of the research, said body is independent and exceedingly reputable when it comes to medical research. XeCyranium (talk) 01:32, 20 March 2024 (UTC)

I'd strongly disagree with the idea that consensus in an actively researched field is "set by" an organization through decree. Invoking WP:FRINGE as that editor did to argue against the use of high quality sources is improper, because things which are still actively researched and debated in mainstream science aren't even "alternative theoretical formulations", they're simply unsettled questions. XeCyranium (talk) 01:23, 20 March 2024 (UTC)

Editors really need to stop invoking WP:FRINGE to describe medical views on the use of puberty blockers in children that they disagree with. This very article lists several European countries, all free liberal democracies, who have decided the evidence is lacking and to take a more cautious approach than before, to varying degrees. This is absolutely not fringe, while we are talking about such countries, whose collective populations are over 100 million people. Indeed, the degree to which the USA is an outlier globally may be worth examining, never mind breaking the USA into states as it is not homogeneous in its approach.

This is not MMR autism fraud or weaponised Covid genetically designed to kill non-Chinese, which is what WP:FRINGE is for. And this isn't just a political controversy. Real genuine doctors and scientists disagree on what's best. We need to report that accurately. This is not Twitter. -- Colin° 08:53, 20 March 2024 (UTC)

You again are talking about WP:FRINGE as if it's synonymous with pseudoscience. While this is a common misconception, it clearly is a misconception just from the text of the guideline, which explicitly states that alternative theoretical formulations are WP:FRINGE.

The clear majority view worldwide is that of WPATH. WPATH is not an American organization, it's an international organization. The (large) majority of national medical bodies endorse its conclusion. There are some who disagree, but they are currently a clear minority internationally, and therefore are currently still WP:FRINGE. Loki (talk) 20:01, 20 March 2024 (UTC)

And again, you are misunderstanding what "alternative theoretical formulations" means, which is frustrating given it has a pretty clear definition in the link you posted but I can only assume you didn't read. A set of organizations publishing research on the effectiveness of a set of drugs in treating certain conditions and coming to different conclusions isn't an alternative theory or model. Medical consensus is not set by WPATH declaring support for a procedure, nor is it even set by a majority headcount of organizations that offer support. This isn't climate change or dinosaurs or tectonic plates; the science really is not settled, as every study cited in this article makes clear in their own words. Insisting that your preferred conclusion should be treated as sacrosanct and others as WP:FRINGE isn't in line with the reality of the situation. XeCyranium (talk) 22:27, 20 March 2024 (UTC)

WP:FRINGE full title is Misplaced Pages:Fringe theories. The idea that puberty blockers have limited and low quality evidence to support their use is entirely mainstream. The very sources cited in this article that to support a view they should be used all admit, as any evidence based medical scientist is forced to do, that the evidence base is weak. This is indisputable. There's nothing fringe about that at all.

Some bodies recommend their use, despite this low quality evidence, because in their judgement, the limited evidence is persuasive to them, combined with their own clinical experience and expert opinion (which is the very bottom of the evidence pyramid pictured on MEDRS). Some other bodies take a view that their use be restricted, sometimes heavily. There are plenty European countries that have taken this restrictive approach and they all do so in their own way. That the UK does it one way and France another and Norway another doesn't magically make the UK or France or Norway into some kind of lunatic fringe that Misplaced Pages cannot mention. Nor does it mean the core of this article should pretend to our readers that it is universally agreed that puberty blockers be used in trans children. There is disagreement on how and when to use them and that those on the various cautious ends of that spectrum are not FRINGE. Repeatedly using the WP:FRINGE tag in this matter is disruptive. -- Colin° 10:08, 21 March 2024 (UTC)

I note the above discussion contains efforts by to discredit National Institute for Health and Care Excellence (NICE) because the UK is TERF Island or some such and everyone in this island is clearly mad and should be ignored as a source of anything trans on Misplaced Pages. NICE is at the very very top of the MEDRS "ideal source" pyramid. Like any institution, it can be imperfect and sometimes one finds a review is older than one would prefer. But it is the very kind of thing MEDRS bangs on about when people try to discredit a top line source with lesser ones. Per WP:RIGHTGREATWRONGS we cannot as editors just go around dismissing the very best of reliabe source because we find its conclusions disagreeable or are hugely prejudiced against an entire nation. If one has a problem with what NICE concluded, write to NICE, write to your MP, write a blog, but Misplaced Pages cannot shift it from being top tier because trans politics.

Oh, and per my comments below, NICE is for England and Wales. The Scots have Scottish Intercollegiate Guideline Network (SIGN). -- Colin° 15:24, 19 March 2024 (UTC)

No one is saying that a reviewer being British makes them unreliable, they’re saying that the government of the United Kingdom, and especially England (which NICE is a part of), has a specific history towards trans people, and that that’s worth thinking about when considering a source; and it feels telling that you would reduce this valid criticism to a bigoted assault on the British people as a whole at the behest of what you call “trans politics” Snokalok (talk) 05:01, 20 March 2024 (UTC)

Every country has a specific history towards every marginalized group within that country.

Colin is correct that the process for evaluating sources (at least wrt to Misplaced Pages:Biomedical information) is to evaluate the source first on objective criteria, and not primarily on whether the source got the right answer according to Misplaced Pages editors. If, having reviewed all of the nominally reliable sources (or a representative subset thereof), it turns out that NICE's view is a minority viewpoint, then that's fine; follow the WP:YESPOV policy for handling that viewpoint. But don't try to say that it's unreliable, because it's not. WhatamIdoing (talk) 05:06, 20 March 2024 (UTC)

It doesn't take a detective to realize that some editors here prefer the conclusions of WPATH and are arguing for discounting other sources based on that preference. XeCyranium (talk) 22:30, 20 March 2024 (UTC)

Sure, but that's going to be true for every subject. We each believe our considered views to be rational, so whatever we believe is (as far as we're concerned) close enough to correct that it must be The Truth™. It doesn't matter whether the subject is drug treatments for trans people or how to teach reading to children or the best kind of smartphone. The reason we have to have an NPOV policy in the first place is because it's very hard for humans to differentiate between "thing I personally believe" and "what reliable sources say". WhatamIdoing (talk) 23:14, 20 March 2024 (UTC)

Luckily I am a perfect arbiter of neutrality at all times. But seriously I think the issue is that reliable sources in this case disagree, so it's easy to pick a preferred conclusion. Really we should just present that they disagree. XeCyranium (talk) 16:55, 21 March 2024 (UTC)

Glancing through the discussion above, it appears that the problem is that editors are complaining about "reliability" when they ought to be talking about WP:Due weight.

I recently used this list of the main MEDRS points to show the process of evaluating a source that you want to use to support Misplaced Pages:Biomedical information, and I paste it below with some notes in case it might be useful to editors here.

WP:MEDPRI: What type of source is it (e.g., case study, clinical trial, review article, legally binding practice guideline, etc.)?
WP:MEDSCI: Is it published in a peer-reviewed medical journal? Is the journal's main topic area relevant? Is the publisher reputable? Is the journal listed in MEDLINE and/or otherwise reputable? What does https://www.scopus.com/sources say about its relative ranking? There is No magic number for impact factors, but anything below 1.0 might prompt further investigation. If it is not a journal article, is it a typical med school textbook like Harrison's Principles of Internal Medicine? A respected reference work (e.g., a drug handbook, a guide to lab procedures)? An major national or international body (e.g., WHO, NICE, NIH, AMA, APA, WPATH, etc.)?
WP:MEDASSESS: Is it "high-level evidence, such as systematic reviews"? If it is a medical guideline or a position statement by internationally or nationally recognized expert bodies, does it provide information about the levels of evidence, or is it just conventional wisdom?
WP:MEDDATE: Is it less than five years old? Some older sources might be useful, but you should use up-to-date sources.
WP:MEDINVITRO: Does it rely on pre-clinical/non-human research?
WP:MEDINDY: Does the source have a conflict of interest (e.g., funded by the drug's manufacturer) that would make it not be an Misplaced Pages:Independent source?

But mostly I think the task here is to say that different sources have differing views, and to describe those views. WhatamIdoing (talk) 05:02, 20 March 2024 (UTC)

References

"Conclusions Not So NICE: A Critical Analysis of the NICE Evidence review of puberty blockers for children and adolescents with gender dysphoria". Science-Based Medicine.

United Kingdom

I'm not sure about the wisdom of a United Kingdom section because, despite what the text currently says, there isn't, today, a "British" NHS. For some time now, NHS in Scotland and in Wales have been devolved. The latest ruling about banning puberty blockers in children (outside of clinical trials) is for NHS England alone. The first paragraph is now out of date, due to the ban, though the NHS Wales website has text very similar to what was claimed for NHS England. The NHS England text is quite different now, due to the ban. I haven't been able to find an equivalent text for NHS Scotland. This article in the Scotsman emphasises how different Scotland is, in that they think a ban unlikely at present. -- Colin° 08:51, 19 March 2024 (UTC)

Overall article structure

This article doesn't follow the suggested form at Misplaced Pages: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° 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° 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° 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)

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)

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)

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)

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: XeCyranium (talk) 01:06, 24 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)

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 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)

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