Talk:Puberty blocker

Change to lede

This is going to be a contentious topic and probably has been discussed on this page before, but I propose mentioning the fact that several systematic reviews have failed to find conclusive evidence about the potential psychosocial impact of puberty blockers. Mentioning that rising scepticism in the field of medicine has made puberty suppression the subject of public controversy is vague and doesn't do justice to the reasons why this is the case. Therefore, I propose adding at least a sentence along the following lines: Several systematic reviews failed to find conclusive evidence that puberty suppression improves psychosocial health in transgender adolescents. We may like to add reasons why this is the case (e.g., due to small sample sizes, heterogeneity of results, unreported data etc.), but at least some mention of the current research status in the lede is necessary for the balance of this article.

PS: I'll leave discussing whether or not we should make a distiniction on the basis of consensus-based and evidence-based support for puberty blockers up to others. Cixous (talk) 15:00, 12 July 2024 (UTC)

Yes it has been discussed a lot - see eg. http://en.wiki.x.io/wiki/Talk:Puberty_blocker/Archive_4#Cass_Review

I agree that this needs mentioning in the lede. Void if removed (talk) 15:23, 12 July 2024 (UTC)

Thanks for linking the previous discussion! I think there is enough of a case to mention it in the lede. We have Taylor et al. (2024) and Ludvigsson et al. (2023) who, broadly speaking, come to the same conclusion. Their findings aren't great news either - the Endocrine Society guideline from 2017 stated that there was low quality evidence for puberty suppression (p. 3 for those interested).

I'll give others some time to react as well, but if there's no major objection, I'll add it to the lede. Cixous (talk) 17:35, 12 July 2024 (UTC)

Yes, this is due - and overdue. The consensus-based vs evidence-based distinction seems close to the truth of the matter, but I’m not sure if RSes frame it that way Barnards.tar.gz (talk) 18:12, 12 July 2024 (UTC)

On the consensus-based vs evidence-based distinction: the best explanation thus far I've found is in the BMJ podcast episode with Hillary Cass, though I don't think this is the best source out there. It's a less than ideal situation, not in the least because being consensus-based is a tendentious claim that the medical organisations in question deny. Cixous (talk) 18:34, 12 July 2024 (UTC)

I would support a change to the lead that gives us a weightier summary of §Research status. I'd prefer to more closely match the section's language with something like "Several systematic reviews found that evidence of the effectiveness of puberty suppression in transgender adolescents is low in quality. As for the rest of the section, maybe something like "Critics of the reviews' methodology have said that high-quality evidence like randomized controlled trials would be unethical to obtain."? Firefangledfeathers (talk / contribs) 18:32, 12 July 2024 (UTC)

I wouldn't go for 'effectiveness', but stick closer to what the actual research articles are saying, i.e. 'psychosocial outcome' and/or 'cognitive effects'. After all, puberty suppression is effective when it comes to just that - puberty suppression. Phrasing it as a matter of effectiveness hopelessly obfuscates the matter. Lastly, I support adding a few sentences on critics, though I'm skeptical of 'randomised controlled trials' as proper criticism. No one is actually proposing giving one cohort of trans kids puberty blockers and others a placebo to see if mental health improves for the simple reason that this would never get past an ethics committee. Cixous (talk) 18:41, 12 July 2024 (UTC)

I prefer to go WP:LEADFOLLOWSBODY. Do you think the body needs to be adjusted, since it also mentions RCTs? You've sort of landed on the main point of the criticism there, since the upper tier is (at least according to the cited sources) reserved for RCTs. If I grade you on a 6 point scale but we all agree it would be unethical for you to get a 6, we probably haven't selected the best scale. Good point on effectiveness. How about "Several systematic reviews found that evidence supporting the use of puberty suppression in transgender adolescents is low in quality."? Firefangledfeathers (talk / contribs) 18:45, 12 July 2024 (UTC)

I understand where you're coming from, but I'd like to be as specific as possible here. A proper systematic review only synthesises high- or moderate-quality evidence, so stating that they found the evidence was 'low' is not what they did. If anything, it'd be appropriate to state the evidence was weak. As the most recent (and AFAIK only; could have gone into sexual development as well, but I forgot about that) specifically mention psychosocial outcomes and cognitive effects, I'd stick to being precise about that. That being said, I'm okay with writing things differently if that's what the majority of editors want.

On the adjusting of the body: I think the entire article could benefit from some rewriting (I'd even go as far as removing the entire 'political challenges' section, as it's practically geared to a US context). Discussions about RCTs have their place, but I think this criticism is missing the point. As Ludvigsson et al. (2023, p. 2288) points out: However, controlled trials do not necessarily require placebo treatment, but could for example build on the date or time of starting hormonal therapy to generate comparison group (i.e., controlled trials do not mean you have to deny participants endocrinological interventions). Cixous (talk) 19:02, 12 July 2024 (UTC)

Didn't the reviews synthesize high- or moderate-quality studies, but still find the evidence to be of low quality? Firefangledfeathers (talk / contribs) 19:14, 12 July 2024 (UTC)

You could phrase it that way, though I usually stick to high/low-quality studies and weak/strong evidence. That being said, I don't believe there's a right or wrong here. Cixous (talk) 20:12, 12 July 2024 (UTC)

Re choosing the right scale - we value RCTs because of their ability to distinguish the treatment effects from the placebo effect. If a treatment cannot be subjected to a RCT, that doesn’t mean the treatment gets an automatic pass - it means there is an upper bound to the certainty we can obtain. It’s possible that someone will figure out a way to do an ethical RCT for this treatment, and it’s possible that someone will find some other way to reject the null hypothesis. It’s also possible that we can’t find such alternatives, and only weaker evidence is attainable, in which case that upper bound on certainty would remain.

I am reminded of string theory - an attractive idea that has proven resistant to empirical testing. We might believe it to be impossible to test. If that were the case, the right stance would be to treat it as a provisional or tentative or hypothetical theory - with low certainty. The wrong stance would be to use a weaker form of empiricism (e.g. simulation), and treat the claim as true because it passed the weaker test. Barnards.tar.gz (talk) 19:22, 12 July 2024 (UTC)

That makes sense, though I wouldn't have said anyone's asking for a free pass, just a better measurement tool. To be clear, I don't think we need to hash it out. If we want to summarize the criticism present in the body, this seems like one chunk that gets enough weight for a lead mention. Firefangledfeathers (talk / contribs) 19:33, 12 July 2024 (UTC)

I'm fine with mentioning it in the lede, but we should make sure that it isn't presented as an argument against the systematic reviews. After all, the systematic reviews (especially Taylor et al.) do no object to the absence of RTCs, but to the absence of high-quality evidence with homogenous results. Cixous (talk) 20:15, 12 July 2024 (UTC)

Aren't the sources we're citing presenting this as an argument against the systematic reviews? Firefangledfeathers (talk / contribs) 20:49, 12 July 2024 (UTC)

I believe the current article represents it's sources somewhat ambiguously. The statement The use of puberty blockers for gender-affirming care has attracted some criticism, due primarily to the lack of randomized controlled trials within the research base doesn't reference any sources that criticise the lack of RTCs, but sources that state the use of RTCs is unethical. It would be more logical to phrase that as Scientists regard randomized controlled trials as unethical for testing the efficacy of puberty blockers. Again, I'd like to point out that this is a completely normal, even redundant thing to say, because an ethics committee would never approve of an RCT in this case. That doesn't automatically mean that you can't do controlled studies (i.e., including an untreated comparator group, such as adolescents on a waiting list/pre-post studies where you compare a treated group with patients who got to a clinic for their first meeting/non-gender dysphoric adolescents of the same age and/or social background). The NICE review (p. 45-46) actually criticised earlier studies for their lack of comparators while stating that RTCs may well be unfeasible.

The other major source for the Research status section is Cal Horton's analysis. Without going into major detail about their stance against the GRADE approach used by NICE, it is important to note that they criticise the NICE Review and the Interim report of the Cass Review, and not the commissioned systematic reviews. While the NICE reviews evidence for the purpose of healthcare recommendations, it is not a systematic review (as in, a meta-analysis).

So, to finally answer your question, the sources do not present it as an argument against the systematic reviews, but (a) they're somewhat unfortunately represented in the body, and (b) most of what they're saying isn't actually super revolutionary or even necessary. No one is actually saying (barring the nitwits at SEGM, obviously) that we should use RTCs, not even the systematic reviews. As a result, I don't feel mentioning criticism of emphasis on RTCs is a right move at all, because the systematic reviews aren't doing that and the sources critising RTCs do not pertain to these. Cixous (talk) 14:29, 13 July 2024 (UTC)

While the NICE reviews evidence for the purpose of healthcare recommendations, it is not a systematic review (as in, a meta-analysis).

The two NICE reviews were systematic reviews, and Zepf et al (2023) was a further update, following the same methodology but with more recent papers.

The whole RCT thing seems like a big red herring anyway - we know that the York systematic reviews found some moderate to high quality evidence, so this is not an insurmountable bar and nobody AFAIK is actually suggesting they're a requirement. Void if removed (talk) 15:44, 13 July 2024 (UTC)

Ahh, thanks for the clarification! I always thought that the NICE Reviews were reviews that were somewhat less strict than systematic reviews. You're also right about the RCT thing. Nobody is actually requesting this (not even the NICE Review). Cixous (talk) 15:48, 13 July 2024 (UTC)

You seem to have missed that the reviews contain explicit criticism of current research not meeting "double blind" levels of testing. -- Cdjp1 (talk) 21:26, 24 July 2024 (UTC)

Could you perhaps point me to a source that criticises the current research base for not being double blinded? AFAIK, it hasn't been the focus of criticism at all. The Cass Review mentions double-blinded RTCs as a gold standard, but does not state that they should or should not be used in studies on puberty suppression (p. 48-51). Taylor et al. (2024) makes no mention of double-blinded studies or RTCs at all. Ludvigsson et al. (2023, p. 2288) mentions randomised control trials, but sheers away from the use of a placebo and also notes that the research population is "highly vulnerable", but also doesn't mention double-blinded studies as a necessity. Cixous (talk) 15:17, 25 July 2024 (UTC)

I would support mentioning this if contextualized properly, something like Systemic reviews have found puberty suppression improves psychosocial functioning with a low certainty but noted that could be evidence it is effective in preventing dysphoria and associated mental health conditions from worsening due to incongruent puberty.

The research status section says the NICE review says it is plausible, however, that a lack of difference in scores from baseline to follow-up is the effect of GnRH analogues in children and adolescents with gender dysphoria, in whom the development of secondary sexual characteristics might be expected to be associated with an increased impact on gender dysphoria, depression, anxiety, anger and distress over time without treatment. That specific conclusion was reiterated in the subsequent reviews cited. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 21:28, 12 July 2024 (UTC)

I'm all for contextualisation, but could you perhaps point me to where this specific conclusion was reiterated in Taylor et al. (2024) or Ludvigsson et al. (2023)? Cixous (talk) 14:30, 13 July 2024 (UTC)

Meant to say "review" - Zepf et al[1] say: Overall, based on the results of the previous studies presented here and discussed here, there is no solid evidence that GD in particular and mental health in general improve with the administration of PB and CSH in minors. An alternative and equally important interpretation for those affected could nevertheless be that an unchanged experience of GD and body (dis)satisfaction after PB administration already represents a relative treatment success: PB administration could possibly lead to a further clinical deterioration. by blocking the development of secondary sexual characteristics, which is experienced as stressful.

But regarding the other two:

Ludvigsson et al 2023[2] said Psychosocial and mental health Table 2 outlines the six studies that examined psychosocial outcomes and cognitive effects.14–19 Three of these studies found significantly improved overall psychosocial function after GnRHa treatment as measured by the Children's Global Assessment Scale (CGAS).14–16 Two of these studies observed no statistically significant change in gender dysphoria.15,16 Two of these studies reported significantly improved self-rated quality of life after treatment measured through Kidscreen-27, Short Form-8 (SF-8), Child Behaviour Checklist (CBCL) (parent report), and Youth Self Report (YSR),16,17 while another study reported no statistically significant differences in anxiety and depression between those who started and not started hormone therapy.18 Because these studies were hampered by small number of participants and substantial risk of selection bias, the long-term effects of hormone treatment on psychosocial health could not be evaluated.

Taylor et al[3]: Regarding psychological health, one recent systematic review14 reported some evidence of benefit while others have not. The results in this review found no consistent evidence of benefit. Inclusion of only moderate- quality to high-quality studies may explain this difference, as 8 of the 12 studies reporting psychological outcomes were rated as low-quality

My two main concerns are

1. we contextualize that reviews are divided on how much weight to give the evidence. Some found "PBs improve mental health", other found "PBs don't seem to improve mental health / we're not super sure" - the dividing line being how much weight they give the low-quality evidence (and in medicine, low-quality evidence doesn't mean a treatment shouldn't be offered) - but nobody is in disagreement the underlying studies show mental health improvements.
2. We note "this keeps psychosocial health stable" could be evidence it's working by stopping worsening stress from an incongruent puberty as noted in the NICE review and Zepf et al

Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 23:14, 13 July 2024 (UTC)

Systemic reviews have found… It would be misleading to frame the systematic reviews as having any positive finding. The key takeaway from all of these reviews is what they all agree on and all emphasise: the non-finding of conclusive or high-quality evidence. The it is plausible sentence you have quoted from NICE is only part of a passage which exists to outline that the range of uncertainty is great enough that it encompasses the possibility of positive effects. This is by no means an endorsement that the treatment improves psychosocial functioning with a low certainty. Barnards.tar.gz (talk) 09:33, 14 July 2024 (UTC)

Taylor et al[4]: Regarding psychological health, one recent systematic review14 reported some evidence of benefit while others have not

Equally important to the non-finding of conclusive or high-quality evidence is the finding of inconclusive or low-quality evidence.

Reviews say the evidence is inconclusive or weakly points towards benefits. We should reflect that. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 16:18, 15 July 2024 (UTC)

You are cherry picking positive-sounding studies and ignoring the actual conclusions of the papers you are citing. Proper weight should reflect the actual conclusions of the systematic reviews, to whit:

Zepf et al: Conclusions: The currently available studies on the use of PB and CSH in minors with GD have significant conceptual and methodological flaws. The available evidence on the use of PB and CSH in minors with GD is very limited and based on only a few studies with small numbers, and these studies have problematic methodology and quality. There also is a lack of adequate and meaningful long-term studies. Current evidence doesn’t suggest that GD symptoms and mental health significantly improve when PB or CSH are used in minors with GD. Psychotherapeutic interventions to address and reduce the experienced burden can become relevant in children and adolescents with GD. If the decision to use PB and/or CSH is made on an individual case-by-case basis and after a complete and thorough mental health assessment, potential treatment of possibly co-occurring mental health problems as well as after a thoroughly conducted and carefully executed individual risk-benefit evaluation, doing so as part of clinical studies or research projects, as currently done in England, can be of value in terms of generation of new research data.

Ludvigsson et al 2023: Results: In 21 studies, adolescents were given gonadotropin-releasing hormone analogues (GnRHa) treatment. In three studies, cross-sex hormone treatment (CSHT) was given without previous GnRHa treatment. No randomised controlled trials were identified. The few longitudinal observational studies were hampered by small numbers and high attrition rates. Hence, the long-term effects of hormone therapy on psychosocial health could not be evaluated. Concerning bone health, GnRHa treatment delays bone maturation and bone mineral density gain, which, however, was found to partially recover during CSHT when studied at age 22 years. Conclusion: Evidence to assess the effects of hormone treatment on the above fields in children with gender dysphoria is insufficient. To improve future research, we present the GENDHOR checklist, a checklist for studies in gender dysphoria.

Taylor et al: Conclusions There is a lack of high-quality research assessing puberty suppression in adolescents experiencing gender dysphoria/incongruence. No conclusions can be drawn about the impact on gender dysphoria, mental and psychosocial health or cognitive development. Bone health and height may be compromised during treatment. More recent studies published since April 2022 until January 2024 also support the conclusions of this review.

Your quote from Zepf omits the final sentence of the paragraph, which reads (modulo Google Translate): However, a control group would have been required to prove this possible effect of PB administration discussed here, so that such an interpretation can currently only be of a speculative nature. You are cherry-picking the part of the paragraph which makes it look like they found and endorsed a positive finding, but the final sentence makes it clear that they are (as with the NICE example I mentioned earlier) actually just illustrating the wide range of uncertainty, and that any positive finding would be speculative. It would be a gross misrepresentation of this study to falsely balance the headline conclusion of "significant conceptual and methodological flaws" with speculation.

None of these review papers see fit to mention the possibility of positive findings, even as low-quality findings, in their conclusions. The isolated low-quality studies are not "equally important" to the conclusion. It would therefore be a misrepresentation of research status to summarise as "evidence is inconclusive or weakly points towards benefits".

As something of an aside, I think a major conceptual flaw in play here is the idea that lots of low-quality evidence can add up to high-quality evidence. It's true that there are multiple studies purporting to show benefit. These are the ones that entities like WPATH like to point to to justify themselves as evidence-based. But it's just not true. All of those positive-sounding results - every single one of them - is completely consistent with a placebo effect. Particularly when the benefits are hard or impossible to measure objectively, the placebo effect can be very strong. These patients are getting treatment, and they're getting what they want, and they're getting the thing that they've been told will improve their lives. This is a perfect storm of placebo effect! It's actually remarkable that the studies showing marginally-positive benefits are only showing marginally-positive benefits. Under these conditions, results should be through the roof! That we only have low-quality studies weakly pointing to marginal benefits is damning with faint praise. Barnards.tar.gz (talk) 10:20, 20 July 2024 (UTC)

This debate is nonsense. The purpose of puberty blockers is not to cure gender dysphoria. The purpose of puberty blockers is to delay puberty so that transgender children, their parents, and their physicians have more time to decide if hormone therapy is appropriate. They are just a delay tactic since we know that puberty blockers are (more or less) safe for children, as we've been treating children with puberty blockers since the 1950s for precocious puberty (which isn't true for hormone therapy). No one cares if puberty blockers have a "positive effect" on gender dysphoria, depression, anxiety, anger or distress, as that is not what they are used for, so why are we talking about that? What people care about is: Do they successfully delay puberty? Are they safe? Do they have negative side effects? Those are the things we should include in the lead. Anything else is political propaganda. Nosferattus (talk) 14:19, 15 July 2024 (UTC)

See Cass p173-180 for a discussion of the various intended benefits of using puberty blockers. It’s not just “time to think”. It is reasonable to assess the evidence for whether or not the intended benefits are achieved. Barnards.tar.gz (talk) 15:59, 15 July 2024 (UTC)

Taylor et al[5]:

1. Rationales for puberty suppression in the Dutch treatment protocol, which has informed practice internationally, were to

1. alleviate worsening gender dysphoria,
2. allow time for gender exploration, and
3. pause development of secondary sex characteristics to make passing in the desired gender role easier.6

1. Practice guidelines propose other indications for puberty suppression, including

1. allowing time and/or capacity for decision-making about masculinising or feminising hormone interventions, (which is really just 1.2 repeated another way)
2. and improving quality of life. 4 7 8

Absolutely none of those contradicts Nosferattus's statement.

It is reasonable to assess the evidence for whether or not the intended benefits are achieved. - the intended benefit is delaying puberty so you're not forcing a kid through an incongruent puberty as you deny them hormones. It is not to cure their GD and not a single source says it does.

What people care about is: Do they successfully delay puberty? - this 100%. If we're going to toss in some reviews say it keeps mental health stable, others say it improves it, others say it inconclusively improves it - then we've got to include the note that GD is known to worsen due to incongruent puberty. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 17:27, 15 July 2024 (UTC)

I’m with Nosferattus’ point, puberty blockers don’t exist to make things better, they exist to keep things from getting worse. Expecting otherwise is placing undue onus on them that HRT is more responsible for. Snokalok (talk) 17:51, 20 July 2024 (UTC)

You’re describing a benefit of the treatment. The systematic reviews are clear that there is no high quality evidence that this benefit exists. To be clear, this doesn’t mean the benefit definitely doesn’t or absolutely can’t exist - it just means there is no high quality evidence for it. To return this thread to @Cixous’s starting point:- this lack of high quality evidence is the reason why some countries are going cold on the treatment, and it does our readers a disservice to be vague about this. Barnards.tar.gz (talk) 19:40, 20 July 2024 (UTC)

Are you saying there is no high quality evidence that puberty blockers delay puberty? Nosferattus (talk) 02:41, 21 July 2024 (UTC)

No, there is no dispute that puberty blockers do delay puberty. The dispute is over whether this delay constitutes a benefit. Barnards.tar.gz (talk) 07:12, 21 July 2024 (UTC)

As previously discussed, per best available MEDRS there is no clearly agreed rationale for this treatment, so the standard by which it is deemed a "success" is also unclear. Void if removed (talk) 07:51, 21 July 2024 (UTC)

Thanks for bringing back the discussion to its actual topic, @Barnards.tar.gz. I suggest adding the sentence I initially proposed (see above). If anyone feels like more contextualisation is necessary, they can start a new/different discussion about that. For now, a clear vote in favour of or against mentioning the findings of the review would be great.

PS: sorry for the late reply. My laptop sadly crashed :/ Cixous (talk) 17:08, 23 July 2024 (UTC)

My vote would be against as it misleadingly implies that puberty suppression is intended to improve psychosocial health in transgender adolescents (rather than simply a means to delay the use of transgender hormone therapy). Nosferattus (talk) 21:39, 23 July 2024 (UTC)

Perhaps Several systematic reviews failed to find conclusive evidence that puberty suppression benefits transgender adolescents would be better? Barnards.tar.gz (talk) 08:20, 24 July 2024 (UTC)

I'm not disputing that puberty suppression was (partially) intended for assuring gender dysphoria would not worsen, but it has an impact on associated symptoms (e.g., depressive symptoms, anger/anxiety issues etc.). Part of what made puberty suppression so appealing was its positive, reductive effect on associated symptoms [1]. As someone else pointed out, a point of controversy arose when GIDS was unable to replicate these findings about psychosocial health and gender dysphoria.

Gauging psychosocial health is standard in clinical trials focusing on puberty suppression, because it tells researchers whether or not their rationale (not worsen psychological stress) actually works even when gender dysphoria remains at the same level. To call a focus on psychosocial health a misleading implication, seriously misses the point of what studies have been measuring over the past decade.

@Barnards.tar.gz: I'm not sure how to feel about your compromise. I'd like to stay as close to the source as possible and be as clear as possible, so I'd rather say psychosocial health and unclear effects on gender dysphoria when the sources state that. Cixous (talk) 14:09, 24 July 2024 (UTC)

@Cixous: Your suggested wording doesn't say "not worsen"; it says "improves". And if we're talking about not worsening, the reviews support the conclusion that puberty blockers (or at least GnRH analogues) do not worsen gender dysphoria, anger, or anxiety, and there is low quality evidence that it may reduce depression. Here's what the NICE review says specifically in its Results section:[6]

• Impact on gender dysphoria: This study provides very low certainty evidence that treatment with GnRH analogues, before starting gender-affirming hormones, does not affect gender dysphoria.
• Impact on mental health: depression: This study provides very low certainty evidence that treatment with GnRH analogues, before starting gender-affirming hormones, may reduce depression.
• Impact on mental health: anger: This study provides very low certainty evidence that treatment with GnRH analogues, before starting gender-affirming hormones, does not affect anger.
• Impact on mental health: anxiety: This study provides very low certainty evidence that treatment with GnRH analogues, before starting gender-affirming hormones, does not affect levels of anxiety.

So if you really want to "stay as close to the source as possible", how about: Systematic reviews have found that puberty suppression in transgender children and adolescents, prior to starting gender-affirming hormones, has no significant effect on gender dysphoria, anger, or anxiety, but it may reduce depression. Nosferattus (talk) 03:38, 25 July 2024 (UTC)

That's a fair point. Do you have any references from the York review and/or Ludvigsson et al. that support that puberty suppression may reduce depression? If so, I'm fine with the way you prhase it. Cixous (talk) 14:54, 25 July 2024 (UTC)

Taylor et al says:

No conclusions can be drawn about the effect on gender-related outcomes, psychological and psychosocial health, cognitive development or fertility.

Void if removed (talk) 15:22, 25 July 2024 (UTC)

Thanks Void! I propose the following: As of 2024, several systematic reviews have failed to find significant changes in psychosocial health and levels of gender dysphoria. Long-term effects on fertility and cognitive development remain unknown. Cixous (talk) 15:30, 25 July 2024 (UTC)

That seems like a decent summary for the lead. Maybe we should start an Efficacy section in the body for more detailed discussion. Nosferattus (talk) 01:03, 26 July 2024 (UTC)

Thank you! I'll give users some time to object to it, but if there is no objection, I'll add it tomorrow. I also agree that an efficacy section is due. Maybe it can be a subsection of a (rewritten) research status section?

PS: I think the lede may benefit from further clarification on the divergent reasons of US states versus European countries being more cautious about puberty suppression. I remember a European Academy of Paediatrics policy statement going briefly into this a few months ago. This addition is another discussion though, that we may want to get into after adding this text into the lede. Cixous (talk) 17:48, 26 July 2024 (UTC)

This fails precision, so it would immediately get a Template:Quantify tagged on it. How many systemic reviews were there that concluded this specific outcome? Were there others other than the Cass Review? Raladic (talk) 18:01, 26 July 2024 (UTC)

From the top of my head: the NICE Review, Taylor et al. (2024), Ludvigsson et al. (2023). I'm not sure if Zepf et al. (2023) goes into long-term effects, but it reaffirms the NICE Review conclusions. Cixous (talk) 18:07, 26 July 2024 (UTC)

So then we should potentially say three, not several if it's clear all 3 concluded the exact same thing. The lead has to summarize what the article body says, but currently the Puberty blocker#Research status section only discusses the NICE review in detail with a by-sentence of the Cass review having a "similar" conclusion, which isn't the same as the very specific conclusion that the sentence implies, so instead it would have to be softened since the sentence implies that all of them concluded the very strongly worded same conclusion.

The proposed sentence also leaves out the criticism from notable other trans medical organizations, such as WPATH, so it would fail WP:NPOV by only summarizing one side, without the other. Raladic (talk) 18:15, 26 July 2024 (UTC)

I'm fine with adding a sentence on WPATH, but I feel we should try to steer away from bothsideism. It is completely fine to mention the WPATH stance on this, but we shouldn't make it seem as if reaffirming that the evidence pool is actually high-quality makes a systematic review redundant. I think the best way we can go here is to highlight a disagreement between evidence-based and consensus-based evidence aggregation.

PS: It actually makes 4 systematic reviews then, not 3.

PS: Sorry for the late reply. I seem to have gotten myself involved into a series of unfortunate events. Cixous (talk) 07:48, 4 August 2024 (UTC)

I'm currently traveling, so I can't research it myself, but I'm curious what the other reviews (besides NICE) have to say about depression. Nosferattus (talk) 18:29, 26 July 2024 (UTC)

It looks like Taylor et al consider the evidence on depression to be "moderate" rather than high quality. Thus they ultimately dismiss it in the conclusions. Ludvigsson et al. combine the various studies for statistical analysis and find no significant difference in the combined data. Since NICE and Taylor et al do actually report evidence of significant changes regarding depression, just not high quality evidence, I think we might have to add a caveat to any lead summary (similar to Cixous's original proposal), i.e. … systematic reviews have failed to find conclusive evidence of significant changes in psychosocial health …. Nosferattus (talk) 00:34, 28 July 2024 (UTC)

That would be nice actually. It does not mean that the desired effects of puberty blockers do not exist, but simply that it can't be deduced from the current evidence base. Would the originial proposal I made do? Cixous (talk) 07:51, 4 August 2024 (UTC)

No, as I mentioned before there are problems with the framing, for example, "failed to find" rather than "did not find" and "improves" rather than "significantly changes". Also, I don't think it makes sense in the lead. It should be added to the "Gender dysphoria" section to provide balance with statements about systematic reviews that did find positive effects on psychosocial health, e.g. Rew et al. If we put it in the lead it makes the article sound contradictory: the lead and the "Gender dysphoria" sections would say opposite things since they are talking about different reviews with different conclusions. We need to flesh out the information in the article body before we add more content to the lead, IMO. Nosferattus (talk) 23:46, 4 August 2024 (UTC)

I get where you're coming from adn we can meet each other at the middle in this case. I'm also all for adding a (more detailed) discussion of the reviews to the 'gender dysphoria'/'research status' section, but I still think including it in the lede is warranted considering multiple systematic reviews have come to more or less the same conclusions. Perhaps a joint approach is an idea (i.e., adding info to the 'gender dysphoria' section and the lede simultaneously)?

PS: Could you please link Rew et al.? Haven't read that one :). Cixous (talk) 17:51, 6 August 2024 (UTC)

Rew et al. is available on Sci-Hub, but the spam blacklist won't allow me to link to Sci-Hub. The more I read all these reviews, the more it seems apparent that the main difference is how high the review sets the bar for evidence. Hopefully we can explain that in the text so that it doesn't sound like these reviews are just contradicting each other. Nosferattus (talk) 18:53, 7 August 2024 (UTC)

(sorry for the late reply ://).

Yeah, I agree with giving weight to different systematic reviews in the body. I do not deny a focus on the body is ideal, but I believe that there is consensus to justify mentioning the research status in the lede. Cixous (talk) 09:09, 23 August 2024 (UTC)

• @Cixous @Barnards.tar.gz @Nosferattus Uninvolved editor here...

Before you all continue: I had to rollback to a May 12th version of the article due to copyright violations. Also be aware: there are going to be students working on this article soon.⸺RandomStaplers 05:43, 25 July 2024 (UTC)

Peer reviews from Group #6

Question 1. Do the group’s edits substantially improve the article as described in the Wikipedia peer review “Guiding framework”?

The group did a great job discussing the role of puberty blockers in individuals with precocious puberty and expanding on medical consensus in other countries. The lead is well executed but does contain information on medical boards specific to America and Australia. I would recommend including information on international guidelines, since country specific guidelines are expanded later on. The sections are organized in a chronological order. As part of the “Guiding Framework” and the group’s goals, I agree with adding information on underrepresented populations. The content is also well written and easy to read. A. Shahbazi1 (talk) 03:24, 30 July 2024 (UTC)

The article is very comprehensive and provides a lot of details regarding the subject, not just medical information but also social implications around the subject. Although the article is heavily focused on the political environment in America of puberty blockers, the article also provides the guidelines around the world regarding the use of puberty blockers, which helps to provide a more holistic view. Cbtrinh (talk) 23:41, 29 July 2024 (UTC)

The group provided an in-depth explanation of puberty blockers and the numerous ways they can affect/ impact individuals. The article references guidelines from international medical organizations, which provides insight into the consensus and findings regarding puberty blockers. In addition, the article incorporates information from multiple credible sources around the world. This allows readers to gain a better understanding from different perspectives and see how different countries have approached the research. Dphan2 (talk) 04:32, 30 July 2024 (UTC)

I think the group discusses the role of puberty blockers in individuals with precocious puberty well and also improves upon the worldwide view by including organizations outside of the United States that supply the medications. The additional information for precocious puberty is useful for those experiencing it. The additional information about other companies that produce around the world improves accessibility for individuals looking to Wikipedia across the globe. They also added some information about mechanisms of action to help supplement neutral, scientific information. The group does a great job overall, adding in much-needed scientific information and additional sources. Htran2026 (talk) 05:30, 30 July 2024 (UTC)

The article provides a comprehensive overview of puberty blockers, their various uses, and the risks/benefits of their use. The addition of drug names and suppliers around the globe could greatly improve accessibility and education for people seeking more information of the various medications available. There is a heavy focus on the controversy over the use of puberty blockers in the United States, and although links are provided for organizations across the globe, a quick summary of arguments from both sides could be helpful. Ybramos (talk) 20:11, 30 July 2024 (UTC)

Question 2. Has the group achieved its overall goals for improvement?'

While the team has expanded on precocious puberty and medical consensus in other countries, I believe there is room to add additional information based off the goals they have listed. It appears that long term data is limited, but the group can add information on whether there are any ongoing trials to assess long term effects. In addition, it is hard to follow the political challenges section. I am unsure of which countries are being mentioned here aside from the U.S. The section could be divided into smaller categories like the medical organizations section. A. Shahbazi1 (talk) 03:24, 30 July 2024 (UTC)

The team has added a section about the different medication classes of puberty blockers and provided examples of these medications by name. I think a basic mechanism of action should be provided for each of the drug classes for clarity on how each drug class differs from each other. Otherwise, I think the group achieved most of their goals for improvement. Cbtrinh (talk) 23:49, 29 July 2024 (UTC)

The article is very informative and has met several of the goals listed above; however, there is room for improvement, as not all goals have been fully met. For example, it would be helpful if the article included infographics to help readers better understand the mechanism behind agonism and antagonism. In addition, I agree that more information regarding the different types of puberty blockers would be beneficial for readers to understand the difference between their mechanism of action and functions. Dphan2 (talk) 04:59, 30 July 2024 (UTC)

The group completed some of their proposed edits to the articles including adding drug names, indications for use, and safety and efficacy profiles of these medications. An area of improvement would be to include mechanism of action and adverse effects for each type of puberty blocker, and when one type of puberty blocker could be considered over another. One of the proposed edits was to add a Health Disparities section, which would have been a great addition to this article. Ybramos (talk) 20:11, 30 July 2024 (UTC)

The group achieved some of the overall goals for their project. They added in worldwide sources, including companies from outside the US. They also added in information about new antagonists and linked specific drug names. They also added in information about precocius puberty blockers, which was also helpful. They're missing more development on health disparities and mechanisms of actions. Overall, I think they achieved most of their goals. Htran2026 (talk) 22:25, 30 July 2024 (UTC)

Question 3A: Does the draft submission reflect a neutral point of view?

I believe the legal status and political challenges can be reworded to have a more neutral tone. For example, instead of saying "some opponents...", the phrase can be reworded to say "an argument can be made that..." Otherwise, I think the first half of the article does reflect a neutral point of view. Cbtrinh (talk) 23:55, 29 July 2024 (UTC)

The draft reflects a neutral point of view in the sense that it includes information from various sources globally. It is very transparent regarding the research/ lack of research conducted. Dphan2 (talk) 05:36, 30 July 2024 (UTC)

Question 3B: Are the claims included verifiable with cited secondary sources that are freely available?

Based on what the team added, most of the sources are secondary and freely available. In the precocious puberty section, citations 20, 21, and 22 back up the paraphrased information in the article. Source 20 was published in 2008 and is outdated; however, the source is only used to describe a mechanism. Sources 23 and 24 are a bit outdated and do describe treatments; I would confirm there is no additional updates from more current sources. Sources 24 and 26 appear to be primary sources as they are pilot studies. I would recommend finding a secondary source if available. A. Shahbazi1 (talk) 19:50, 29 July 2024 (UTC)

Question 3C: Are the edits formatted consistent with Wikipedia’s manual of style?

The article displays clear headings and a lead section that briefly states what the article will cover. However, some headings could be used and may be helpful in organizing information such as Contraindications, Adverse effects, Drug interactions, Mechanism of action, Manufacturing, Society and culture (which may include: Legal status, Economics, Brand names), and Research. Citations and references are appropriately added and consistent. Ybramos (talk) 20:48, 30 July 2024 (UTC)

Question 3D: Do the edits reflect language that supports diversity, equity, and inclusion?

Overall, the article is written in a way that does not seem to exclude any populations or groups of people. With that said, the use of the word "patient" does make it sound like people who seek to use puberty blockers are needing them to "fix" a medical issue, which is not always the case. Replacing the word "patient" with "individual" or "person" could reduce the negativity associated with the use of these medications. Another possible area for improvement is to use Layman's terms rather than medical jargon to make the article easier for anyone to understand. People with little to no knowledge of puberty blockers being able to read and understand the article is a good way to improve awareness and education on the subject. Ybramos (talk) 20:31, 30 July 2024 (UTC)

I think the edits do reflect language that supports diversity, equity, and inclusion. They use terms within their sections that I thought were inclusive. Many of the other edits were strictly informative, i.e., drug companies, drug names, chemicals, or mechanisms. With precocius blockers, I thought they used exclusively inclusive language, like "individuals" or "persons," and only used categorical words when reference another study that used that terminology. Areas of improvement would be to make it more lay-language. It can be difficult to read, so increasing accessibility in this way would be great. Htran2026 (talk) 22:48, 30 July 2024 (UTC)

Change to lead - banking the above discussion

Now that the hiccup of the major deletion is over (see [copyright problem removed]) and it would be a shame for all that constructive discussion to not be reflected in the page.

I will add now based on the consensus above in July:

• "As of 2024, several systematic reviews have failed to find conclusive evidence of significant changes in psychosocial health and levels of gender dysphoria. Long-term effects on fertility and cognitive development remain unknown"Peckedagain (talk) 12:05, 17 August 2024 (UTC)

Does the lead give too much focus to organisations who support it, (especially USA ones), than a balanced summary should? [I edited] to express the spread of views: "on one hand.... on the other' but that [was reverted] by Crossroads.

I will try another phrasing, and see what you think.Peckedagain (talk) 12:05, 17 August 2024 (UTC)

This page is out of date and has numerous glaring inaccuracies

I have been making small steps to improve this page the last few days -and in the process have realised the page is a much bigger problem than I first realised.

The Cass Review page has benefited from many editors reviewing the latest state of play around gender dysphoria: and not least about puberty blockers.

The latest Cass page states that in the last 6 months the state of art has changed radically re blockers:

• the UK has banned them for both state health care and private health care
• "the evidence base,...had already been shown to be weak... continues to be a lack of high-quality evidence"
• "the lack of evidence means no conclusions can be made regarding the impact on gender dysphoria and mental health, but did find evidence of bone health being compromised during treatment"
• "The review disagreed with the idea of puberty blockers providing youth patients with "time to think""
• most international guideines "were said to lack editorial independence and developmental rigour, and were nearly all influenced by the 2009 Endocrine Society guideline and the 2012 WPATH guideline, which were themselves closely linked. The Cass review questioned the guidelines' reliability"

And debate on the Cass page agreed that the Review's view that the evidence as weak was not due to the lack of RCTs (randomized controlled trials )

And yet this page has much content that contradicts the above:

• "The use of puberty blockers for gender-affirming care has attracted some criticism, due primarily to the lack of randomized controlled trials within the research base" -
• "Puberty blockers are intended to allow patients more time to solidify their gender identity...the medication can be stopped, allowing puberty to proceed."
• "The statement was made that the treatment was fully reversible, "
• "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."
• "Puberty blockers are associated with such positive outcomes as decreased suicidality in adulthood, improved affect and psychological functioning, and improved social life.
• "Puberty blockers have clearly beneficial, lifesaving impacts on a scale of up to six years,
• "WPATH... declared puberty-blocking medication to be medically necessary ... because longitudinal data shows improved outcomes for transgender patients who receive them"
• "In the short term, they are generally considered safe and well-tolerated by most individuals."

In addition the page contains:

• unscientific evidence: from 2010 of just one person (The longest follow-up study followed a transgender man...)
• As I flagged up above - a whole paragraph given to a mere activist: Cal Horton.

Weasel words

• "National Institute for Health and Care Excellence ....evidence for puberty blocker outcomes... was of very low .. but that it was plausible that the outcomes would have been worse without treatment"

Poor sources:

• URLS that no longer exist, and the body that publish them no longer has any page at all about PBs (St Louis hospital)
• WebMD - a non-authoritatve source, whose page paints a rosy-eyed view of PBs
• "A 2019 study found that a "multidisciplinary approach" is necessary" - but the source includes now discredited claims 'a physically reversible option to suspend sex hormone production, reduce the anxiety of ongoing physical development and allow further space for psychotherapeutic intervention and exploration." https://adc.bmj.com/content/103/7/631

What is the best way ahead -

1. delete 80%, and copy back the Cass Review content that is much higher quality
2. incremental changes?
3. any other approach?

Peckedagain (talk) 14:42, 17 August 2024 (UTC)

@Peckedagain I'm a bit confused here about what issues you have with this page. It wouldn't make sense to ignore a large proportion of research in favour of the Cass Review. Also this page is about puberty blockers, not the Cass review. It might be helpful for you to add cleanup tags to the areas you believe need work instead of trying to fix the page all by yourself, this way you can discuss with other editors what actions should be taken. CursedWithTheAbilityToDoTheMath (talk) 00:26, 18 August 2024 (UTC)

HI @CursedWithTheAbilityToDoTheMath

> "I'm a bit confused here about what issues you have with this page"

Well , I listed them. I'm not advocating "to ignore a large proportion of research in favour of the Cass Review." The Cass review page is more recent than much on this page, and has had alot of editor discussion to come up with an agreed authoritative view on issues, not least puberty blockers. So much of this page here has been superceded by the Cass page content. Yet this page remains unchanged -and therefore wrong.

I can't see any reason why this page should be left as a 'fossil' when other wiki pages (Cass page) contain more accurate and uptodate content that this page directly contradicts? But maybe you can think of a reason? Peckedagain (talk) 01:11, 18 August 2024 (UTC)

And that is the core of where you are not quite right.

The government of one nation has issued a review for use of policies in that country. That is the purpose of the Cass Review, not more, not less. The worldwide consensus is not in line with the UK's conclusion (as has been shown by the worldwide response by various national and international health organizations to the Cass Review, criticizing it) and we represent the global worldview on Wikipedia, not that of one country. So the swathing editing of global articles to one country's narrow view is generally not WP:DUE. Raladic (talk) 01:20, 18 August 2024 (UTC)

@Peckedagain I highly suggest you check out Wikipedia:Recentism. Just because information is newer does not mean it trumps other information. Again, I think you're getting the scope of this article confused. This article is not about the Cass review; it's about puberty blockers. These two topics are not the same and therefore do not deserve to have content that is nearly the same. An agreed upon consensus for the Cass review page does not automatically transfer over to other pages. I also think it's important to consider WP:DUE here. The UK does not represent the whole world, and therefore we should not be generalizing one country's findings to apply to the rest of the world. CursedWithTheAbilityToDoTheMath (talk) 01:26, 18 August 2024 (UTC)

I agree with Raladic and CWTATDTM. The Cass Review is only one study, and a fairly controversial one at that. We should not overhaul this page over the result of one study. Loki (talk) 02:04, 18 August 2024 (UTC)

The Cass Review is just one of numerous systematic reviews of puberty blockers. Why would it trump all the others? Plus most of the points you mention are already discussed in the article, although I have no idea what this one means: "The review disagreed with the idea of puberty blockers providing youth patients with "time to think"". Perhaps you could elaborate. Nosferattus (talk) 02:03, 19 August 2024 (UTC)

As I replied to you a month ago, linking an earlier discussion from May with citations, Taylor et al found no singular rationale, ie that we cannot simply say they provide "time to think" as that is neither clearly what they do, nor clearly why they are given.

The Cass Review does not "trump all the others" - it concurs with them. The York review into puberty blockers simply confirmed what every other systematic review has found, with AFAICT the sole exception of Baker et al (2021), which the York reviews suggest found differently because it included low-quality evidence, which all the other reviews filtered out. Void if removed (talk) 08:22, 19 August 2024 (UTC)

You're also forgetting about Rew et al. which found "good" and "excellent" quality positive benefits. It seems at least some of the reviews, e.g. Taylor et al., exclude "moderate quality" evidence, for example, of puberty blockers' effect on depression, not just low quality evidence, so it's a bit more complicated. I don't understand your argument about puberty blockers not providing time. That is clearly the rationale for treating transgender children with puberty blockers, and we cite MEDRS sources that say that (and could cite more). Do you have a citation that contradicts this? If so, what does it say specifically? Nosferattus (talk) 13:37, 19 August 2024 (UTC)

some of the reviews, e.g. Taylor et al., exclude "moderate quality" evidence

This is false, Taylor et al included moderate evidence.

Do you have a citation that contradicts this?

This is now the third time I've responded to this request. Please see the link I have already provided, which will lead you to the relevant quote and citation from Taylor et al. Void if removed (talk) 14:23, 19 August 2024 (UTC)

In the Taylor et al. results it says that the de Vries study showed "moderate" quality evidence for "reduction in depressive symptoms", yet the entirety of their Conclusions section is "There are no high-quality studies using an appropriate study design that assess outcomes of puberty suppression in adolescents experiencing gender dysphoria/incongruence. No conclusions can be drawn about the effect on gender-related outcomes, psychological and psychosocial health, cognitive development or fertility. Bone health and height may be compromised during treatment. High-quality research and agreement on the core outcomes of puberty suppression are needed." Depression is certainly an aspect of psychological and psychosocial health, so it seems they excluded it from their conclusions because it is only "moderate" quality. Should our article discuss their results in detail or only their final conclusion? Nosferattus (talk) 16:09, 19 August 2024 (UTC)

The quote you cite definitely doesn't contradict "the idea of puberty blockers providing youth patients with 'time to think'". It just claims there is disagreement about what the primary aims of puberty blockers are. There is nothing there negating 'time to think' as an aim of treatment. In fact, your own quote says that the Dutch protocol gives "allow time for gender exploration" as a rationale. Personally, though, I think 'time to think' is a bit overblown, as the vast majority of children that take puberty blockers for gender dysphoria go on to hormone therapy later. I think the real purpose of puberty blockers is to simply block puberty (and thus keep gender dysphoria from getting worse as discussed in the NICE Review) and to delay hormone therapy. Nosferattus (talk) 16:06, 19 August 2024 (UTC)

Here's what the lede says:

Puberty blockers are used to delay the development of unwanted secondary sex characteristics in transgender children, so as to allow transgender youth more time to explore their gender identity.

That is a strong and singular claim of purpose: blockers are given for time to explore.

What does taylor et al say?

Rationales for puberty suppression in the Dutch treatment protocol, which has informed practice internationally, were to alleviate worsening gender dysphoria, allow time for gender exploration, and pause development of secondary sex characteristics to make passing in the desired gender role easier. Practice guidelines propose other indications for puberty suppression, including allowing time and/or capacity for decision-making about masculinising or feminising hormone interventions, and improving quality of life.

That's 4 or 5 different reasons there, from improved mental health to better cosmetic outcomes. Do you think the statement in the lede is a wholly accurate rendition of this MEDRS? I don't. I think there are multiple reasons, not just simply "time to think/explore", and according to Taylor et al this is partly why the evidence base is so poor - there's no clearly agreed reason, therefore no clearly agreed measure of success. Void if removed (talk) 09:15, 20 August 2024 (UTC)

It is not a matter of ignoring the majority of the research - it is about assessing what the highest quality MEDRS say - and the systematic reviews commissioned by Cass are highest quality MEDRS, and they concur with other systematic reviews. What we should not be doing is highlighting individual papers or findings to present an overly-confident picture, when higher quality MEDRS in the form of systematic reviews do not do so. These are the best quality synthesis of the available data, and WP:RECENTISM doesn't really apply here. York et al came out in April. Zepf et al was February this year. This is not breaking news, this is the most recent, most thorough, best-quality MEDRS superceding what came before.

Amazingly, we give less space to the NICE review, Zepf et al and Taylor et al than we do to one activist/researcher's opinions on the NICE review. This is severely imbalanced. Void if removed (talk) 09:08, 19 August 2024 (UTC)

So would you support removing the part in the current article about puberty blockers' effect on IQ? It is only mentioned in a single review and is based on a single study that was described as poor quality evidence by the review. Nosferattus (talk) 13:44, 19 August 2024 (UTC)

I would phrase it in line with Taylor et al, ie:

No conclusions can be drawn about the effect on gender-related outcomes, psychological and psychosocial health, cognitive development or fertility. Bone health and height may be compromised during treatment. High-quality research and agreement on the core outcomes of puberty suppression are needed.

And I think this level of summary should be in the lede. Void if removed (talk) 14:27, 19 August 2024 (UTC)

I'm glad we agree that poor quality evidence should be excluded from the article. What about "moderate" or "good" quality evidence (according to review evaluations)? Nosferattus (talk) 16:19, 19 August 2024 (UTC)

I ask you to revert your last change, as your edit comment completely misrepresents this discussion. Void if removed (talk) 17:02, 19 August 2024 (UTC)

I'm sorry if I misunderstood your response to my question. Just to clarify, do you think the "Neurological effects" section should include the "poor quality" evidence about effects on IQ, or do you think it should only include the statement from Taylor et al that "No conclusions can be drawn about the effect on ... cognitive development", as it does now? I thought your response above meant you just wanted the Taylor et al conclusion in that section, as you said "I would phrase it in line with Taylor et al". Nosferattus (talk) 19:26, 19 August 2024 (UTC)

What you've done is remove a link to a different systematic review that incorporates animal studies and finds cognitive impacts. I think that review should stay, but worded better, to clarify that it is a systematic review of animal studies (significantly, the only one). I think that the prior wording is misleading - "poor" is being taken out of context, and the focus on "IQ" misses that the IQ studies were a minority of those considered. The complexity and sex-specificity of the impact and lack of reversibility are all notable, and removing this systematic review entirely is unjustified. I would suggest reinstating and rephrasing as:

A 2024 systematic review which incorporated animal studies found some evidence of sex-specific impact on cognitive function in mammals, and no evidence that cognitive effects were fully reversible. Void if removed (talk) 09:26, 20 August 2024 (UTC)

It's not a great review. Published in 2024 in an open source journal, and using animal studies seems like a bit poor usage.

Could possibly still be WP:PRIMARY and be removed based on that. Bluethricecreamman (talk) 23:20, 21 August 2024 (UTC)

I've put this content back in now, with the wording above. Void if removed (talk) 09:36, 21 August 2024 (UTC)

I'm not implying that there isn't issues with this current page, I haven't looked at it enough to say there isn't. My main point is that this page isn't solely about the Cass review. I'm not educated enough on the topic to say much about the Cass review itself. CursedWithTheAbilityToDoTheMath (talk) 22:36, 19 August 2024 (UTC)

Hi @CursedWithTheAbilityToDoTheMath

You're quite right - I think every editor here would agree that 'this page isn't solely about the Cass review.'.

So I guess we also would agree that where the Cass Review page has been thrashed out by editors of all persuasions and reached it's current state -that this PB page, which has had a lot less editing attention, would benefit from using the same editors-have-agreed-upon content from the cass page where that page covers blockers - and would be better than leaving this page containing content that on consensus was actually removed from Cass page. Peckedagain (talk) 23:07, 19 August 2024 (UTC)

I might not be understanding what you are trying to say here but again just because a consensus was reached at the Cass review talk page doesn't mean that translates over to this page. CursedWithTheAbilityToDoTheMath (talk) 00:56, 20 August 2024 (UTC)

I think doing WP:TNT like this would be horrible without broader discussion... If you are going to restart this page or large portions of it, it would warrant doing an AfD.

If you are going to do edits in a way that evolves this page, we can work through that much easier.

I am not quite certain if there is a significant failing of the PB page here tbh. Bluethricecreamman (talk) 21:11, 20 August 2024 (UTC)

A valid question was raised - PB should not be rewritten based on a single country's review content

Radalic on my Talk page wrote:

• "Also note that the re-write of the article based on a single country's review content as you tried to summarize is not WP:DUE"

The question was helpful, and for anyone else thinking the same, my answer was:

• But that is not what was being done. The Cass page , after consensus of editors on many sides, makes some statements that are universal and not limited to one country. Not least regards the lack of good evidence about the effectiveness of puberty blockers for those with gender dysphoria. The Cass review included all worldwide evidence: so that can't be minimised as 'just 1 country stuff'.
• The Blockers page contains some claims of universal truth that are contradicted in the cass page. Which had more Talk-page detailed discussion too.
• So it is only logical, to review the PB page: because the 2 pages do 100% contradict themselves in some of the claims of universal truth.
• Yes it is also true that where Cass is talking about specific 1-country stuff (eg what went wrong at UK clinics.... UK whisteblowers) that is not relevant to the PB page. We would both agree 100% on that, I guess. Peckedagain (talk) 00:00, 20 August 2024 (UTC)

There are at least eight systematic reviews about treatment with puberty blockers: Zepf et al, Ludvigsson et al, Taylor et al, Baker et al, Rew et al, Soliman et al, the Nice Review, and the Cass Review. Most of these are from the last 5 years and overlap in their primary source coverage. They have very different methodologies, however, and come to different conclusions. So yes, treating one of those reviews as the gospel is WP:UNDUE, especially when it is the review that has been the most heavily criticized and politicized. What we need is to distill the actual results from these various reviews, not just replace this page with content from the Cass Review page. Nosferattus (talk) 00:21, 20 August 2024 (UTC)

I haven't communicated my opinions very effectively on this topic in some of my previous replies but this was the point I was trying to make. CursedWithTheAbilityToDoTheMath (talk) 00:58, 20 August 2024 (UTC)

Also, people seem to keep forgetting that this article is about puberty blockers in general, not just puberty blockers for gender dysphoria. If anything needs to be added to the lead, it is discussion of treatment of precocious puberty with puberty blockers (which has been practiced since the 1950s). Right now this is just briefly mentioned in a single sentence. Nosferattus (talk) 01:23, 20 August 2024 (UTC)

@Nosferattus

• "What we need is to distill the actual results from these various reviews,"

But the Cass page did this already, why do it again? The Cass review itself included all worldwide evidence: and according to the Cass page is the newest, most thorough review of all the evidence.

• "especially when it is the review that has been the most heavily criticized and politicized.

It is entirely to be expected that the longest, deepest review would create the most criticism: because

A) it's global in it's review of the evidence and therefore it's findings are global: statements of universal truth (eg about puberty blockers) that are not just UK truths

B) it's findings were a shock to those how had followed the widespread opinion that there was (for example) good evidence that puberty blockers have proven mental health benefits for those with GD. The Cass page makes it clear - there is no such good evidence.

Alot of good faith work was done by many editors since the Cass came out in April. The task on this PB page is to 'build on the shoulders of giants' and bring it up to date: so that it no longer includes claims that contradict the Cass page and were specifically deleted from there because they are not founded: and the Talk page shows you the reasoning behind that editors concensus.

But of course, if something incorrect is spotted in the Cass page, take it to that page. But the Talk page shows that all of the page was laboured over: so there are unlikely to be criticisms of it , that have not already been responded to. Peckedagain (talk) 21:03, 20 August 2024 (UTC)

In fact: thinking further of (B): we must as editors be kind to our readers -and not feed contradictory statements on the two pages. we need to be kind to the many parents of GD children who have for years taken advise from the medical profession and whose children have used PBs and some had surgery. Because it is the biggest shock for them to read that there is no good evidence of mental heath benefit for the very invasive treatments their children had. Some of those children will have life long health complications: and out of empathy to those parents: that is the most heart breaking revelation. That they somehow cooperated in causing that lifelong harm to their own child. Many will find it hard to forgive themselves, for what they allowed to happen - even though in reality they could have done nothing different than take the advise of the medical experts they had.

So for those parents sake - let's not leave contradictory statements of fact about the evidence in the two pages. Peckedagain (talk) 21:14, 20 August 2024 (UTC)

Please read WP:SOAPBOX and WP:NPOV. CursedWithTheAbilityToDoTheMath (talk) 21:57, 20 August 2024 (UTC)

Your statements are transphobic and offensive. And what "life long health complications" are you talking about? Even the Cass Review doesn't make such ignorant unfounded claims. I hope you will take off your self-imposed blinders and take a look at some of the other sources. The Cass Review certainly doesn't "include all worldwide evidence" and is not "statements of universal truth". For starters, it only evaluated studies related to transgender children, and excluded all studies related to precocious puberty. So just like all the other reviews, it had a specific scope and that scope is not the same as the scope of this article. Nosferattus (talk) 22:11, 20 August 2024 (UTC)

I would also like to add that no research article contains "statements of universal truth", the medical field is constantly evolving and research is only ever a reflection of what evidence we have today. CursedWithTheAbilityToDoTheMath (talk) 22:27, 20 August 2024 (UTC)

@CursedWithTheAbilityToDoTheMath you are 100% correct: 'statements of universal truth' was shorthand for

• things that apply universally - ie to all countries not just the home country of the review
• things that true to the best of our knowledge - but we may change them in the future when new evidence comes along.

Peckedagain (talk) 22:42, 20 August 2024 (UTC)

@Nosferattus

So what worldwide evidence did the Cass Review not include? There is nothing on the Cass page about missing evidence, or have I missed something there?

If you read the Talk page this has all been covered a couple months back: with the input of highly experienced MEDRS wiki editors. The Cass page says: "The review concluded that the lack of evidence means no conclusions can be made regarding the impact on gender dysphoria and mental health, but did find evidence of bone health being compromised during treatment." - that is not a UK-specific statement but a universal one, isn't it?

> Your statements are transphobic and offensive.

That was 100% not my intention, I apologize if my words hurt your feelings. Please point out where I did that, so I can understand your perspective and avoid doing it again.

> life long health complications

The Cass page says under 'Recommendations': "NHS England should ensure there are proper detransitioning services available'. I understand that for those people, there can be complications. Cass says for hormone therapy: "found insufficient and inconsistent evidence regarding physical risks". A quick google found this paper, I don't know if its a strong one or not: "Current limited evidence from non-randomized studies suggests that transgender women taking GAHT have increased risks of myocardial infarction, ischemic stroke and VTE. The current evidence does not indicate increased cardiovascular risk in transgender men receiving GAHT." Peckedagain (talk) 22:36, 20 August 2024 (UTC)

Again the talk page for the Cass review does not translate over to all of Wikipedia. You made claims not backed in evidence. "I apologize if my words hurt your feelings" is not taking accountability. The user never claimed you hurt their feelings so I'm not sure where you are getting that. CursedWithTheAbilityToDoTheMath (talk) 22:41, 20 August 2024 (UTC)

@CursedWithTheAbilityToDoTheMath

I intended to invite Nosferatu to show me how I had been 'transphobic and offensive'. But I invite you too, to help clarify that: if you wish, whilst your online now. It's your choice, either way. Peckedagain (talk) 22:46, 20 August 2024 (UTC)

@CursedWithTheAbilityToDoTheMath

Also, could you expand on: "the Cass review does not translate over to all of Wikipedia." thx Peckedagain (talk) 22:47, 20 August 2024 (UTC)

Just because a consensus is reached on the talk page of one article doesn’t mean that said consensus should be applied to the rest of Wikipedia. Things that are relevant for one page may not be relevant on another. CursedWithTheAbilityToDoTheMath (talk) 22:57, 20 August 2024 (UTC)

@CursedWithTheAbilityToDoTheMath Again, I agree with you 100%. It is a truism. But in the specific context here: I had compared the two pages, and listed 10-20 places where they make contradictory statements of universal truth about the very same thing. That is bad for our readers isn't it? And relatively easy to work on: as the heavy-lifting to-n-froing debate in Cass talk can be referred to as the reason why Cass page has it's content: and compare the Talk on this page. If the Talk evidence here is superceded by or weaker than in the Cass page: then we can change this page to match Cass. Or vice versa.

Maybe there is a good reason not to do that process, but to leave up the glaring contradiction, but i can't think of one right no, can you? Peckedagain (talk) 23:24, 20 August 2024 (UTC)

Please read WP:NPOV and WP:TRUTH. Nosferattus (talk) 23:49, 20 August 2024 (UTC)

Hi @Nosferattus, I have read them -which specific part of them should I take note of: and regards to which words I wrote?

If your mean the Truth page is relevant because I used the phrase 'universal truth' - then yes i agree; the word truth was just common parlance and can be swapped, eg to

• 'scientific findings that have scientific applicability in all countries -until better findings, on better evidence, come long'

Regards NPOV - please do spell out my exact words you're thinking of. This is my second time of asking. Peckedagain (talk) 00:43, 21 August 2024 (UTC)

I can see that when I wrote:

• there is no good evidence of mental heath benefit for the very invasive treatments their children had

It would have been more neutral to have written:

• there is no good evidence of mental heath benefit for the Puberty Blockers their children had

Which is what the Cass page does say.

And regards

• life long health complications

The Cass page says that there is no good evidence to say Puberty Blockers do not have side effects. we all know that any medical intervention introduces new risk: it is never zero, but for some interventions can approach zero.

So would it be scientific to believe that a non-trivial intervention like PB, will mean that 100% of those using it will have no long term side effects for the rest of their lives? There is no evidence available today to support that claim.

Maybe you have a different view? But either way: stating these two things is not transphobic, is it? Isn't it just stating the data we have? It would be wonderful if the Cass page said that there was strong evidence of no side effects - due to the findings of the cass review. But it doesn't. Peckedagain (talk) 01:02, 21 August 2024 (UTC)

And as a precaution - if I suddenly go silent on this page and don't respond any more, it is because there is an arbitration against me, and a friendly editor has told me that I may get a 6 month ban. (I've only been on wiki a little over 6 months so far) Peckedagain (talk) 01:10, 21 August 2024 (UTC)

@Peckedagain: First, the Cass Review is not the most recent review. The evidence review phase of the Cass Review was conducted in 2020. The work between then and the final report focused on interviews with practitioners and evaluation of the UK's practices related to gender-affirming care for young people. Taylor et al., Zepf et al., and Ludvigsson et al. are all more recent as far as systematic reviews go, and include studies not considered by the Cass Review. (Taylor is about PBs, Ludvigsson is about PBs and hormone therapy, and Zepf is also about both.) As far as what evidence was excluded from Cass, the Cass Review's evaluation of puberty blockers did not include results that spanned both puberty blockers and hormone therapy (which is a valid choice, but one that was critisized by WPATH). It also didn't include any studies about treatment of precocious puberty with puberty blockers, as that was outside its scope (but is within the scope of this article). Nosferattus (talk) 23:30, 20 August 2024 (UTC)

@Nosferattus You are making claims that were made and discounted in the Cass page. Such as "The evidence review phase of the Cass Review was conducted in 2020" whereas Cass Review also included later studies than 2020. It would be helpful, to avoid all of us editors sitting through the same debate again: if for each concern you raise there, you could look in Cass Talk for the consensus there: and share that summary here: to explain why you think it is not sufficient. But actually, now I think about it - it sounds like you are talking here on PB but really it is the Cass page you think should be changed? Have I read that right?

Either way; it would be most helpful if you'd pull from Cass Talk and share here the summary of it, regards each of your issues below: as background to explaining why you think the reasoning there needs to be over-turned:

1. Cass Review is not the most recent review 'it was back in 2020'
2. "did not include studies that spanned both puberty blockers and hormone treatment (which is a valid choice, but one that was critisized by WPATH).
3. "excluded studies about treatment of precocious puberty with puberty blockers, as that was outside its scope"

Sorry if I sound impatient - but on the Cass page talk there was alot of circular debates where the same issues would come up, be shown to be unfounded and not wiki enough to be included: and then weeks later the same all over again, and again weeks later. Sometimes the same editor again. I'm sure you don't wish for that style of Talk, either. Peckedagain (talk) 23:53, 20 August 2024 (UTC)

OK, you're right, the evidence review, although conducted in 2020, was updated in April 2022 (according to the final report). But Taylor et al. is from 2024, Ludvigsson et al. is from 2023, and Zepf et al. is from 2023. So it still isn't the most up to date. Points #2 and #3 are not "issues", they are just examples of methodology and scope differences between Cass and other reviews. This is why reviews that seem to be analyzing the same topic can come to different conclusions. From Wikipedia's point of view, there is no "universal truth", there is only what reliable sources report. To quote WP:NPOV, Wikipedia must "fairly represent all significant viewpoints that have been published by reliable sources, in proportion to the prominence of each viewpoint in those sources." Nosferattus (talk) 01:15, 21 August 2024 (UTC)

Thanks for agreeing. Yes, I agree with you that my shorthand 'universal truth' meant 'reliable sources that report something scientific that is valid to all countries not just UK (because some editors kept suggesting that Cass findings on the effectiveness/safety of Puberty blockers only had relevance to the UK. which is obviously not a supportable stance, I'm sure you'd agree)

I will stay out of your mention of Taylor / Ludvigsson etc: as it seems you are in ongoing disagreement with another editor on that -and they have supplied helpful sources, so hopefully you two'll reach consensus shortly. Peckedagain (talk) 01:38, 21 August 2024 (UTC)

The Cass Review is not, itself, a systematic review. The Taylor et al 2024 review of puberty blockers is one of the systematic reviews commissioned by the Cass Review, and the one that informs the Cass Review's findings on puberty blockers. This: Taylor et al., Zepf et al., and Ludvigsson et al. are all more recent as far as systematic reviews go, and include studies not considered by the Cass Review. is completely wrong.

The relevant MEDRS for this page is Taylor et al 2024. Void if removed (talk) 09:42, 21 August 2024 (UTC)

For the interested, the full series of systematic reviews commissioned by Cass, which provide the peer-reviewed evidence that the Cass Review is based on, is here. The scope of Cass is far greater than simply blockers. While the discussions on the Cass Review page are interesting, and some aspects of Cass and its fallout in the medical community (especially in Europe) could be relevant here, consensus on one page does not translate to consensus on another.

IMO the biggest problem Cass raises for this page - which I raised on talk months ago - is how to weight WPATH and APA guidance after the York systematic reviews found their guidelines to be poor? Systematic reviews and medical body guidance are supposed to be in accord and equivalent MEDRS - but we have a disconnect, with equivalent MEDRS criticising each other. I don't see any of this reflected in the article. Instead we simply say eg. Puberty blockers have clearly beneficial, lifesaving impacts on a scale of up to six year and The World Professional Association for Transgender Health's Standards of Care 8, published in 2022, declared puberty-blocking medication to be medically necessary and recommends them for usage in transgender adolescents once the patient has reached Tanner stage 2 of development, because longitudinal data shows improved outcomes for transgender patients who receive them which I think is a significant misrepresentation of the difference of opinion in MEDRS. Void if removed (talk) 09:58, 21 August 2024 (UTC)

Yes, that describes succinctly biggest elephant in the room: WPATH / Cass being in contradiction to each other on PB and yet our PB page is silent on that. Peckedagain (talk) 10:28, 21 August 2024 (UTC)

Also, while I'm on here - Rew et al is given far too much importance. It comes to stronger conclusions than more recent reviews, despite being based on fewer papers and weaker evidence (and arguably employing weaker methodology). We derive the following very bold wikivoice claim directly from there: Puberty blockers have clearly beneficial, lifesaving impacts

No subsequent systematic review comes anywhere close to this, and this claim in Rew et al is derived from one paper - Turban 2020 - which is an analysis of self-reported survey data and so I cannot fathom how they arrived at the quality score they did. This is, IMO, seriously overstating the evidence. There's no way we should be stating this in wikivoice, and definitely not without at least counterbalancing it with the more recent, more comprehensive evidence stating no clear benefits. Void if removed (talk) 10:33, 21 August 2024 (UTC)

I agree that the article needs to address the differing conclusions from the different systematic reviews. This needs to be addressed in the article body first before we start making sweeping changes to the lead which just cause the article to be more self-contradictory. And we need to provide balance per WP:NPOV, not simply gut everything in the current article and replace it with conclusions from the Cass Review. It's also difficult to discuss these issues in good faith while editors are pushing transphobic tropes about puberty blockers being "invasive treatments" that cause "lifelong harm", etc. On a final note, I find it ironic that you criticize the methodology and quality scores from Rew et al. (which is original research), but then turn around and insert results into the article based on animal studies, which as WP:MEDRS warns, do not translate consistently into clinical effects in human beings. Nosferattus (talk) 01:11, 22 August 2024 (UTC)

while editors are pushing transphobic tropes about puberty blockers being "invasive treatments" that cause "lifelong harm", etc

In general, any wikipedia article uncritically pushing that without major asterisks is extremely transphobic and uninformative, and pushing to completely destroy this article with that in mind is WP:POVPUSHING in its most naked form.

The addition of a lit review making highly ungeneralizable claims based on animal studies seems especially problematic. Bluethricecreamman (talk) 01:46, 22 August 2024 (UTC)

Check the talk history - the balance issues have been discussed for months, at least since the release of Zepf et al. There are more recent, better reviews than Rew, and there's no good reason for the current imbalance. Nor is there a reason to give so much space to low quality negative opinion of the NICE review. The release of the York review in April simply adds weight to the existing argument for a rebalance towards less certainty. That's all.

The Baxendale systematic review included human and animal studies, this is not just a case of eg. chucking a single mouse study into an article about cancer and claiming some wonderdrug is a cure. This source is absolutely fine, and nowhere near overemphasised.

Also OR is allowed on talk pages, and the editor I believe you're complaining about has already been topic banned so there should be no difficulty discussing these issues now. Void if removed (talk) 07:53, 22 August 2024 (UTC)

If we're doing our own research on the soundness of these studies, the Baxendale paper is absymal, IMO. Since you can't give animals IQ tests, all of the animal research she evaluated assessed behaviors correlated to cognitive development, which she divided into 3 categories: "positive interactions with the environment" (including social interactions), "responses to stress", and "performance on cognitive tasks (maze tasks)". No consideration is given to whether confounding variables like changes in physical size, speed, strength, or hormone levels (which are all associated with puberty) might be biasing those results, as they are all based on physical or social activities (rather than strictly cognitive activities). And the one human study that she gives any credence to was an IQ study of 2 dozen southeast Asian girls that had precocious puberty and were all adopted into Dutch families. In that study the author explains that adopted children tend to have lower verbal and math IQ scores as well as behavioural and emotional problems, and that the decline in IQ scores "could be explained by the adoption status of the children" rather than the puberty blockers as he had no control group. (And why he chose such a confounding group as his study group is beyond me.) Baxendale makes absolutely no mention of this in her review, but remarks "it is noteworthy that at least one patient in this study experienced a significant loss of 15 [IQ] points". So Baxendale doesn't mention the unique confounding factor highlighted by the author, but does highlight a single outlier as "noteworthy". At best this is bad science, at worst, dishonest. She then goes on to discuss in detail another human IQ study that she admits had no baseline data and showed no statistically significant results. And regarding reversibility, Baxendale admits that only a single study on male sheep even addresses this topic. So yes, this is just as bad as declaring a cancer cure based on a mouse study, in my opinion. It's also remarkable how frank Baxendale is in her lengthy introduction about how this review was conducted in order to prove her preexisting hypotheses, which is normal in clinical studies, but strange for a systematic review. Nosferattus (talk) 19:39, 26 August 2024 (UTC)

And taking all that into account "Another 2024 systematic review, using both human and animal studies found some evidence of sex-specific impact on cognitive function in mammals, and no evidence that cognitive effects were fully reversible" is a fair, one-line and attributed assessment of this review, that does not give undue prominence to its results.

Whereas "Puberty blockers have clearly beneficial, lifesaving impacts on a scale of up to six years" is a strong, definitive wikivoice claim based on Rew et al. This latter is untenable IMO. Void if removed (talk) 08:41, 27 August 2024 (UTC)

Puberty blockers banned in the UK?

Right now both the lead and article body state that prescribing puberty blockers to patients under 18 in the UK is now "banned" except for clinical trials. In both cases this is cited to Wikipedia! According to the actual NHS policy document: "Puberty suppressing hormones (PSH) are not available as a routine commissioning treatment option for treatment of children and young people who have gender incongruence / gender dysphoria… We have concluded that there is not enough evidence to support the safety or clinical effectiveness of PSH to make the treatment routinely available at this time." This is hardly a "ban". According to the BBC, the new policy "will not allow them to be prescribed 'routinely' outside of a research trial, but that individual clinicians can still apply to have the drugs funded for patients on a case-by-case basis."[7] The policy document also doesn't mention anything about whether or not puberty blockers should be prescribed for other conditions such as precocious puberty. If anyone has suggestions for how this can be better worded, please chime in. Nosferattus (talk) 01:43, 20 August 2024 (UTC)

There is this primary one from gov.uk and this article is currently used on the Cass Review page for citing the ban itself, so we could probably add those two as sources for it. The wording by most (all?) sources I've seen definitely uses the term ban. Raladic (talk) 01:53, 20 August 2024 (UTC)

Ah so there is an actual ban, albeit a temporary ban (until September 3) that only covers gender dysphoria or incongruence. Nosferattus (talk) 01:57, 20 August 2024 (UTC)

It won't be temporary, the new goverment that just took over confirmed it will be permanent - article on that here. Raladic (talk) 02:02, 20 August 2024 (UTC)

Thanks for the sources! I'll tweak the wording accordingly and add some of those sources. Nosferattus (talk) 02:11, 20 August 2024 (UTC)

Here's my edit. Hope that looks good. Nosferattus (talk) 02:25, 20 August 2024 (UTC)

Looks good, but I just realized that the first paragraph in Puberty_blocker#United_Kingdom is a bit duplicative to the Puberty_blocker#Ban_on_private_clinic_prescription subsection which also says the same thing (and in more details).

Should we maybe just consolidate it down into the subsection (and probably rename the subsection since the ban is not just on private clinics)? Raladic (talk) 02:29, 20 August 2024 (UTC)

@Nosferattus I know it is not etiquette to criticise other editors, and let make plain that this is not my intent. However it is true that you are stating things here, that a read of the Cass page show to be unfounded. eg

• This is hardly a "ban".

The Cass page makes it very clear that there is a ban! It's not something buried deep in the page.

I am not criticising your talk here - but I am wondering why you don't get up to speed with the Cass page first, in detail, before talking here. It will benefit everyone who reads this page. As per the list I put together above, there are 10 or 20 ways in which this page makes statements that are contradictory to the Cass page: so the discussion here will be more fruitful if it starts with an accurate view of Cass for each, and not be diluted ith misreadings.

this is not a criticism, as I know I too have barged into pages without reading up first: so I am pointing the finger at myself just as much. I hope you'll take this in the positive spirit it is intended. Peckedagain (talk) 21:25, 20 August 2024 (UTC)

I just edited to correct the ban date under 'United Kingdom' and add the date to the lead. Peckedagain (talk) 22:11, 20 August 2024 (UTC)

Slightly off-topic, but what do editors think of devoting a few extra sentences to banning puberty blockers in the lede/body? A handful of American states as well as a few European countries have restricted access to puberty blockers, but the former have decreed a stricter ban out of mostly political reasons, whereas the latter have enforced less strict bans (as reflected in this discussion) mostly for evidential reasons. After all, let's not forget that the UK is not the first European country to implement such restrictions. I therefore propose that we change the current sentence into sth like this: As of 2024, Norway, Finland, Sweden and the UK have restricted access to puberty blockers for patients under 18, solely prescribing them in clinical trials.

The last two paragraphs in the lead definitely need more rewriting than that, but I think this is a good start. Cixous (talk) 09:30, 23 August 2024 (UTC)

The word "ban" is used on the government document. However, the document title uses the word "restriction". A "ban" need not be absolute. Smoking is "banned" inside public buildings in the UK but isn't "banned" entirely. If we merely say something is "banned" then the reader will assume it is entirely banned, which they wouldn't if we said "restricted". I don't mind using the word ban as long as we make very clear the UK has conditions where PBs may be prescribed to under 18s on the NHS. My understanding (correct me if I'm wrong) is that is different to the US position in many states. -- Colin°^Talk 10:32, 24 August 2024 (UTC)

That is true and I think it needs clarifying. As I point out above, it's important to distinguish European restrictions from US bans, because their justification and enforcement differ. Cixous (talk) 18:25, 24 August 2024 (UTC)

I edited the lede myself, unaware of this discussion and coming to similar conclusions to the points mentioned above. The mention of the UK's ban is out of place. The lede really should summarise the following perspectives:

• Medical support for puberty blockers
• Medical caution about puberty blockers (i.e. the view that the evidence is insufficient)
• Political opposition, which should be acknowledged but is more of a 'Society and Culture' issue in a medical article.

Anywikiuser (talk) 22:03, 28 August 2024 (UTC)

That wasn't the conclusion of @Nosferattus - they were asking for clarification on the scope of the ban (as previously, the statement was linked by someone to inside wikipedia instead of a proper external RS) and that's why we had this talk page discussion to clarify on scope and duration as you can see above and after that, they themself expanded on the lead of the UK ban as that section in the lead summarizes the legal use of puberty blockers - it's not a section that discusses efficacy or other politics (that is covered in the summary paragraph below. Raladic (talk) 22:26, 28 August 2024 (UTC)

Lead summary of the support for use of puberty blockers

Per WP:BRD - @Anywikiuser - you tried to change the prose of the summarization of the lead, which summarizes from the article the global view of the support for the use of puberty blockers. You instead introduced a new starting sentence that reframes the wide global support into that of contention with the addition about something totally different. Which in the case of Finnland isn't even part of the Puberty_blocker#Finland section, which states that their guidelines prioritize therapy, but still support the use of puberty blockers, which you changed into something very different that isn't even in the article. The lead section (prior to your change) summarized the legal support for the use of puberty blockers, not discussions of evidence or a discussion of the efficacy of it. It's about whether they support using them at all, which is why the UK was listed as the outlier on a now outright ban. You have also now hit the limit of WP:3RR, so please self-revert your last reversion to avoid running afoul of our rules on edit-warring. Raladic (talk) 21:40, 28 August 2024 (UTC)

I count 2 reverts each there, on a WP:CTOP. I suggest both just stop edit warring and discuss the changes. Void if removed (talk) 21:53, 28 August 2024 (UTC)

The intial change by the @Anywikiuser is a reversion of the status-quo itself that appears to try to reframe the summary very similar to that of another user that was reverted just days ago and that user was tbanned for the very same POV pushing recently, so the initial re-changing it back to the same POV counts as a manual reversion, so that's 3 reversions with the first being manual and the other [8] and [9] being automated reversions, so that's 3.

If the first wasn't so strikingly similar to that of the banned user, then yes, it might be two reversions, but as that first one is so similar, you'll find that most people would agree it looks like a manual reversion of the initial status quo, especially with the total change of the context of what the summary section there summarized, as was also literally just discussed as consensus, with the only thing left potentially is to add the mention on restrictions from Norway, Sweden and Finland (after those restrictions actually are in the article sections, since the WP:LEADFOLLOWSBODY) as Cixous pointed out, but also seeing the sections on Norway, Sweden and Finland, neither of those countries actually banned the use, just changed some recommendations.

So again, please self-revert your last change per it being otherwise a violation of WP:3RR against current consensus. Raladic (talk) 22:06, 28 August 2024 (UTC)

Any similarities between my edits and the earlier one are most likely a result of parallel thinking. Moreover, the 3 revert rule applies to edits made in a 24-hour window, whereas the earlier edit was made on 17 August.

I don't understand your argument that the lede should not discuss efficacy. (In this case, this would be about whether puberty blockers improve mental health outcomes, as their physical effects are somewhat known.) If anything, that is a more important issue than any 'society and culture' issues. Moreover, I thought the lede was discussing efficacy anyhow. When it says that the use of puberty blockers "is supported by" some medical organisations", doesn't that mean that they not only think they should be legal, but also that they are efficacious?

It is important to remember that doctors stances are more nuanced than a rigid binary of support and opposition. The stance of the Finnish Ministry of Health is an example.

Finally, isn't it self-evident that medical institutions have differing opinions on the matter? Anywikiuser (talk) 23:09, 28 August 2024 (UTC)

Yes, it is self-evident that medical institutions have differing opinions about the matter, but the question is which org is WP:DUE in lede. AMA, APA and AAP are all among the biggest, most-mainstream American medical orgs. Endocrine Society supports it as well as among a gigantic foice.

Meanwhile, specialist orgs, with arguably right-leaning views seem to disagree about them. To suggest that there is significant medical debate when AMA, the BIGGEST of the BIGGEST of medical orgs, endorses their usage is WP:FALSEBALANCE.

I'm reverting it and strongly suggest to stop WP:EDITWAR. Bluethricecreamman (talk) 23:17, 28 August 2024 (UTC)

If this article were dealing with a purely American perspective, this would be tenable, but this article is supposed to deal with a global perspective. As the body notes, in contrast to the lede, some medical institutions in other countries now take a more cautious stance (which does not mean they "oppose" them). Moreover, my edit would have left 18 organisations mentioned to support puberty blockers and 2 that argue that the evidence is uncertain, which is hardly suggesting a 'balance' in those perspectives. Anywikiuser (talk) 08:51, 29 August 2024 (UTC)

To suggest that there is significant medical debate

There is significant medical debate, as documented in WP:RS. To suggest that the AMA has the final word on international medical matters is US-centrism.

Never mind that - as has been raised here before - we have systematic reviews strongly criticising the Endocrine Society, AAP and APA's guidance as circular and lacking developmental rigour. Continuing to argue to keep this out of the lede is untenable. Void if removed (talk) 09:45, 29 August 2024 (UTC)

I'd also like to point out that the European Academy of Paediatrics, the European counterpart of the APA, has a different take on puberty blockers. They essentially point out, among other things, that (i) it is feasible that some European countries may tackle the lack of evidence differently and that (ii) treatment should take into account the rights of a child (though they shy away from being super specific about what this entails). Their point of view is, in summary, more nuanced. They do not recommend puberty blockers but do not dissuade their use either.

Another European organisation, the European Society for Sexual Medicine, does unambiguously support puberty blockers. One cannot simply dismiss one over the other. IMO they should both be included, because the information in the current lede is heavily reliant on American organisations. Cixous (talk) 10:21, 29 August 2024 (UTC)

It's worth noting that the AMA, for example, is not a purely scientific organisation, being a professional organisation with a goal of protecting its members and promoting political positions. What this means for enwiki is laid out in WP:MEDORG: Guidelines do not always correspond to best evidence, but instead of omitting them, reference the scientific literature and explain how it may differ from the guidelines. This is an area where the evidence-based scientific viewpoint is currently discordant with (some of) the consensus-based medical viewpoint(s). These are both significant viewpoints, so per NPOV, we need to cover them both and explain how they differ. The current lead over-weights the consensus-based viewpoint, soft-pedals the scientific viewpoint, and fails to confront the discord head-on. The inclusion of the European Society for Sexual Medicine isn't ideal, because (a) it's not mentioned in the body, and (b) it's a red link, so is it even a notable org? Barnards.tar.gz (talk) 18:41, 29 August 2024 (UTC)

I believe you have a point here. Perhaps it's better to simply summarise that, broadly speaking, there is a clash between consensus-based and evidence-based viewpoints regarding puberty blockers. It'd even make the article more pleasant to read than just simply listing fifteen-thousand organisations. I hope for once that this discrepancy can just be mentioned without the need to argue endlessly back and forth about whether or not it is the proper way to phrase things. Cixous (talk) 19:46, 31 August 2024 (UTC)

Add new reference

A comprehensive study conducted in 2024 by the HealthSense, the UK charity which promotes evidence-based medicine, calls gender dysphoria treatment 'the canary in the coalmine' for its selective evidence base (which it claims is far from unique to this issue) and rejects complaints against randomized controlled trials, pointing out that they are applicable to almost all treatments including surgery. It concludes that where outcomes are not clear or where evidence is controversial it is unfair to patients to adopt interventions except as part of ethically approved and properly conducted research. See original paper at https://www.healthsense-uk.org/publications/background-briefings/10-background-briefings/428-evidence-and-gender-dysphoria.html. Rachelgoodwin (talk) 08:02, 7 September 2024 (UTC)