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This is an old revision of this page, as edited by Cixous (talk | contribs) at 06:21, 15 May 2024 (→Summary: Reply). The present address (URL) is a permanent link to this revision, which may differ significantly from the current revision.

Overall article structure

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

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

Comparison of article structures
Puberty blocker Analgesic Antacid Anticonvulsant Antidepressant MEDMOS suggestion

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

An article scoped along the lines of use of puberty blockers in trans adolescents does seem like it would be a notable topic separate from this article. The use of puberty blockers for precocious puberty is pretty non-controversial and we're not really doing that justice in the current structure of the article. As far as I can recall, there are some known adverse effects for their use in precocious puberty that we don't really cover in this article at present, with the current section on adverse effects almost exclusively focusing on their adverse effects from use on trans youth.
We already have articles on feminising hormone therapy and masculinising hormone therapy, so creating a specific article to summarise the use and politics surrounding the use of puberty blockers in trans youth wouldn't be unreasonable in my opinion. If we did create one, we should leave a summary style blurb and section behind pointing towards that specific article while restructuring this one. What we'd call that article I don't know though, though I'm not sure "trans children" is correct. This type of medication is typically prescribed at Tanner 2, so "trans adolescents" might be more appropriate. Is there anything more concise than Delaying puberty in trans adolescents? Sideswipe9th (talk) 00:18, 21 March 2024 (UTC)[reply]
I think such a split might well be useful. Combining the two is a bit like the issue we have at ketogenic diet where the article is about an epilepsy therapy that is nearly exclusively used in children, but people want to talk about the weight loss fad diet in overweight adults (which currently sits at Low carbohydrate diet). They have similarities but the population groups are totally different, the proportions of food kinds (i.e. dose) is different, and the side effects and intended effects are different. What similarities there are has to come from sources explicitly noting similarities. -- Colin°Talk 11:47, 21 March 2024 (UTC)[reply]
If this gets split out, I think as far as naming I'd suggest separating out the current section that's taken over this page, so something like Puberty Blockers (Gender-affirming Care). Anything else is going to be subject to value judgements about tanner stages, age limits, terminology used in RSs and so on. Void if removed (talk) 13:57, 21 March 2024 (UTC)[reply]
What I worry about with this wording is that it risks leading a passive observer to think of the two as entirely different treatments, when really this is one treatment being used for multiple purposes.
Perhaps “Use of Puberty Blockers in Gender Affirming Care” Snokalok (talk) 14:33, 21 March 2024 (UTC)[reply]
No, it is two entirely different treatments, even if the same drug is used. There are quite a lot of drugs used to treat entirely different things. Like epilepsy drugs for neuropathic pain. Precocious puberty has totally separate causes, treatment intention and age when stopped.
This article currently is a weird one. It isn't a drug article like Triptorelin and it isn't a drug-class article like Gonadotropin-releasing hormone agonist. Those drugs could be used for prostate cancer, say, and nobody is blocking puberty in a 70-year-old man.
Is "gender affirming care" quite right? The puberty blocking is "to temporarily halt the development of secondary sex characteristics" and "allow patients more time to solidify their gender identity, without developing secondary sex characteristics, and give transgender youth a smoother transition into their desired gender identity as an adult". I'm not aware that anyone is affirming agender/immature as an body option, where the child remains forever pre-pubertal? Are they? It facilitates a later gender affirming stage, which is either to go on to sex hormones or to affirm that assigned-at-birth?
The "gender affirming" use of these drugs isn't "puberty blocking" but to reduce testosterone in trans women, say, who are also taking female hormones.
So I'm wondering if reliable sources talk about these being pre gender affirming care, or something like that? -- Colin°Talk 17:56, 21 March 2024 (UTC)[reply]
Your understanding is actually incorrect, puberty blockers are administered to trans children in the exact same manner as they are to cis children with precocious puberty. They’re not used concurrently with estrogen to block testosterone, those are medications like cyproacetate. Puberty blockers are used prior to estrogen to buy time to decide since puberty is a time sensitive matter. Snokalok (talk) 23:45, 21 March 2024 (UTC)[reply]
Regardless, the common medical parlance is to refer to them as gender affirming Snokalok (talk) 23:47, 21 March 2024 (UTC)[reply]
I suspect we disagree on what "exact same manner" means. If you look at the clinical guidelines for PP and what the clinician has to test for, consider, the range of possible treatments, the issues to monitor, when to start, when to stop, not forgetting the biggie of age-group, there's nothing the same about it other than what's in the medicine and its administrative route. I don't think we should conflate two different treatments, which each have entirely separate clinical guidelines, licencing (or lack of), eligibility criteria, causes, aims, and so on. -- 08:55, 22 March 2024 (UTC) Colin°Talk 08:55, 22 March 2024 (UTC)[reply]
This sort of thing is why I suggested just using what's there now as the least bad/most likely consensus. Getting into the whys and wherefores and age groups and terminological conflicts is gnarly. Frankly, when medical bodies are at odds over what the purpose even is or who it applies to, any title will inevitably pick sides on that disagreement.
I think it is clearest to use the language of the NICE reviews and NHS clinical commissioning ("children and adolescents with gender dysphoria/incongruence") but this is language WPATH etc are moving away from as pathologising so comes with its own set of conflicts. "Gender-affirming care" while not IMO as clinically bland and explanatory, does have the advantage of longstanding consensus on this page, and in the interests of avoiding yet another source-counting debate over who is or is not FRINGE I'd just stick to what's there right now, personally. Void if removed (talk) 09:30, 22 March 2024 (UTC)[reply]
@Sideswipe9th, I think "children" is fine, because Tanner II is usually around age 10 or 11 these days. In biological terms, they may be pubertal adolescents, but in social and legal terms, they're still children.
If we split the article, would it make sense to split by sex (male/female) or gender (trans boy/girl/non-binary) as well? The considerations (e.g., effects of endogenous testosterone on facial structure) do not apply equally to all body types or life goals. WhatamIdoing (talk) 17:13, 21 March 2024 (UTC)[reply]
On children vs adolescents; I'm pretty sure the reliable literature on this topic use either adolescent or youth, not children. The treatment protocols for trans children (pre-pubertal) are basically just social transition (ie name and pronoun changes, allowing the child to chose their own clothing and hair style, etc). Pubertal suppression really doesn't start until Tanner 2, at which case most sources I'm familiar with consider the individual an adolescent.
On splitting by sex or gender; No, I don't think we need a split on gender or sex here. There'd be a large amount of repetitive content between the two/three articles, as the treatment protocol itself is the same; same medications, same dose, same dose schedule. The differences in effects on secondary sex characteristics could be handled I think by separate subsections for male and female. Sideswipe9th (talk) 18:09, 21 March 2024 (UTC)[reply]
Just realised the argument on children vs adolescents in the title would be stronger with sources. WPATH SoC 8 has separate chapters for children, adolescents, and adults, and doesn't discuss puberty blockers until the adolescent chapter. The Endocrine Society guidelines also start their guidelines on puberty blockers in the "treatment of adolescents" chapter. The Australian SoC for trans and gender diverse children and adolescents don't give any guidance on puberty blockers until their adolescent chapter. The American Psychological Association's guidelines only briefly discuss puberty suppression in the context of adolescents.
The only major English language guideline (not searched other languages due to language barrier) that I've found that deviates from discussing puberty blockers solely in the context of adolescence is the NHS England guidelines and the 2020 NICE evidence review that has been subject to extensive discussion above. Both of those discuss puberty blockers for both childhood and adolescence. However the majority of the studies within the NICE evidence review use adolescents when referring to their respective cohorts. Sideswipe9th (talk) 18:32, 21 March 2024 (UTC)[reply]
The medical guidelines are talking about adolescents. Shall we prioritize the medical viewpoint over other viewpoints?
The options look like this:
  • Medical viewpoint: The patient is 11 years old and Tanner stage 2, so "adolescent".
  • Social viewpoint: The 11-year-old next door is a great kid.
  • Legal viewpoint: 11 year olds are children.
Wikipedians have a tendency towards overmedicalization. Is that a tendency that we want to embrace here, or to resist? WhatamIdoing (talk) 01:22, 31 March 2024 (UTC)[reply]
I don’t support separating this as it is the same medicine. I will also note that sources will often talk about precocious puberty and transgender children in the same article in reference to each other. Also “Delaying puberty in trans children” is not a neutral wording as it gives the impression this is an experiment on trans kids, which it is not. -TenorTwelve (talk) 07:23, 23 March 2024 (UTC)[reply]
@TenorTwelve, what makes you think that delaying puberty is treating trans kids like guinea pigs? Presumably the goal of giving puberty blockers to trans kids is to delay puberty, so "delaying puberty" sounds like a pretty simple, factual description to me. WhatamIdoing (talk) 02:04, 13 April 2024 (UTC)[reply]
I am not comparing children’s health care to an experiment and if I gave that impression, I apologize. I’m looking at this from multiple angles. “Delaying puberty” is factually correct. My worry is that it could be misinterpreted in a way to question the motives of the administration of health care. Though that wasn’t my point. I wrote this to oppose separating the article into precocious puberty and trans care because they are the same medicine and the two are often mentioned jointly in reliable sources.-TenorTwelve (talk) 09:27, 13 April 2024 (UTC)[reply]
I wonder if it's really true that the two are often mentioned jointly in reliable sources, or if it's instead more true that sources about trans kids mention precocious puberty (e.g., as a way of indicating that it is a medical treatment that's been successfully used for years in a condition that isn't socially controversial). It could be that the trans sources mention PP but the PP sources don't mention trans. WhatamIdoing (talk) 00:25, 17 April 2024 (UTC)[reply]
I've done a little literature search on PubMed. Here's what I've found. The term "puberty blocker" is not used in the literature to refer to treatment for precocious puberty. There are a number of treatments for precocious puberty and "GnRH analogues" or "GnRH analog" are the terms that those dealing with precocious puberty used to refer to the treatment it shares with trans kids and we have an article on them: Gonadotropin-releasing hormone agonist. If you try searching for "puberty blocker" and "precocious puberty" together you will find nothing. Whereas searching for "puberty blocker" or "puberty blockers" uncovers only trans topics. If you search for "GnRH analogues" and similar words and for individual drugs, you find that they get used for precocious puberty but also for treating female and male cancers that are hormone encouraged, and other random stuff. And nobody says to a 60 year old with prostate cancer that we're going to put you on puberty blockers.
The term "puberty blocker" is a trans-therapy term. I think that's a killer blow for the the idea that this article is about precocious puberty at all, or about any other uses of these drugs such as cancer treatment. And I suspect there's a good reason people choose to link this to the treatment for precocious puberty rather than breast cancer as "Around 10% of the patients taking XYZ die of breast cancer within five years" doesn't sound so great.
If you look in the history, you see the first version of this article was talking about treating trans kids and the mention of precocious puberty is explicitly talking about an earlier use of such drugs, but not this one.
The very fact that such drugs are not licenced for treating trans kids means that even articles on the individual drugs will suffer generally from a weakness of literature on their use for that, since the manufacturer never ran trials on that group. So I think the literature on the drugs themselves and the literature on precocious puberty will not generally mention treating trans kids other than as an aside.
In contrast of course there is motivation in the trans literature to refer to the earlier, safe, licenced treatment for an entirely different patient group. In that regard, it is similar to how e.g. an article on migraine treatments might mention that some of the drugs are also used to treat other conditions, but just as aside.
Rather than split the article, I suggest the article titled Puberty blocker focus entirely on the therapy for trans kids, mentioning precocious puberty as an aside, as that is exactly what the literature does with that term. -- Colin°Talk 08:17, 17 April 2024 (UTC)[reply]
All excellent points, @Colin Zeno27 (talk) 09:53, 17 April 2024 (UTC)[reply]

Cass Review

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

Link to the various studies supporting the review.
This review in particular is informative:
Two international guidelines (World Professional Association for Transgender Health and Endocrine Society) formed the basis for most other guidance, influencing their development and recommendations. - This validates the notion that stuffing the lead with mentions of lots of different orgs is misleading, if the ultimate source of the guidelines is actually WPATH and the Endocrine Society.
Conclusions Most clinical guidance for managing children/adolescents experiencing gender dysphoria/incongruence lacks an independent and evidence-based approach and information about how recommendations were developed. - MEDRS is clear that we should prefer independent and evidence-based sources, but we still need to report the WPATH/Endocrine Society position, as they clearly remain influential. We're not trying to pick a winner of the two POVs, but to accurately summarise what the two POVs are.
Overall, the review seems to further strengthen the MEDRS credentials of the "European caution" camp, so I think the following remains the best second paragraph for the article:
Few studies have examined the effects of puberty blockers for gender non-conforming and transgender adolescents. The World Professional Association of Transgender Health and the Endocrine Society both endorse the use of puberty blockers as a medically necessary gender-affirming intervention. However, systematic reviews have found the evidence of benefits to be of low-certainty, and some European countries have subsequently moved towards restricting the use of puberty blockers.
Barnards.tar.gz (talk) 10:36, 10 April 2024 (UTC)[reply]
"Few studies have examined the effects of puberty blockers for gender non-conforming and transgender adolescents."
This is directly contradicted by the Cass Report, which examined over 50 studies on that exact topic. It simply threw out all but one, and while I'm not commenting on that decision here, I am saying that we can't say "few studies" based on the Cass Report Snokalok (talk) 11:16, 10 April 2024 (UTC)[reply]
How about Few high quality studies have examined the effects of puberty blockers for gender non-conforming and transgender adolescents Void if removed (talk) 11:21, 10 April 2024 (UTC)[reply]
Better, but I feel high quality on its own has been well established as misleading to a reader. Perhaps, "Few studies using randomized controlled trial (...) outside of that, the studies there are indicate XYZ (...) Endoresement by world orgs (...) however systemic reviews have found low certainty due to the aforementioned lack of randomized controlled trials" Snokalok (talk) 11:24, 10 April 2024 (UTC)[reply]
The quality assessment is nothing to do with RCTs. Void if removed (talk) 11:29, 10 April 2024 (UTC)[reply]
By all means, tell me where in the paper I can find the methodology of quality assessment. I had difficulty finding reference to anything outside of RCT's myself. Snokalok (talk) 11:59, 10 April 2024 (UTC)[reply]
See the systematic review into puberty blockers here: https://adc.bmj.com/content/early/2024/04/09/archdischild-2023-326669
An adapted version of the Newcastle-Ottawa Scale for cohort studies was used to appraise study quality. Only moderate-quality and high-quality studies were synthesised.
This is "The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses".
They assessed:
11 cohort, 8 cross-sectional and 31 pre-post studies were included (n50). One cross-sectional study was high quality, 25 studies were moderate quality (including 5 cohort studies) and 24 were low quality.
Void if removed (talk) 13:10, 10 April 2024 (UTC)[reply]
I’m not ignoring this, it just takes time to read through on my breaks. Snokalok (talk) 07:18, 11 April 2024 (UTC)[reply]
Right, after having read up, this still requires an external control, which of course raises well documented ethical issues. Additionally, ascertainment of exposure requires blind interviews, but its again impossible to do a blind anything for puberty blockers, because puberty is very visible. Snokalok (talk) 09:58, 12 April 2024 (UTC)[reply]
The ethical issues with a control group are the same as any ethical issue with a control group, ie, they might be denied useful treatment. But until you do the study, you don't know. It might be you make them worse. Without a control you don't know, that's the point.
And studies were marked down for other reasons, like having atrocious dropout rates. If 70% are lost to followup how can you have any confidence in the results? Adding together bad data doesn't give you good data, it just gives you more bad data.
It is clearly possible to attain a high quality study design, since one was included. Void if removed (talk) 13:53, 12 April 2024 (UTC)[reply]
Anyway, if we're resurrecting this, we should bring in all the names.
@Sideswipe9th @LokiTheLiar @XeCyranium @Your Friendly Neighborhood Sociologist @TenorTwelve @Colin Snokalok (talk) 11:22, 10 April 2024 (UTC)[reply]
Also - they didn't "throw out" all but one - they assessed their quality, and found only one was high, with the rest moderate or low. That doesn't mean they disregarded the others. See https://adc.bmj.com/content/early/2024/04/09/archdischild-2023-326669
Eg,
Regarding psychological health, one recent systematic review reported some evidence of benefit while others have not. The results in this review found no consistent evidence of benefit. Inclusion of only moderate-quality to high-quality studies may explain this difference, as 8 of the 12 studies reporting psychological outcomes were rated as low-quality.
The conclusion:
There are no high-quality studies using an appropriate study design that assess outcomes of puberty suppression in adolescents experiencing gender dysphoria/incongruence. No conclusions can be drawn about the effect on gender-related outcomes, psychological and psychosocial health, cognitive development or fertility. Bone health and height may be compromised during treatment. High-quality research and agreement on the core outcomes of puberty suppression are needed.
Void if removed (talk) 11:27, 10 April 2024 (UTC)[reply]
Perhaps that first sentence isn’t needed at all. Considering this is the lead, mention of what studies have been done and how many and of what quality, is arguably detail subsumed by the recommendations of the main players. Discussion of studies and quality can be covered in the body. Barnards.tar.gz (talk) 12:23, 10 April 2024 (UTC)[reply]
I'm preliminarily against any change here, and agree with Snokalok's criticisms of taking this too seriously.
I would like to wait a little bit to give other organizations (like WPATH) a chance to respond to this. Loki (talk) 13:37, 10 April 2024 (UTC)[reply]
What are you hoping a statement from WPATH will do? Unless they capitulate entirely, there will still be two POVs of comparable weight that need to be covered in the article lead, which is currently completely lacking one of them. Barnards.tar.gz (talk) 18:00, 10 April 2024 (UTC)[reply]
I still find "of comparable weight" dubious. But regardless, the point here is that the Cass Review being released should not by itself change our coverage of this topic until we have a firmer idea of where it falls within the broader scholarship. Loki (talk) 18:51, 10 April 2024 (UTC)[reply]
A new systematic review is MEDRS, why would we wait to see if WPATH agree with it? This is the broader scholarship. Void if removed (talk) 19:49, 10 April 2024 (UTC)[reply]
I think that highlights the real issue. It's not that the Cass Review is a game-changer for this article. Rather, the situation remains where we're seeing medical academia and organisations split between a "pro" camp and a "European caution" camp, but only the former of the two is currently represented in the lede. Snokalok's earlier suggestion comes across to me as the best starting point on what to add to the lede. Anywikiuser (talk) 22:20, 10 April 2024 (UTC)[reply]
I disagree with the characterization of “European caution camp”, primarily because as the article says, it’s not all of Europe or even Western Europe, it’s a handful of countries within Europe compared to many more that still actively recommend puberty blockers. Snokalok (talk) 07:14, 11 April 2024 (UTC)[reply]
The proposed change doesn't use the phrase "European caution camp", that's just an air-quoted shortcut for the purpose of this discussion. The proposed change is to use the word some which is true even if not all European countries reach the same conclusion. Barnards.tar.gz (talk) 07:56, 11 April 2024 (UTC)[reply]

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

including one study in its actual evaluation
I would like to know where this particular myth has come from because that's simply not true. I've linked the review above. Only one study was high quality, but they included studies that were high and moderate quality in the synthesis. Void if removed (talk) 21:02, 10 April 2024 (UTC)[reply]
Though I can't be sure, it likely comes from a very poorly worded press release from Cass published alongside the review. PATHA and AusPATH then made a joint statement saying that In one review, 101 out of 103 studies were discarded.
Honestly we're best waiting for a few days/weeks for things to settle here before considering integrating substantive content from or about the Cass Review, whether it be in this article or any other. The early indications from other relevant medical bodies outside the UK is that this review is highly controversial, and seemingly out of step with international best practices. Rob Agnew, the chair of the British Psychological Society's Section of Sexualities has said on his LinkedIn that he "and many other clinicians, will be having a look at the final Cass Review in detail and trying to answer the question 'Why was Cass unable to find the research needed to provide trans youth with vital medical approaches that other countries found?'" Given the length of the report, the linked series of papers in the BMJ, and that seemingly no-one outside of certain elements of the UK press were given advance copy of the report's findings, it will take some time for the review and its content to be properly analysed and contextualised for our own purposes.
I know from my own skimming of the content, there are some real oddities present. I found Cass' opinion that the WPATH guidelines "lack developmental rigour and transparency" to be particularly galling, given how her own review has been conducted under a veil of secrecy, with the names and qualifications of the review panel members being withheld both earlier in the process and seemingly now post-publication with the panel members not being named in the report. This may even be outright false, given that WPATH were very open about both the methodology and list of contributing members behind the SoC 8. Sideswipe9th (talk) 01:35, 11 April 2024 (UTC)[reply]
I'll put my name down as in support of waiting. Alpha3031 (t • c) 11:04, 11 April 2024 (UTC)[reply]
It will also be interesting to see if reliable sources compare Cass' findings against the forthcoming joint German, Austrian, and Swiss guidelines that are due to be published shortly. There was a press briefing about those guidelines at the end of March, and the takeaways from that is that the German lead guideline seems to be diametrically opposed to what the Cass Review has found, particularly with regards to the prescription of puberty blockers at a Tanner stage appropriate time. Sideswipe9th (talk) 02:05, 11 April 2024 (UTC)[reply]
it likely comes from a very poorly worded press release from Cass published alongside the review
I see - people are confusing the research on hormones with the research on blockers. The systematic review on blockers is separate, so this particular objection (which has come up twice on this talk) is, aside from anything else, incorrect.
I found Cass' opinion that the WPATH guidelines
This is not Cass' opinion - this is the results of an independent analysis: https://adc.bmj.com/content/early/2024/04/09/archdischild-2023-326499
Table 6 in the review lays this out quite clearly.
It will also be interesting to see
It will - but right now we have one systematic review and WPATH saying one thing, and four systematic reviews saying another. The balance in the lede is way off, and continually bringing up the same old blogposts from partisan activists doesn't change that. Void if removed (talk) 08:04, 11 April 2024 (UTC)[reply]

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

The Cass Report is more nuanced on the subject, but this is a digression. Anywikiuser (talk) 11:01, 11 April 2024 (UTC) [reply]
Cass cites a Nadrowski paper which claims that FtMs are "fleeing womanhood" to escape male sexual violence and porn. Very scientific. Edit: sorry yeah this is off topic for puberty blocker. We can strike or remove these three comments. Zenomonoz (talk) 11:54, 11 April 2024 (UTC)[reply]

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

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

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

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

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

But the BMJ systematic reviews I link to above are not Cass and very much not surprising: they did what systematic reviews do all the time, and the activist voices complaining about studies being rejected is also not surprising because that's a common refrain too. The homeopaths and the herbalists do that all the time.
It is inappropriate and unnecessary to be comparing the LGBT community to fringe homeopathy. Yo could have just left the majority of your final paragraph out. SilverserenC 20:42, 12 April 2024 (UTC)[reply]
He's not saying it's the whole LGBT community, or even the whole trans community. Let's not take this out of proportion. Anywikiuser (talk) 19:40, 13 April 2024 (UTC)[reply]
I'm not even remotely comparing the LGBT community to fringe homeopathy. I'm talking about some of their arguments. That they make the same flawed and dim arguments. Try to spot them and you'll become a better editor. -- Colin°Talk 19:54, 13 April 2024 (UTC)[reply]
I think even that is dubious and that your choice of comparison is seriously flawed. If you wanted to say they were making unscientific arguments, there's lots of better comparison points than total quacks.
But we should probably drop this, because I don't think it's going to go anywhere productive. Loki (talk) 20:08, 13 April 2024 (UTC)[reply]
I'm not just saying they are making unscientific arguments. They really are spreading disinformation in support of their cause. Which is bad, no matter how noble the cause. The very discussion on this page is a classic "a lie can travel halfway around the world while the truth is still putting on its shoes" -- Colin°Talk 20:12, 13 April 2024 (UTC)[reply]
I'm also finding the idea that someone can "do a systematic review on one study" to be evidence that people (and the sources they're relying on) don't know what they're talking about. This is unfortunate, as I believe that most of the editors on this page are capable of writing systematic reviews.
Typically, a systematic review is done on "the entire contents of the PubMed database", so if you start one today, you're doing it "on" 38.6 million publications. Then you start filtering: Maybe you only want studies from the last 20 years. Only certain types of publications (e.g., excluding letters to the editor). Only studies that contain certain keywords. Only studies that include specific populations.
That process apparently got them down to 50 relevant studies, which they then assessed manually according to a pre-chosen, scientifically accepted, industry-standard rubric (they chose the Newcastle–Ottawa scale). This step isn't difficult; it's mostly tedious and occasionally expensive (if you have to buy a lot of paywalled studies). The results of that assessment determines which studies they read for content. In this case, they accepted 26 out of 50 (55%) for evaluation. (This, by the way, is not a bad acceptance rate; I've seen many systematic reviews from the famous Cochrane Collaboration that accept zero studies. The write-up is short and simple: "No good evidence, Further research is needed, good luck treating your patients between now and then".)
With the accepted studies in hand, the interesting part begins: You read the papers and figure out what their results are. Does it say anything about ____? Does it give any subgroup information (e.g., race, sex, age)? Does it reach a statistically significant result? Wait, I thought there were articles saying there were improvements to psychological functioning – oh, interesting, all of the ones reporting big improvements are low-quality papers.
I would be surprised if we didn't see special pleading in social media about why low-quality studies with the Right™ results needed to be included anyway, so that the report would have ended up with the Right™ results – after all, that happens all the time, and the motivations are perfectly understandable and usually noble – but I do hope that Wikipedia editors can avoid repeating errors like "systematic review on one paper", and I hope that we can improve this article by being clear about facts that are settled. For example, it may not be clear whether delaying pubertal development has long-term positive outcomes compared to other treatment alternatives, but it is clear that a year of puberty blockers results in a delay in pubertal development. Let's say that, clearly and directly. WhatamIdoing (talk) 01:53, 13 April 2024 (UTC)[reply]
I think in including this it should be noted for the puberty blockers review that the evidence was taken from April 2022 and earlier. I know it is obvious to people with familiarity I'm systematic reviews that they have to lag behind by a couple of years but I think making this explicitly obvious helps the common reader. LunaHasArrived (talk) 09:12, 14 April 2024 (UTC)[reply]
The April 2022 date was used to gather studies for synthesis but they do spend five paragraphs individually discussing the research since then until January 2024, and consider whether those studies change their conclusions or add information, and their answer is no. So I don't think it would be fair at all to claim this review was two years old already, as they seem to have gone out of their way to make it especially up-to-date. -- Colin°Talk 15:22, 14 April 2024 (UTC)[reply]

Consensus-based vs evidence-based

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

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

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

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

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

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

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

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

3. From the Taylor/Hewitt systematic review of guidelines[1]:

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

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

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

We should not ignore international consensus on this issue because of one study complaining about it. Loki (talk) 15:12, 17 April 2024 (UTC)[reply]
There is no international consensus, there are a multiplicity of viewpoints, with the centre of gravity of one cluster being WPATH and the centre of gravity of the other cluster being the European nations detailed already in the article. When we have a study (of the highest quality) suggesting that "the international consensus" is only "apparent consensus" due to circular reasoning, and that it is not as evidence-based as it claims, we cannot treat it as the only game in town. Barnards.tar.gz (talk) 16:16, 17 April 2024 (UTC)[reply]
It's not on the basis of one study complaining about it, though their complaints are entirely consistent with the reason MEDRS gives low weight to non-evidence-based opinions. The highest form of evidence for efficacy and safety comes from systematic reviews. Expert opinion is one of the lowest forms. In wiki voice we absolutely should state what these reviews have found, wrt what evidence there is and isn't. We need to say that some organisations disagree but we can only put their opinions as opinions. The lead currently gives enormous weight to spelling out which US organisations have published press releases, even if many of those organisations are not themselves involved in creating such guidelines and so are merely affirming "what he said".
We have first class sources saying that some organisations guidelines are non-evidence based. Which is fine if that's the approach they want to take. But we can't invent facts just because we wish it were otherwise. There are aspects of puberty blockers for which there is no good evidence they help, in wikivoice, and there are aspects for which there is modest evidence they harm. Claims by some organisations that they think there is evidence need to be backed up with their own systematic review that says so, because press releases don't trump that.
Per WP:MEDSAY we shouldn't restrict the wiki-voice facts about puberty blocker evidence to be "Cass Review stated that". For example, when we have systematic reviews that a drug is effective for focal epilepsy but not effective for migraine, we simply state that, without reference to where or how that information was arrived at. Time we did the same for puberty blockers. That isn't to say we ignore the controversy. -- Colin°Talk 11:37, 20 April 2024 (UTC)[reply]
There's one thing above systematic reviews in (one of) the pyramids in WP:MEDASSESS and that's "clinical practice guidelines". Clinical practice guidelines have not changed because of the Cass Review outside of the UK, and international clinical practice guidelines are not likely to change.
Furthermore, WP:MEDSCI says we should summarize scientific consensus and so far the scientific consensus on puberty blockers does not appear to be changing.
I agree it's strange that a series of major systematic reviews do not appear to be changing the overall scientific consensus on puberty blockers yet. But it's ultimately the consensus that we cover here, not any individual study, no matter how strong it may appear to us. And it's not like this would be the only time this has happened, either. In our article on masking for COVID we mention that Cochrane review that didn't find evidence of effectiveness... as one line, and then follow up with a line criticizing it. (Admittedly, this is partly because there are tons of systematic reviews in this area, but still.) Loki (talk) 03:03, 21 April 2024 (UTC)[reply]
Also from WP:MEDORG: Guidelines do not always correspond to best evidence, but instead of omitting them, reference the scientific literature and explain how it may differ from the guidelines.
Which is exactly what we should be doing here: not omitting the WPATH guidelines, but also explaining how they differ from the scientific literature.
Also, the phrase the overall scientific consensus is problematic here.
  • Firstly, there is no gold-standard source telling us what the (singular) overall scientific consensus is.
  • Secondly, I am guessing you are treating the WPATH (and WPATH-derived) guidelines as the yardstick of consensus - but we have now seen numerous reasons why that consensus may be flawed or illusory.
  • Thirdly, "consensus" and "evidence" and "science" are distinct terms of art in this context, which must not be conflated. As an illustration, the new German guidelines under development[2] are an "S2k-level" guideline. What does that mean? It's a German (AWMF) schema for positioning guideline reliability:[3]
S2K guidelines: S2K guidelines are developed by a committee of specialists in the medical field in question. The recommendations made are consensus-based. Because medical information isn’t systematically collected and assessed here either, the information that the recommendations are based on isn’t very reliable.
Figure 1 in this article explains the difference between consensus-based guidelines and evidence-based guidelines - the latter being needed to reach the higher level of an S3 guideline.
Needless to say, just because a group of doctors have reached consensus on a position, that doesn't mean (a) that all doctors agree with that position, or (b) that the position is based on scientific evidence. Medical reversal is a thing. In fact, WPATH is not primarily a scientific organization. It is a professional association. No doubt many of their members do conduct and publish scientific research, but as an organization it also seeks to further the interests of its own members, meaning it has one foot outside the domain of science. Therefore, even if WPATH represented universal medical consensus amongst doctors (it does not), this would not translate directly to scientific consensus. Barnards.tar.gz (talk) 09:12, 21 April 2024 (UTC)[reply]
Loki, what happens to a pyramid when the blocks below are removed? It falls down. The pyramid on the left, with clinical guidelines above meta-analysis and systematic reviews is drawn on the assumption that those guidelines are built on top of them. We now have a serious review of those guidelines PMID 38594049 and PMID 38594048 which clearly exposes that they are not. It's a pyramid for a reason, Loki.
There are three separate issues here. What the science says about the evidence, and what various groups declare to be recommended practice and what in fact occurs in the field (which sometimes is discovered to be way below standard). For the first, a systematic review, looking at all the studies in that area, grading them, and producing a scientifically sound conclusion is our best source. Often the evidence and the guidelines are gloriously in sync but here they are not and that isn't just editor opinion but something we also have the highest possible source for.
For example, in the UK our healthcare uses different metrics than the US to recommend for very expensive treatments (like the latest drugs). This can mean different treatments are recommended than in the US and that affects our clinical guidelines. Or the US may take a more "don't want to get sued" approach which means their guidelines include far more tests "just in case" then in the UK where wasting money is a concern. So guidelines can differ from the evidence base for various reasons. Sadly also sometimes professional or supposedly grass-roots bodies can come under the influence of those who do not care for the evidence but have other priorities. -- Colin°Talk 09:56, 21 April 2024 (UTC)[reply]
Adding a new source - statement from ESCAP strongly endorsing the findings of the NICE and Zepf reviews and recommending psychological intervention as a first line treatment.
https://link.springer.com/article/10.1007/s00787-024-02440-8
ESCAP calls for healthcare providers not to promote experimental and unnecessarily invasive treatments with unproven psychosocial effects and, therefore, to adhere to the "primum-nil-nocere" (first, do no harm) principle.
Void if removed (talk) 20:28, 29 April 2024 (UTC)[reply]
Adding another source - position statement from the Royal College of GPs, endorsing the Cass Review: https://www.rcgp.org.uk/representing-you/policy-areas/transgender-care
GPs are advised against:
Prescribing puberty blockers for a patient aged under 18, even on a shared care basis, given the concerns about the evidence base in this area as well as the specialist expertise required to monitor dosage and side effects. The Cass Review1 notes that ‘the Review has already advised that because puberty blockers only have clearly defined benefits in quite narrow circumstances, and because of the potential risks to neurocognitive development, psychosexual development and longer-term bone health, they should only be offered under a research protocol. This has been taken forward by NHSE and the National Institute for Health and Care Research (NIHR)’ and that ‘if an individual were to have taken puberty blockers outside the study, their eligibility may be affected’. This precludes GPs from ever prescribing puberty blockers, excepting any GPs working on clinical trials in this area.
Void if removed (talk) 14:07, 1 May 2024 (UTC)[reply]

Updates to UK section

I don’t want to get involved in editing a medical article. But I think the UK section of this article should be updated to say (a) that private clinics may have trouble with the regulator if they prescribe puberty blockers [4], and (b) that the Scottish Sandyford Clinic has announced that it has ‘paused’ prescribing puberty blockers [5]. Sweet6970 (talk) 16:56, 18 April 2024 (UTC)[reply]

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

Culture wars, article split suggestion

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

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

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

I agree. I think it may be beneficial to create a separate article for puberty blockers in trans minors in general (sth along the lines of Puberty blockers in transgender healthcare), because most of the article is now about their application in gender-affirming medicine, instead of summarising this and the other uses they currently have. Cixous (talk) 18:11, 20 April 2024 (UTC)[reply]
I think you mean well but I believe that would be highly likely to turn into a WP:POVFORK, and even if not just means two difficult pages to deal with instead of one. Here's how: One article would contain only MEDRS and have a balance of POVs that reflects the views of different medical bodies around the world, whereas the other would, over time, get loaded up with newspaper and magazine thinkpieces, disproportionately from Americans, and reflecting mostly just the views of American journalists, and new ones constantly being written every time some American state proposes some legislation or other.
Better too to keep the amount of 'culture war' text under control. It's sufficient to say what the LGBT advocates say and why they say it, and same for the other side, with some detail to mention legal status by location, but not with excessive detail or falling into the trap of re-reporting the same reactions in every state. To be NPOV, all of this should be closely contextualized with the MEDRS in the same article, and vice versa. Crossroads -talk- 23:32, 20 April 2024 (UTC)[reply]
The political aspects of the topic are intertwined with the medical and scientific aspects, so a split would probably act to de-contextualize the two from each other. It would be better to keep this as an article primarily about the medical treatment, and keep a lid on the political statements with reference to WP:NOTEVERYTHING. Barnards.tar.gz (talk) 10:03, 21 April 2024 (UTC)[reply]
Wrt "Puberty blockers in transgender healthcare" see my comments above: that is what this article really is and really should be alone. Look up at what I wrote at "literature search on PubMed": the literature simply does not use the term "puberty blocker" for any other treatment outside of trans kids. This article should focus solely on that, with mention of precocious puberty and hormone related cancer therapy as one or two sentence asides. We already have an article on the class of drugs (Gonadotropin-releasing hormone agonist) and articles on those other medical conditions, so the only purpose of this article should be trans therapy.
Per Crossroads I disagree with the creation of a culture war article. I don't see the battle over prescribing puberty blockers as any different to the battle over the "medical pathway" (i.e., drugs and surgery) in trans adolescents and young adults. We already have Transgender health care with a section on Gender-affirming care.
As WhatamIdoing noted earlier, this article is missing sections or priority on the medical aspects. -- Colin°Talk 10:06, 21 April 2024 (UTC)[reply]
Honestly, I would oppose a split over treatment vs "culture war" because I think it just creates a forum for rehashing the same controversy as here, but with worse sources. Void if removed (talk) 09:06, 23 April 2024 (UTC)[reply]
I think I agree with Colin here. It's certainly true that we already have an article on the drugs, so this article should be for the treatment (the way we have separate articles on spironolactone versus HRT).
I'm not entirely sure whether we should also have an article for the controversy as well. My first inclination is to say yes, so we can get the political stuff out of this article and just have the medical facts of the matter. But I could probably be convinced otherwise. Loki (talk) 23:45, 29 April 2024 (UTC)[reply]

Yes. Perhaps moving this article to Puberty blockers in transgender healthcare is the way to go, and pointing the entirely uncontroversial use of medication to block puberty in cases of premature puberty back to the main medication article. By the way, the article says "The most commonly used puberty blockers are gonadotropin-releasing hormone (GnRH) agonists". I'm not aware there are any others; am I ignorant? — The Anome (talk) 10:21, 21 April 2024 (UTC)[reply]

There's no need for a lengthier title. Per WP:PRIMARYTOPIC, this is what ~everyone calls it. Barnards.tar.gz (talk) 10:27, 21 April 2024 (UTC)[reply]
I think the issue here is that there are just two uses of medication as "puberty blockers"; for the (uncontroversial) treatment of premature puberty, and for (hightly controversial) transgender care. (By the way, the article says "The most commonly used puberty blockers are gonadotropin-releasing hormone (GnRH) agonists". I'm not aware there are any others; am I ignorant?) Only the latter of the two is a political shitstorm, and that has become what this article is about; Puberty blockers in transgender healthcare is now the WP:PRIMARYTOPIC here. — The Anome (talk) 10:30, 21 April 2024 (UTC)[reply]
Anome, would you please read what I wrote earlier at "literature search on PubMed" above. There are no, zero, nada, none, never any uses of the words "puberty blockers" outside of transgender healthcare. If you are treating precocious puberty then the literature talks about GnRH agonists. If you are treating prostate cancer then the literature talks about Androgen deprivation therapy (aka castration therapy) but some of the drugs (not all) in these have overlap.
If the literature hadn't already had a term for their use in trans healthcare then GnRH agonists in transgender healthcare might have a place, but it does. It's called puberty blocker. There is no need for a separate article. -- Colin°Talk 11:34, 21 April 2024 (UTC)[reply]
See also WP:COMMONNAME. The use of puberty blockers in transgender healthcare is what the overwhelming majority of sources mean when they discuss "puberty blockers".
To your question, Spironolactone is an example of a non-GnRH-agonist drug used to block male (only) puberty. Barnards.tar.gz (talk) 10:39, 21 April 2024 (UTC)[reply]
Ah! You're right. Thanks. -- — The Anome (talk) 10:47, 21 April 2024 (UTC)[reply]
Lupron is used too. I believe spironolactone and lupron are used predominantly in the US, whereas decapeptyl is used more commonly in Europe. Cixous (talk) 11:17, 21 April 2024 (UTC)[reply]
It sounds to me like editors have a rough agreement to:
  • make this article exclusively about trans kids (e.g., maybe mention precocious puberty in passing, but otherwise remove information about non-trans kids/other uses for the same drugs), and
  • keep the article title at Puberty blocker (because, in practice, that phrase is only used for trans kids, so it's already sufficiently specific).
Does anyone disagree? If you disagree, please say something now. WhatamIdoing (talk) 01:30, 2 May 2024 (UTC)[reply]
Anecdotally, even searching Google Scholar with "puberty blockers" "precocious puberty" returned exclusively results on trans kids. So, no objections here. Loki (talk) 04:12, 2 May 2024 (UTC)[reply]
Same here. Perfectly fine to do that Cixous (talk) 12:09, 7 May 2024 (UTC)[reply]
Okay, I'll have a go at that soon. WhatamIdoing (talk) 17:08, 8 May 2024 (UTC)[reply]

Use in post-pubescent people

I ran across a study that mentioned that drop-out rates were high if puberty blockers were started after age 15. Tanner stage 5 is usually at age 15. Is there a point to taking puberty blockers when puberty is finished? WhatamIdoing (talk) 17:13, 8 May 2024 (UTC)[reply]

[6] offers this: In the data the Cass Review examined, the most common age that trans young people were being initially prescribed puberty suppressing hormones was 15. Dr. Cass’s view is that this is too late to have the intended benefits of supressing the effects of puberty and was caused by the previous NHS policy of requiring a trans young person to be on puberty suppressing hormones for a year before accessing gender affirming hormones.
(It’s an odd source as it is based on an interview with Cass but doesn’t give any direct quotes from Cass; parts give the impression of being paraphrased or editorialised). Barnards.tar.gz (talk) 19:17, 8 May 2024 (UTC)[reply]
Thanks. That sounds like a bureaucratic reason rather than a biological one. WhatamIdoing (talk) 20:43, 8 May 2024 (UTC)[reply]
Indeed. But there are still gender-affirming outcomes even from late prescription of puberty blockers. The suppression of testosterone in males will reduce facial hair growth, and the suppression of estrogen in females will reduce or stop menstruation. Also, puberty and sex-specific development isn’t necessarily finished by 15. Barnards.tar.gz (talk) 21:14, 8 May 2024 (UTC)[reply]
This relates to another point that concerns me in this article: we currently cite Horton to say that "RCTs are widely considered unfeasible and unethical for transgender youth due to the fact those in the control group would have to be denied treatment".
I think this sets up Horton (and others) for ridicule, because control groups don't have to be no-treatment control groups, and eventually someone's going to notice this. One could have, e.g., a randomized controlled trial in which half the older teens get puberty blockers and half get slightly earlier access to cross-sex hormones. One could also have a trial in which younger kids are randomized to puberty blockers first and other mental health problems second vs the other way around, or starting at Tanner stage 2 vs 3 (what one source calls "complete absence of adult sexual function" is expected with the first, at least in trans women).
In fact, Horton quotes one saying "many would consider a trial where the control group is withheld treatment unethical", and I think we are misrepresenting the source by changing that "where" (as in, "if") into a "because it always means". I'm going to see if I can make this alleged fact somewhat more closely align with the cited source. WhatamIdoing (talk) 05:36, 9 May 2024 (UTC)[reply]
Or we could just drop Horton from this section, in the same way as I wouldn't quote Nicole Kidman (to pick an entirely random name) on the ethics of randomised controlled trials in any patient group. Horton has an opinion, but their expertise in societal matters and obvious personal interest in the topic seems to have elevated them to the point where we are citing them as though they are an authority on medical trial design (on the Cass Review talk page, they were argued for on the basis that we didn't at the time have any other peer reviewed criticism, which is a weak argument). See profile where they may merit quote on e.g. how or whether to include parents in the decision making process. The article focuses perhaps too much now on the NICE review which has been superseded by the York one commissioned by Cass. That review used an alternate grading scheme that doesn't have the criticism that GRADE has, making all this stuff about GRADE moot. The overall summary this section/paragraph should leave is that multiple systematic reviews over the years have complained that the evidence quality in this area is very poor. -- Colin°Talk 08:15, 9 May 2024 (UTC)[reply]
Horton cites others for this point, so I don't think that we're relying entirely on Horton for the claim. WhatamIdoing (talk) 16:52, 9 May 2024 (UTC)[reply]
I dug into those citations over at the Cass Review talk. They're more equivocal than presented here, and one is a self-citation. Void if removed (talk) 17:26, 9 May 2024 (UTC)[reply]
And we've had a discussion about poor citations already! The first citation describes a "withholding" scenario for a treatment that works. It is kind of a chicken and egg problem in that if the current studies aren't, in some people's opinion, strong enough to show it works. Why are we claiming it works and so we can't possible do more studies? At what point does our possibly overconfidence prevent us becoming more realistically confident? The second citation is a guest editorial, which we would regard as an opinion piece. Horton's paper doesn't admit to being an opinion piece, but it is hard to read it as anything other than that, dressed up in fancy writing.
Anyway, I don't think you'd be impressed if my source was the Daily Mail and I countered your objections by saying the Daily Mail cited other sources. -- Colin°Talk 17:39, 9 May 2024 (UTC)[reply]
I think that whole section is an issue. "widely considered infeasible and unethical for transgender youth" is a strong claim in wikivoice, and the citation is basically WP:RSOPINION and likely good only for an attributed opinion, if Horton's opinion is considered WP:DUE.
Weasel words in the source like "many would consider" don't inspire confidence.
In fact if you dig into the actual citations for claims like this, what they actually say is that RCTs are considered unethical in situations where there is good evidence a treatment works, and thus denying it to a control group would be unethical. The whole point of this current situation is there isn't good evidence the treatment works, nor a clear consensus on what it is even being used for, and so that argument doesn't actually apply. Void if removed (talk) 08:33, 9 May 2024 (UTC)[reply]
That's true but as me and WAID and one of the systematic reviews suggested, there are ways of doing an RCT that doesn't deny anyone a treatment that is known to be beneficial. Most European countries have long waiting lists for treatment in this area and nobody is utilising that as a control group. Or to use gender clinics in different countries as groups for comparison.
Plus it is rather a strawman because there are other flaws in the trials beyond their lack of control. Not least of which is that the founding trials are really old at a time when clinics got an equal small number of children and adolescents mostly AMAB. Compared with huge numbers of mostly AFAB adolescents with multiple other issues. And if you read the papers on the Dutch approach, they explicitly guard that patients must "have no serious psychosocial problems interfering with the diagnostic assessment or treatment". Something I think the Dutch team commented on in their response to the Cass review which was mostly "We do it like this anyway". Regardless of the medical facts about puberty blockers, there were clearly issues with how the London team were going about things, which have been discussed in a book on the clinic and in many other venues. Having a waiting list longer than puberty, as is the case, wasn't working. -- Colin°Talk 16:18, 9 May 2024 (UTC)[reply]
Perhaps we could dedicate a specific section to discussions regarding study design from various perspectives, including a bioethical one. For instance, a name I've seen floating around a lot in the literature is S. Giordano, a bioethicist at Manchester University (who was, among other things, cited in de Vries et al. 2011). I'm not per se against the inclusion of Horton, but I agree that multiple sources with a different point of view can show the discussion on study design is much more nuanced than it is often portrayed (as Colin illustrates above quite nicely; control trials don't have to mean you deny another group treatment. I believe there are actually studies in the making which use people on the waiting lists as a control group, though I would need to double-check that).
PS: I can confirm what Colin says in his reaction. A large part of the VUmc response was about lauding the Cass Review for recommending extra mental health interventions. The 2017 report by the Dutch Ministery of Health (cited by this page, actually) specifically states that one of the demands that ought to be met before puberty suppression is the lack of psychological comorbidities (or, if they cannot be easily treated, the lack of severe psychological comorbidities). Van der Loos et al. (2023, p. 405, figure 5) shows that the time between the first appointment and puberty suppression varies each year, but is, modally speaking, roughly around the one year mark.
PPS: Just wanted to say that we should look out with claims like 'absence of sexual function' due to puberty suppression. One source may have put it that way, but we can't really say anything conclusive about that. Puberty suppression in trans women may lead to less penile tissue, which may preclude trans women from having penile-inversion vaginoplasty. Colonovaginoplasty does have a higher complication rate (I don't know if that applies to peritoneal pull-through vaginoplasty as well). When it comes to sexual functioning, however, it is not known if it impacts sexual functioning as much as some sources claim. The evidence on this is pretty scarce, though it seems to point into the direction that it doesn't have an enormous impact. The best thing we can do now, is hope for more data and thorough meta-analyses. Cixous (talk) 18:18, 9 May 2024 (UTC)[reply]
In re "absence of sexual function", it may well be understudied, and therefore to have scant scientific evidence, but the leaked documents quote Marci Bowers (WPATH’s president) as saying "To date, I’m unaware of an individual claiming ability to orgasm when they were blocked at Tanner 2."[7]
Have you seen any source saying this isn't a common problem? Or that it isn't lifelong? WhatamIdoing (talk) 18:35, 9 May 2024 (UTC)[reply]
In terms of finding sources, has anyone seen an informed consent document (or information about one) for puberty blockers?
For example, if your kid has leukemia and needs chemotherapy, (in the US) you are given pages of information about the drugs, including both short-term risks (e.g., infections) and also long-term side effects, such as damage to most major bodily systems, including heart, kidneys, lungs, liver, and brain, as well as a significant risk of irreversible total sterility. The choice isn't that hard (either he gets these drugs and maybe I won't have grandkids, or he doesn't take these drugs and definitely I won't have grandkids, because he'll die before then), but it is fully disclosed by both the drug manufacturer and the individual providers/clinics, because the alternative is an endless series of lawsuits over lack of informed consent.
Is there anything similar for puberty blockers? Whatever goes into the informed consent process could make a reasonable basis for organizing the ==Adverse effects== section. WhatamIdoing (talk) 18:58, 9 May 2024 (UTC)[reply]
I've seen some lol, their adverse effects sections match up pretty closely with our own off the top of my head, though I don't believe I've seen them mention idiopathic intracranial hypertension (perhaps newer ones do).
I just found this one from Fenway health that seems fairly similar to the one my clinic uses (which I can't find online) [8] Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 19:43, 9 May 2024 (UTC)[reply]
Thanks for that; I found it helpful. A quick precis:
  • Timing: It takes a while to see visible effects, puberty restarts after about six months off the drugs. No word about how many years it's safe to take these (could a non-binary person take them until old age?) and no mention of the usual length of time to take them.
  • Long-term effects: height effect uncertain, long-term effects uncertain (and no examples of possible harms are given).
  • Social risk: Someone might notice the kid isn't going through puberty.
  • Fertility requires "complete biological puberty" but non-reproductive aspects of sexuality aren't mentioned.
WhatamIdoing (talk) 20:24, 9 May 2024 (UTC)[reply]
The problem with Bowers' statement is that it is not rooted in methodological observation. It might be true, but scientifically speaking we can't say that. I know of one abstract (van der Meulen et al., 2023) of a still unpublished study that compares the sexual functioning between late puberty suppression (T4/5) and early purberty suppression (T2/3) and purportedly found no difference between the two groups when it came to ability to orgasm. Obviously, we can't say much about the study yet, and there may be flaws (the p-value isn't fantastic, 37 participants isn't an awful lot, and we don't know if 'problems during sexual intercourse' stem from merely physiological concerns or if they have a psychological dimension etc.), but I'm willing to give more authority to an ESSM abstract than an individual's statement. Obviously, this doesn't mean this discussion is closed (again, one unpublished study doesn't say an awful lot); it merely means that there is more nuance to this all. Cixous (talk) 19:15, 9 May 2024 (UTC)[reply]
That link says that it was published on 6 July 2023. WhatamIdoing (talk) 19:26, 9 May 2024 (UTC)[reply]
Jup, the abstract was published on that date. The full study hasn't been in a journal (yet). Cixous (talk) 12:46, 10 May 2024 (UTC)[reply]
In fact if you dig into the actual citations for claims like this, what they actually say is that RCTs are considered unethical in situations where there is good evidence a treatment works, and thus denying it to a control group would be unethical. The whole point of this current situation is there isn't good evidence the treatment works, nor a clear consensus on what it is even being used for, and so that argument doesn't actually apply.
  • Puberty blockers are prescribed instead of hormones because of the belief that it gives trans kids time to change their mind about transitioning while not causing them distress through incongruent puberty.
  • Nobody disagrees that puberty blockers block puberty. They are prescribed to block puberty and we know they are effective for that. IE, there is clear consensus the treatment works for what it is prescribed for.
  • For the record, I consider forcing trans kids to take blockers (which they usually don't actually want, it's just better than nothing) for years instead of giving them hormones to be deeply unethical - but in the context of transgender healthcare puberty blockers are a conservative treatment that clearly work for what they are prescribed for.
  • We know incongruent puberty causes trans people distress and necessitates further medical procedures down the line. What exactly is ethical about forcing trans kids to go through incongruent puberty and irreversible changes because you want to record how much they'll suffer when there's a known method of preventing that?
Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 20:12, 9 May 2024 (UTC)[reply]
This is probably off-topic, but I think the problem is the assumptions in "We know incongruent puberty causes trans people distress and necessitates further medical procedures down the line". What we actually know is that incongruent puberty causes some trans people varying amounts of distress and necessitates further medical procedures down the line for some of them.
We also know some other things, e.g., that sexual dysfunction and infertility causes some people varying amounts of distress and necessitates further medical procedures down the line for some of them. (We even know that these are risk factors for suicide.) We could ask: What exactly is ethical about risking sexual function and fertility, when there's a known method of preventing that?
What we don't know is: Which people will be more distressed and more harmed by which outcome? Some trans people (e.g., non-binary folks) might be okay with sex-congruent puberty and gutted by infertility. WhatamIdoing (talk) 21:02, 9 May 2024 (UTC)[reply]
We could ask: What exactly is ethical about risking sexual function and fertility, when there's a known method of preventing that?
Many many drugs impact fertility, we don't stop using them purely on that basis or prize it as the end all be all of a person's health. The simplest solution is to ask them if they're ok with going through puberty to preserve fertility and want to discuss fertility options (and state funding for fertility care for all). If somebody says they want to transition and are fine with being infertile, that's their body, they should not be forced through permanent changes of puberty they explicitly don't want because somebody else thinks they might want kids in future.
What we don't know is: Which people will be more distressed and more harmed by which outcome?
If we don't know, then respecting the patient's bodily autonomy and informed consent is a good place to start - those saying they'd prefer transition to fertility will probably be more distressed and harmed by being denied transition, those saying they'd prefer fertility preservation to transition can just do so. People shouldn't be denied a treatment for something definitely causing immediate distress because of the mere possibility something else will in future despite them being explicit they'd prefer transition over fertility. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 21:58, 9 May 2024 (UTC)[reply]
People shouldn't be denied a treatment for something definitely causing immediate distress because of the mere possibility something else will in future
This rule sounds sensible to me as a general principle, but I find that medical ethicists routinely disagree with me. Teenagers are not allowed to run certain genetic tests, no matter how distressed they are about the possibility of having Huntington's disease. Teenagers are also not allowed to get vasectomies or tubal ligations, no matter how certain they are that they will never want biological children.
informed consent is a good place to start
Can you have informed consent when the answer to "What is the long-term risk to fertility and sexual function, if I take this drug for five years and then stop?" is someone shrugging their shoulders, or saying that it's unethical to learn the answer to that question? WhatamIdoing (talk) 22:24, 9 May 2024 (UTC)[reply]
Can you have informed consent when the answer to "What is the long-term risk to fertility and sexual function, if I take this drug for five years and then stop?" is someone shrugging their shoulders
  • Yes, though presumably it would be more than shrugging their shoulders. If those effects are medically unknown, part of informed consent is saying they're unknown. If somebody gives me a vial of unidentified liquid and says "I have no idea what this is, it might cure your headache it might kill you painfully", it would be bloody stupid for me to drink it but I wouldn't be making an uninformed choice. If a doctor says "if you take this for 5 years and stop we don't know what the state of your fertility could be" - that lack of information is the information that informs the consent.
or saying that it's unethical to learn the answer to that question?
  • Please point me to who says trans healthcare research is unethical, I've yet to see anyone claim that. People have raised concerns about certain study designs, sure, but nobody says the research just shouldn't be done. The state of trans healthcare is an absolute shitshow, from lack of access to full denial of care, from the lack of longitudinal studies to known and unknown unknowns, not to mention the history of pathologization and enforcement of gender roles and stereotypes, but a large part of that is because the field is currently having to expend its energy dealing with concerted efforts by quacks to question whether trans people exist or should transition at all.
Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 22:49, 9 May 2024 (UTC)[reply]
Nobody disagrees that puberty blockers block puberty.
Of course - the part there is no consensus about is why block puberty. It ranges from time to think, to alleviate distress, to enable passing better in adulthood. And so this is one thing that makes the evidence base for whether it even works as an intervention so weak - because there is inconsistent purpose, therefore inconsistent measurement of whether the outcome fulfilled any purpose. Void if removed (talk) 21:41, 9 May 2024 (UTC)[reply]
Yes, I think you're right. "It's effective" should be read as "It's effective for ____". To give an analogy, it's true that chemotherapy is effective – but not for headaches, depression, iron-deficiency anemia, hypertension, etc. We are agreed that puberty blockers are effective for blocking puberty, but I think what people want to know is more like are they effective for making teenagers less distressed, helping them make durable decisions, etc? WhatamIdoing (talk) 21:53, 9 May 2024 (UTC)[reply]
The purpose of blocking puberty is simple - to hold out hope the kid isn't trans while handling the possibility they at least might be. They've been painted as this radical intervention when their entire basis is "we think these kids might suddenly change their mind about being trans so instead of giving them HRT, we'll make them wait a few years - if they're cis they can restart puberty, if they're trans they can start HRT later but at least they didn't go through an incongruent puberty".
  • time to think is the primary reason per the above. Whether they actually need that "time to think" is another question (and considering how many go from blockers to hormones, I think they don't), but if you are operating on the premise "the kids who say they're trans might not be so we can't give them HRT too young, but they might be so we can't do nothing" then it is the only solution.
  • PBs can be understood as a weird relic of the pathologization era / the start of the depathologization era. In the pathologization era, trans kids would be put through conversion therapy and only allowed to transition as an adult. That was unethical, but doctors didn't want to let minors transition, so puberty blockers developed as a messy compromise between trans people/youth, parents, pathologizing doctors, and non-pathologizing doctors that nobody was completely happy with - that's why it's based on the conflicting premises "the kids know they're trans, respect them and let them transition" and "they might be wrong, so don't".
  • to alleviate distress - somewhat, it's more so to prevent (worse) distress. Basically every systematic review of PBs has come to the same conclusion: "this doesn't seem to make dysphoria better as it remains mostly stable, but if untreated it would be expected to worsen so this could be evidence of efficacy".
  • to enable passing better in adulthood - this is obvious, it's easier to pass if you didn't go through an incongruent puberty, but it would be true if you just gave the kid HRT
If you operate from the premise some kids are trans but you think a portion who say they are are wrong - PB's make sense.
If you operate from the premise trans kids aren't real, PB's are unethical.
If you operate from the premise trans kids are real and should have bodily autonomy, PB's are a better option than no transition. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 22:26, 9 May 2024 (UTC)[reply]
Here's what MEDRS 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.
And these various aims have led to unclear evidence:
Included studies assessed different outcomes across various outcome domains and employed multiple different measures. Agreement about the primary aim and related core outcomes of puberty suppression in this population would help to ensure studies measure key outcomes and facilitate future aggregation of evidence.
Perhaps if there was clarity as to why puberty is being blocked and what constitutes a good outcome, then good evidence might exist as to whether it was actually working as intended. Void if removed (talk) 08:43, 10 May 2024 (UTC)[reply]
We've just had a major review that concluded the "time to think" rationale is unsupported by evidence. Nearly all the children progressed to cross-sex hormones, which is something that has been known for some time and even highlighted as "evidence" of the persistence of thinking among this group. If anything, the evidence is that going on puberty blockers reinforced the inevitability of a medical pathway. But of course, without control groups, the whole area is open to speculation. I think therefore we need to be careful to separate the rationales people have given for using puberty blockers, from the lack of evidence that they achieve that aim. -- Colin°Talk 09:12, 10 May 2024 (UTC)[reply]
To be honest I think the fact that the majority of people on puberty blockers go on to CSH, doesn't counter the time to think rationale if it is difficult to get puberty blockers in the first place. For example in the UK where one is on a waiting list for years before recieving puberty blockers, the people who would have decided not to continue on to CSH would have just decided not to have puberty blockers. The waiting list effectively acts as the time to think that puberty blockers are meant to be used for, but it only works this way for people who don't want CSH. LunaHasArrived (talk) 10:53, 10 May 2024 (UTC)[reply]
This just means one has to be very careful when using this sort of data and that it doesn't necessarily disprove the time to think narrative. LunaHasArrived (talk) 10:55, 10 May 2024 (UTC)[reply]
It isn't really for you or me or YFNS or Void to judge whether or not they are working on this or that evidence. I'm saying we have a reliable source doubting this rationale is now nothing more than "Something people once thought might be true, and some people still claim even now we know it isn't". Criticism of the Time to Think concept is a pretty big issue. Even to the point of Time to Think (book) being named after it. The pattern of inevitability isn't restricted to GIDS but seen anywhere that uses them. -- Colin°Talk 11:47, 10 May 2024 (UTC)[reply]
100%, I'm not saying puberty blockers do work or for what purpose they do work. I'm just saying that in a country where you wait years to get them, if there were people who would use them to decide whether or not to continue on to CSH, the waiting list filters them out anyway and isn't a fair sample of the idea. The evidence of 95% or whatever continuing just means that in the current way they're being implemented (wait list included) they are not giving people time to decide. LunaHasArrived (talk) 12:14, 10 May 2024 (UTC)[reply]
But what makes you think the review's conclusion on this "time to think" idea was reliant (or even looked at) UK data. The waiting list "filters out" argument is only relevant to the fairly recent explosion in teenage referrals. Most of the studies looked at are pretty old at a time when clinics had a patient or two per week! Colin°Talk 12:37, 10 May 2024 (UTC)[reply]
Honestly speaking I would be really interested to read these reports but if these reports are 20+ years old I think one can easily see how times have changed over the years and the stats might not as accurate to the current patient profile as one would hope. LunaHasArrived (talk) 13:08, 10 May 2024 (UTC)[reply]
And a valid counter-hypothesis is that the time spent waiting for intervention fixates on it as a solution and cements it as a goal, preventing the "thinking" expected while increasing the distress until the "solution" is available. The more time invested waiting, the harder it is to change your mind, per the sunk cost fallacy. Without adequate research actually willing to ask the right questions its a wild stab in the dark as to which of these is more true, but assuming that the longer the wait, the more people who "would have" desisted will drop out is I think over simplified, especially in the current media climate.
And the fact is, for all its flaws, GIDS still had a more rigorous approach than private clinics and the informed consent model of the US where most of the recently touted research was performed. Void if removed (talk) 12:56, 10 May 2024 (UTC)[reply]
If you're mentioning the current media climate, why would anyone want to be seen as trans. Ignoring that though, the main point was that the evidence doesn't say "all people who take puberty blockers continue", just given the current medical frameworks and media climate that is what happens. I.e if one changed the medical frameworks (giving them out easier or any number of other changes), this could significantly change. LunaHasArrived (talk) 13:02, 10 May 2024 (UTC)[reply]
Of course extrapolating study findings more widely is something we leave to the experts. But the point is that if one's hypothesis is that if this approach gives time to think about one's gender and possibly reconsider going onto cross sex hormones, then one might reasonably expect a study looking at this therapy to demonstrate a good portion of the children do indeed reconsider. The absence of good evidence of that is a problem for those making the "time to think" claim, not a problem for those saying "well, where's your evidence?". -- Colin°Talk 13:22, 10 May 2024 (UTC)[reply]
But the point is that if one's hypothesis is that if this approach gives time to think about one's gender and possibly reconsider going onto cross sex hormones, then one might reasonably expect a study looking at this therapy to demonstrate a good portion of the children do indeed reconsider.
Not necessarily, you are conflating "they are mandated time to think because others are worried they might change their mind" with "they need time to think because enough will change their mind". If the hypothesis is "a significant percentage of kids who say they're trans will change their mind given time", and the data shows "the majority don't change their mind given time", the hypothesis was wrong.
I think the key issue is almost everybody knows "time to think" is bullshit, but
  • 1) from a non-pathologizing approach: if delaying their transition doesn't make them change their mind, why delay the transition in the first place is the obvious answer (as moved towards by WPATH SOC 8). But, the issue is parents who won't sign off to a 14 year old starting HRT are slightly more likely to allow them to take PB until 16 then decide (we must remember healthcare access for trans youth is entirely mediated by their parents' fears, concerns, and prejudices).
  • 2) from a pathologizing approach: running on the assumption being transgender and transitioning are things to be avoided if possible, if the majority of kids who say they're trans and want to transition continue doing so after being made to wait in the hopes they'll change their mind, the problem is not enough are changing their mind as hoped.
But worth noting, international medical consensus is: 1) being transgender is not a pathology or a bad thing, 2) this applies to transgender youth too, and 3) attempts to convince trans people they're not trans is unethical and conversion therapy. So, the former holds more weight. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 17:48, 10 May 2024 (UTC)[reply]
Colin, Void, the idea that it's "cementing" a medical pathway relies on a pathologizing framework and relies on fundamental misunderstandings of how the care is provided.
I think you may not understand how the trans youth themselves view blockers - almost none actually want them, they're just a lesser evil. If you want to medically transition and take HRT, you are required to go through the "time to think" if your parent or doctor thinks you're too young.
The reason so many kids go from puberty blockers to hormones is they wanted to go on hormones in the first place and were told the best they could get is blockers. It's not a bunch of kids saying "I don't know my gender or if I want to take HRT, can I pause puberty to figure out", it's them saying "I know I'm trans and want to take HRT, if I have to do this bullshit waiting period until then I will, at least the incongruent puberty won't actively get worse".
If a trans kid is explicit they want to medically transition, and continues to be explicit they want to medically transition, and therefore signs up the delayed "time to think period" required of them to transition, it is mental gymnastics to arrive at the conclusion the waiting period they're forced to go through to transition is what's making them want to transition. The only way the "cementing" idea makes sense is if you handwave away the fact they all explicitly identify as transgender and explicitly want to transition because of some vague unfounded and unevidenced hope that they'll suddenly stop identifying as trans. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 18:23, 10 May 2024 (UTC)[reply]
Thinking back on all these discussions, it looks like the article should say that three reasons are given (e.g., the stories told to legislators and taxpayers):
  • stabilize (not improve) GD-related distress
  • time to think about whether you want cross-sex hormones
  • make future passing easier if you pursue cross-sex hormones
The stories supportable by evidence are:
  • it might not make GD worse
  • if started early enough, it can contribute significantly to passing
  • if started early enough, it has significant negative effects on adult sexual function
  • if done long enough, it has significant negative effects on bone density
What's actually happening in the UK specifically is:
  • teens can't go on CSH until they've done PB for a year, even if they have completed puberty, so it's a bureaucratic step for teens who have already decided to do CSH. Consequently, "time to think" is not easily measured in this population.
I think the place to present part of this in the article is under ==Medical uses==, "Puberty blockers are intended to allow patients more time..." We could follow that list of reasons with the fact that these rationales are only getting lip service in the research (which is not normal: usually, the rationale for treatment is the key outcome). WhatamIdoing (talk) 16:01, 10 May 2024 (UTC)[reply]
I broadly support this. I do think it might not make GD worse isn't the full story though - I don't think anyone suggested it could make it worse and it's prescribed to stop GD getting worse so "might not make it worse" is an inverse of what we know: "It doesn't make GD improve but possibly prevents it from worsening", as evidenced by the NICE and KIND reviews conclusions below.
Studies that found differences in outcomes could represent changes that are either of questionable clinical value, or the studies themselves are not reliable and changes could be due to confounding, bias or chance. 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.[9]
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.[10] Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 17:58, 10 May 2024 (UTC)[reply]
The one study I read earlier this week said that just under 20% of the kids self-reported self-harm before PB and just over 30% of the kids self-reported self-harm after going on PB. The authors said they didn't believe that the +50% relative risk change they actually found was causal (they speculated that if they had had an untreated control group, it might have seen an equal or greater deterioriation). The story reminded me of the path to a good grade in freshman chemistry lab: Draw the curve, plot the points, and take the measurements. We always had a good story for why the results we got didn't line up with the results we thought we were supposed to get.
By the way, if nobody's suggesting that PBs can make mental health worse, then I suggest to you that the research community has too few menopausal women in it. Hormone changes always have the potential to make mental health worse, especially in the short term.
Anyway, for the purpose of article content, I don't think we should overstate this in either direction. It doesn't seem to improve mental health in the short term, and regardless of whether it's proven to the usual level (e.g., the level used to talk about mental health effects for the same drugs when they're used to treat prostate cancer), the community has rationalized the belief that it also doesn't hurt. "Mixed results" is a phrase we use in some other drug-related articles, and it might be useful here. WhatamIdoing (talk) 18:51, 10 May 2024 (UTC)[reply]
By the way, if nobody's suggesting that PBs can make mental health worse, then I suggest to you that the research community has too few menopausal women in it. Hormone changes always have the potential to make mental health worse, especially in the short term.
  • We were discussing GD, not mental health as a whole. You listed it might not make GD worse and I said I do think "it might not make GD worse" isn't the full story though - I don't think anyone suggested it could make it worse and it's prescribed to stop GD getting worse. Gender dysphoria is the distress a person experiences due to a mismatch between their gender identity—their personal sense of their own gender—and their sex assigned at birth. Short term effects on mental health notwithstanding, which I'm pretty sure we already mention in the article, I think the medical community is fairly confident blocking puberty does not worsen gender dysphoria.
I think we should stick to the reviews and "Mixed results" isn't descriptive enough. The NICE and KIND reviews are explicit "this doesn't seem to actively improve or worsen GD or mental health - but those are expected to get worse if untreated so they could be working as intended - but we can't say that for sure" Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 19:12, 10 May 2024 (UTC)[reply]
I don't think that dividing the world into "pathologizing" and "not pathologizing" (or whatever the word is for that) is helpful and comes from activists finding labels to throw at people. For example, "the assumption being transgender and transitioning are things to be avoided if possible" is loaded with the suggestion that anyone thinking that a psychologist might do a bit of their actual job, rather than question why this young person wasn't directly referred to endocrinology the moment the word "trans" crossed their lips, is a transphobic conversion practitioner. It over simplifies the argument make e.g. by Cass who explicitly says they think transition is appropriate and the best thing for some people.
Here's an example: engagement. Who people declare a wish to marry, symbolise this with rings or whatever, and have a period where they have time to think, time to plan and time for their friends to go "Noooooooo!". Nobody is suggesting that marriage is the worst possible outcome to be avoided at all costs. The opposite in fact. It is a recognition that for some couples marriage to each other might not be appropriate. The Dutch protocol that came up with this idea also had the idea that it isn't an appropriate path for everyone who turns up at the clinic. Cass repeats that. Why is accepting that "pathologizing"?
Btw, I think we need to be careful to stick to our sources wrt working out the intentions and evidences. Our sources declare why e.g. time to think is a feature of most protocols. And we have sources debunking that idea. Whether anyone here thinks that debunking might have flaws or not isn't really our concern. And I don't really understand the focus on the peculiar UK use of PB when the reviews looking at them looked at all clinics reporting studies from all over the world. -- Colin°Talk 18:57, 10 May 2024 (UTC)[reply]
I don't think that dividing the world into "pathologizing" and "not pathologizing" (or whatever the word is for that) is helpful and comes from activists finding labels to throw at people. You may think it comes from activists, the World Health Organization and UN[11], the APA, and the scientific literature is all very clear it comes from the fact until about a decade or two ago "transgender identity is a pathology" was a widespread idea, and a harmful one everyone should move away from, and there's been global effort to do so.
For example, "the assumption being transgender and transitioning are things to be avoided if possible" is loaded with the suggestion that anyone thinking that a psychologist might do a bit of their actual job, rather than question why this young person wasn't directly referred to endocrinology the moment the word "trans" crossed their lips, is a transphobic conversion practitioner.
What does a psychologist might do a bit of their actual job actually mean? What is there actual job here? Mandating psychotherapy as a requirement to transition ended decades ago. You seem to be laboring under the misapprehension that if a kid says "I am trans and also have these mental health issues", affirming them means giving them HRT and saying they don't have mental health issues. It doesn't, it just means "identifying as trans" isn't considered a mental health issue - because it isn't. The assumption being transgender and transitioning are things to be avoided if possible - is not loaded with any suggestions, that assumption is just transphobic plain and simple.
It over simplifies the argument make e.g. by Cass who explicitly says they think transition is appropriate and the best thing for some people. - this argument would hold more weight if the pathologizing approach for decades had not been "we'll let some trans people transition only if trying to talk them out of it for years doesn't work". The rhetorical trick "transition is appropriate for some who want it" hides the real message "but we don't think it's appropriate for most who want it" Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 19:46, 10 May 2024 (UTC)[reply]
So here's a question (pun not intended): Are PBs for kids who are Questioning (sexuality and gender)? Or just for kids who are consistently, persistently, insistently trans? WhatamIdoing (talk) 02:04, 11 May 2024 (UTC)[reply]
In both theory and practice, they are only given to the latter in the hope they're the former.
To get prescribed puberty blockers, you have to have diagnosed gender dysphoria or gender incongruence. Both of those are defined by 1) insisting you are transgender 2) insisting you want to medically transition.
The original dutch protocol[12] was explicit they're given to 1) to prevent psychological trauma from the wrong puberty 2) making it easier to pass but also 3 as a very helpful diagnostic aid, as it allows the psychologist and the patient to discuss problems that possibly underlie the cross- gender identity or clarify potential gender confusion under less time pressure. It can be considered as ‘buying time’ to allow for an open exploration of the SR wish (8). They defined the requirements for this treatment as being the same as the 16-18 year old camp, which was (ii) suffering from life-long gender dysphoria that had increased around puberty, (iii) functioning psychologically stable, and (iv) supported by their environment.
So they only gave it to the kids who were really sure they wanted to transition, who they cleared as otherwise psychologically healthy per their diagnostic criteria, but still with the expectation that they were wrong and the "waiting time" would allow them change their minds. The conflict between hope they'll desist and reality they won't is exemplified with the quote: By starting with GnRHa their motivation for such exploration enhances and no irreversible changes have taken place if, as a result of the psychotherapeutic interventions, they would decide that SR is not what they need. However, until now, none of the patients who were selected for pubertal suppression has decided to stop taking GnRHa. On the contrary, they are usually very satisfied with the fact that the secondary sex characteristics of their biological sex did not develop further. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 20:38, 12 May 2024 (UTC)[reply]
Can we (realistically) source that? "These are only given to kids who are definitely already trans" (if true, etc.) would be a useful thing to state in the article. WhatamIdoing (talk) 00:18, 13 May 2024 (UTC)[reply]
I didn't say "definitely already trans", I said diagnosed with GD/GI, which in medical terms means the person went to a clinic and said "I consider myself different gender than assigned at birth and want to medically transition".
I don't think this is hard to source, the York review on PBs is about them in relation to adolescents experiencing gender dysphoria/incongruence and analyzed about 10,000 of them[13]
The WPATH soc 8's chapter 6 (Adolescents) provides a decent overview and says We recommend health care professionals use gonadotropin releasing hormone (gnrH) agonists to suppress endogenous sex hormones in eligible* transgender and gender diverse people for whom puberty blocking is indicated, it's statement 6.12 going into more details.[14]
The dutch protocol's requirements, per my other comments but summarized by the Cass review: Minimum age 12, life-long gender dysphoria increased around puberty, psychologically stable without serious comorbid psychiatric disorders that might interfere with the diagnostic process and family support ie they only gave it kids they were pretty sure already were trans.[15]
From the endocrine society[16]: We suggest that adolescents who meet diagnostic criteria for GD/gender incongruence, fulfill criteria for treatment (Table 5), and are requesting treatment should initially undergo treatment to suppress pubertal development.
Here's another review starting with Increasingly, early adolescents who are transgender or gender diverse (TGD) are seeking gender-affirming healthcare services. Pediatric healthcare providers supported by professional guidelines are treating many of these children with gonadotropin-releasing hormone agonists (GnRHa), which reversibly block pubertal development, giving the child and their family more time in which to explore the possibility of medical transition. and the majority (71%) of participants in these studies required a diagnosis of gender dysphoria to qualify for puberty suppression and were administered medication during Tanner stages 2 through 4. [17]
What I'm trying to get at is statements in the lead such as 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. would be more appropriately Puberty blockers are prescribed to transgender early adolescents after Tanner Stage 2 to delay the development of unwanted secondary sex characteristics with the aims of preventing gender dysphoria from worsening, making it easier to pass in future, and giving the minor time to change their mind. The practice of perscribing puberty blockers for these purposes began in the 1990s in the Netherlands due to transgender youth suffering distress from incongruent puberty and having difficulty passing as they were required to wait until the ages of 16-18 to begin hormone therapy. The majority of youth who request blockers later request hormone therapy. We need to be clearer about why they're prescribed - the previous treatment for early adolescents who everybody involved agreed was obviously transgender and wanted to medically transition was to let them go through an incongruent puberty until the age of majority. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 02:30, 13 May 2024 (UTC)[reply]
"the assumption being transgender and transitioning are things to be avoided if possible" is not the most helpful framing in an article about a medical treatment, because most of the medical literature doesn't deal in the question of whether someone has a certain identity, but rather in terms of whether someone has gender dysphoria. The framework that research operates in is not "transition is to be avoided if possible", it's "gender dysphoria is to be avoided if possible" - and I think there is universal agreement that dysphoria is a bad thing. Cass, for example, makes no statement on whether a trans identity is a desirable or undesirable outcome, and seems to view that as out of her remit. The goal of eliminating gender dysphoria gets confused as being "the elimination of trans identity, and thence trans people", causing horror and accusations of conversion therapy. Barnards.tar.gz (talk) 14:32, 11 May 2024 (UTC)[reply]
The definition of GD is 1) being explicit you are transgender and 2) explicitly wanting to transition. To transition, you are required to get a GD diagnosis. GD replaced transsexualism/gender identity disorder as the diagnosis because the medical establishment needed to provide transition care without framing being trans as the disorder. Trying to separate the frameworks of "how to treat GD" and "how to treat trans people" is like trying to unmix paint.
There is no way to treat GD that is not transition. There is literally no evidence, after ~100 years of looking from thousands of medical professionals and millions upon millions poured into research, of any other treatment for those suffering it than letting them transition. The goal of eliminating gender dysphoria without transition is the goal of making those who want to transition stop wanting to transition, which is conversion therapy, plain and simple. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 20:52, 12 May 2024 (UTC)[reply]
Is this working from a definition of trans that is "AMAB kid is definitely a girl and has been her whole life and would like a body to match", but excluding some non-binary and gender fluid folks (i.e., the ones who aren't interested in related medical interventions)? WhatamIdoing (talk) 00:23, 13 May 2024 (UTC)[reply]
No, this isn't working from a definition of trans at all. "Gender dysphoric people" is medical speak for "the subset of trans people who want to medically transition" per part 2 of the above definition. You can be trans and not want to transition, but if you want to transition you are required to get a GD/GI diagnosis due to insurance, bureaucracy, and the medical system, for better or worse, requiring a code for what you're being treated for. I should have said Trying to separate the frameworks of "how to treat GD" and "how to treat trans people who want to medically transition" is like trying to unmix paint. Doctor's don't give people HRT for the common cold, so as much as they don't want to pathologize 1) trans people or 2) the subset who want medical transition, they give it the second for the code "GD".
However, that being said, depending on where you live you can require a GD diagnosis to change your documentation even if you don't want to medically transition (or can't). In which case, treatment is still individualized these days, you are not required to transition a certain way for a GD diagnosis - you can forego hormones, or surgery, or specific surgeries and not others, and etc - and you are not required to be a "certain kind of trans person" for a GD diagnosis (such as the old standard of the "true transsexual" which required being attracted only to men, desiring to assimilate, wanting bottom surgery, and successfully fulfilling gender stereotypes such as wearing only dresses).
When I say There is no way to treat GD that is not transition, that is because it is equivalent to there is no way to treat [insisting you are transgender and want to medically transition] that is not transition, at least ethically. Because, for over 100 years, doctor's have realized when somebody says "I'm trans and want to medically transition", they will not stop (of their own free will) until you aid their transition because every alternative has been tried. Conversion therapy from religious to secular and talk to electroshock. Anti-depressants and anti-psychotics. Asylums and Applied Behavioral Analysis. If somebody insists they want to medically transition, no treatment has been devised, despite considerable effort, that will change their mind. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 03:04, 13 May 2024 (UTC)[reply]
1) There is subtle but significant slippage when we paraphrase "having GD" as "being transgender". An ontological element has crept in which is not the focus of the medical literature. You said in another comment that GD is "medical speak" - yes, it is, and in a medical article, it's important that we use medical terminology.
2) The idea that There is no way to treat GD that is not transition cannot possibly be true, unless desistance never occurs (but clearly it does). Indeed, this is the very heart of the matter: we don't know which kids will desist. For those that do, their GD may have been alleviated by some process that is not transition, even if that process amounts to doing nothing at all. Is desistance to be counted as conversion therapy?
This is the kind of problem that is all too easy to slip into if you treat GD as merely a medical billing codeword for "being transgender" - it denies the existence of the cohort of people for whom the condition is not a permanent one. Barnards.tar.gz (talk) 16:58, 13 May 2024 (UTC)[reply]
1) When the majority of MEDRS acknowledge "this is medical speak for this demographic because we're in an awkward place of acknowledging their health needs without classifying their existence as a disorder", we should too. The medical literature is very flat out about this and you are trying to unmix paint by appealing to MEDRS which agree the paint is mixed.
2) Please show RS that there is a treatment for GD other than transition. Insofar as there is any evidence of "desistance" - it shows that's only true for (at an overestimated maximum) 10%. If, we don't know which kids will desist, mandating the "treatment" that will be fine for 10% but cause 90% to suffer is self-evidently ridiculous. Desistance, for the record, is based on stats from Kenneth Zucker who treated trans and gender-noncomforming children (ie, not just those who identified as trans) and tried to convince them not to be gender noncomforming or trans at all, to prevent the trans kids from growing up trans and just in case the gender noncomforming kids might grow up trans - he explicitly put steering the kid away from identifying as trans and gender-noncomformity as a treatment goal. He is known for conversion therapy, specifically gender identity change efforts, ie the evidence of high "desistance" rates is a conversion therapist took kids who were trans/gender-noncomforming, put them all through conversion therapy in case they were trans, and then recorded "most didn't identify as trans" as evidence he was effective when that was true when they entered. In actual MEDRS, it is agreed the vast majority of kids who want to transition / consider themselves trans do not "desist"
This is the kind of problem that is all too easy to slip into if you treat GD as merely a medical billing codeword for "being transgender" - which is why I said it's the codeword for "being transgender and wanting to medically transition". it denies the existence of the cohort of people for whom the condition is not a permanent one. But what is the condition according to MEDRS? "identifying as transgender and wanting to medically transition". You can say "some of them might be wrong and or regret transitioning", sure, but the condition according to MEDRS remains the same.
If somebody desires medical transition, what is the treatment, ie the course of action that MEDRS agree is appropriate? For a while it was "try and convince them not to want that", which didn't work, so it became "try and convince them not to want that, then let them medically transition if it doesn't work", which didn't work especially well and still had ethical isues, so it became "help them medically transition with informed consent in accordance with their goals and without judgement", which has worked better and comes from taking human rights and medical ethics into account.
What's funny about this is as I was typing I realized: there actually is one other recognized semi-treatment for GD in adolescents that's not transition: PB and time to contemplate transition, which are given instead of HRT in the hopes the youth will "desist". Even then, if the "GD" (desire to medically transition) persists, it is recognized that nothing apart from transition would help - so we've come full circle to the medical system has been unable to treat "wanting to medically transition" successful in any way other than "letting them transition" or "making them wait a bit so they're sure they want to transition, without making them go through an incongruent puberty, and then letting them transition", which in either case is the same end treatment. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 17:50, 13 May 2024 (UTC)[reply]
The suggestion that desistance isn’t a real thing and is “based on stats from Kenneth Zucker” seems fringe. Barnards.tar.gz (talk) 20:49, 13 May 2024 (UTC)[reply]
When did I say it wasn't real? I said it's true for (at an overestimated maximum) 10%
“based on stats from Kenneth Zucker” seems fringe. - Kenneth Zucker has an article - you can see he's a FRINGE conversion therapist. You can check gender identity change efforts to find the same. And here are multiple sources (including systematic reviews) explaining how he coined the term desistance (a word borrowed in crimonology and pathologizing trans identities) and his studies claiming the majority of transgender youth "desist" were not supported by their own evidence and there's not even an agreed upon definition of desistance [18][19][20][21] [22] I'll quote the best source ( Defining Desistance: Exploring Desistance in Transgender and Gender Expansive Youth Through Systematic Literature Review)[23]:
  • While a standard definition of desistance does not appear to exist,7,17 desistance alludes to the idea that GD or a TGE identity in pre-pubertal children will either “persist” through puberty or will “desist,” and the child will no longer have GD/a TGE identity after puberty. Articles from the 1960s to 1980s are often cited as the foundation for research on “desistance.”18–21 One of the most significant studies is from a book published by Richard Green in 1987 entitled “The ‘Sissy Boy Syndrome’ and the Development of Homosexuality.”22
  • Despite being the foundation for desistance research, these early articles and books never mention desistance, rather focusing on the “gender deviant” behavior of femininity in people designated male at birth, and how this behavior is more often a predictor of homosexuality rather than “transsexualism.”18–21 No one designated female at birth was included in the studies conducted at this time, and all of these studies employed techniques to actively decrease the gender-deviant behavior, leading to psychological trauma for many of the participants.
  • Desistance as a word has its origins in criminal research,28 and Zucker explains that he was the first person to use desistance in relation to the TGE pre-pubertal youth population in 2003 after seeing it being used for oppositional defiant disorder (ODD).
  • From all of these collections of studies emerged the commonly used statistic stating that ∼80% of TGE youth will desist after puberty, a statistic that has been critiqued by other works based on poor methodologic quality, the evolving understanding of gender and probable misclassification of nonbinary individuals, and the practice of attempting to dissuade youth from identifying as transgender in some of these studies
Good rule of thumb: if you find yourself mentioning FRINGE and Kenneth Zucker in the same sentence, and your argument is criticisms of him and not his own positions are FRINGE, you should really reconsider your argument... Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 21:17, 13 May 2024 (UTC)[reply]
Regardless of what you think about Zucker, he doesn’t own desistance, and the concept isn’t based on him or his stats. It’s the topic of many papers by a range of researchers, and one that is taken seriously by MEDRS sources (e.g. by Cass), not dismissed. Whether the rate is 10% or 80%, it’s a pathway out of GD. So there is a non-transition resolution to GD that manifestly isn’t conversion therapy, and so can you please stop calling everything-that-isn’t-transition conversion therapy? Barnards.tar.gz (talk) 21:59, 13 May 2024 (UTC)[reply]
And as the MEDRS above note, the concept is not actually well defined or supported, and was indeed based on his stats. The claim "most kids who identify as trans change their minds" is pure WP:FRINGE.
The fact Cass quoted Zucker so extensively has in fact been one of the criticisms[24] so can you please stop calling everything-that-isn’t-transition conversion therapy? - I'mma call a spade a spade, Zucker practiced conversion therapy. The "most kids desist" idea was based on studies of youth put through conversion therapy. You cannot dance around that fact. Please don't call conversion therapy everything-that-isn't-transition because WP:CIR and Kenneth Zucker's article is right there as is the paragraph on his work in gender identity change efforts.
Whether the rate is 10% or 80% it's not 80%, and those 2 numbers are very different, , it’s a pathway out of GD. So there is a non-transition resolution to GD that manifestly isn’t conversion therapy, - and you keep ignoring my question, what is the treatment for GD? I am saying "for about 100 years, when a person wants to transition, nothing we do or say can stop them, so the treatment is letting them transition". You are saying "some people, who haven't transitioned, but plan to, decide not to, so when somebody wants to transition the treatment is __________"? (that blank is the question I keep asking you) You repeating "some people change their mind about transition" is irrelevant to the question: "what is the recognized medical treatment for wanting to transition"? Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 22:39, 13 May 2024 (UTC)[reply]
You are slipping the terminology again. "Wanting to transition" is not a medical condition. You might think it sounds kinda like the same thing as gender dysphoria, and there is certainly overlap, but as you can see from the DSM-V[25], it's possible to have a GD diagnosis without wanting to transition. I mention this not to refute your central point, but to illustrate that playing fast and loose with the terminology is risky, and this is a topic where terminology is so important. If you substitute "gender dysphoria" with "being trans and wanting to transition", you've already implicitly begged the question.
I will ignore the CIR aspersion on the assumption that you thought I was trying to make any statement about what Zucker is or isn't, or what the desistance rate is or isn't. What I actually said was that desistance is a concept that has been studied independently of Zucker, so criticism of Zucker doesn't invalidate the concept. When Cass cites Zucker, she immediately then notes criticisms of his study, and then cites other independent studies, not as evidence for a recommended treatment, but to show that desistance is a non-trivial phenomenon worthy of consideration. You might think the desistance studies are poor quality, just like the transition studies, but that's not an argument for ignoring it, just like the poor quality of transition studies isn't an argument for ignoring that transition might benefit some people.
Now to your central point: first, I assume we are talking about youth GD, since we're on the Puberty Blocker page. There is no well-evidenced treatment for gender dysphoria, as we have seen from Cass. It might be that transition works for some people, it might be that some kind of therapy works for some people, it might be that doing nothing at all works for some people. We don't know. The evidence isn't good enough, and the guidelines aren't good enough. More research is needed, and options should be kept open, not shut down with tendentious accusations of conversion therapy for things that plainly aren't. It's very unhelpful for you to stridently present unsettled science as objective fact. Barnards.tar.gz (talk) 09:55, 14 May 2024 (UTC)[reply]
But you're ignoring the sociological context of "who gets a GD diagnosis and why" and "why was the diagnosis created" and "to whom is the diagnosis meant to refer"?
it's possible to have a GD diagnosis without wanting to transition. but it's impossible to transition without a GD diagnosis and the GD diagnosis exists to let people transition billably.
Here's what the APA says about gender dysphoria[26]:
  • In the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), people whose gender at birth is contrary to the one they identify with will be diagnosed with gender dysphoria.
  • DSM-5 aims to avoid stigma and ensure clinical care for individuals who see and feel themselves to be a different gender than their assigned gender. It replaces the diagnostic name “gender identity disorder” with “gender dysphoria,” as well as makes other important clarifications in the criteria.
  • For a person to be diagnosed with gender dysphoria, there must be a marked difference between the individual’s expressed/experienced gender and the gender others would assign him or her, and it must continue for at least six months. In children, the desire to be of the other gender must be present and verbalized.
  • Gender dysphoria is manifested in a variety of ways, including strong desires to be treated as the other gender or to be rid of one’s sex characteristics, or a strong conviction that one has feelings and reactions typical of the other gender. The DSM-5 diagnosis adds a post-transition specifier for people who are living full-time as the desired gender (with or without legal sanction of the gender change). This ensures treatment access for individuals who continue to undergo hormone therapy, related surgery, or psychotherapy or counseling to support their gender transition.
  • Persons experiencing gender dysphoria need a diagnostic term that protects their access to care and won’t be used against them in social, occupational, or legal areas
  • When it comes to access to care, many of the treatment options for this condition include counseling, cross-sex hormones, gender reassignment surgery, and social and legal transition to the desired gender. To get insurance coverage for the medical treatments, individuals need a diagnosis. The Sexual and Gender Identity Disorders Work Group was concerned that removing the condition as a psychiatric diagnosis—as some had suggested—would jeopardize access to care
Here's what the world health organization says about gender incongruence[27]:
  • ICD-11 has redefined gender identity-related health, replacing outdated diagnostic categories like ICD-10’s “transsexualism” and “gender identity disorder of children” with “gender incongruence of adolescence and adulthood” and “gender incongruence of childhood” respectively. Gender incongruence has been moved out of the “Mental and behavioural disorders” chapter and into the new “Conditions related to sexual health” chapter. This reflects current knowledge that trans-related and gender diverse identities are not conditions of mental ill-health, and that classifying them as such can cause enormous stigma. Inclusion of gender incongruence in the ICD-11 should ensure transgender people’s access to gender-affirming health care, as well as adequate health insurance coverage for such services.
  • Gender incongruence of adolescence or adulthood : Gender Incongruence of Adolescence and Adulthood is characterised by a marked and persistent incongruence between an individual´s experienced gender and the assigned sex, which often leads to a desire to ‘transition’, in order to live and be accepted as a person of the experienced gender, through hormonal treatment, surgery or other health care services to make the individual´s body align, as much as desired and to the extent possible, with the experienced gender. The diagnosis cannot be assigned prior the onset of puberty. Gender variant behaviour and preferences alone are not a basis for assigning the diagnosis.
IE - the people who defined GD and GI were explicitly clear, repeatedly, the diagnosis was a workaround to replace "being trans" as the diagnosis - to continue giving care to trans people without diagnosing them with "gender identity disorder" OR "transsexualism". It is not me (or, just me) saying "GD is non-pathologizing medical speak for being trans" - it is the APA and the WHO. And they are in agreement, for those who want to medically transition, the treatment is to help them do so. Not to try convince them they shouldn't. Not to make them wait it out. None of that. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 15:42, 14 May 2024 (UTC)[reply]
They do not literally say that. You are executing a masterpiece of paraphrase and synthesis, and the abstraction is leaking. Barnards.tar.gz (talk) 16:40, 14 May 2024 (UTC)[reply]
Zucker and Bradley put desistance at 88% in a followup study in 2021, but other clinicians have put desistance at 70-80% so even if Zucker's numbers are high, they are miles away from the "1%" desistance numbers often touted. Zucker's cohort is boys seen between 1989 and 2002, the majority are now gay or bisexual men, and this study achieved a 96% participation rate.
Whatever the individual reasons for these outcomes, simply waving research like this away as "conversion therapy" is to say that you would consider those 88% of mostly gay or bisexual men a failure, and they should have transitioned, but have been "converted" away from being the trans women they should have been. Really? Are you 100% sure about that? Can that claim be backed up with MEDRS?
The demographics presenting have changed drastically since this cohort, in terms of age, sex, numbers, and standard of intervention.
It used to be tiny numbers of same/both-sex attracted boys, presenting pre-adolescence, and even conservatively 70% grew out of it. Virtually the entire dutch protocol was based on same-sex attracted boys (only one was heterosexual in the initial cohort IIRC).
Now this has been applied to orders of magnitude more same/both-sex attracted girls, presenting in adolescence, with a lower diagnostic threshold, and if they are given puberty blockers less than 1% grow out of it.
Please stop dismissing difference of medical opinion as WP:FRINGE. The binary framing of "affirmation model" vs "conversion therapy" is a false and unhelpful one. There are huge open questions here, a paucity of high quality research, and this article needs to stick to what MEDRS actually say. Void if removed (talk) 10:35, 14 May 2024 (UTC)[reply]
And those studies are discussed above.
Whatever the individual reasons for these outcomes, simply waving research like this away as "conversion therapy" is to say that you would consider those 88% of mostly gay or bisexual men a failure, and they should have transitioned, but have been "converted" away from being the trans women they should have been. Really? Are you 100% sure about that? Can that claim be backed up with MEDRS? - a nonsensical claim: Zucker did not see "kids who identified as trans and wanted to transition" - he saw "kids who were in any way gender noncomforming".
  • 1) Claiming the majority of kids who say "I'm trans and want to transition" change their mind is stupid when your evidence is "I asked people who didn't identify as trans when they entered my clinic if they identified as trans as trans when they left and their answer continued to be no". and they should have transitioned, but have been "converted" away from being the trans women they should have been. Watch your logic in action: "I asked everyone who walked into a building if they were gay - most said no - when they exited they continued to say no - this is proof the majority of gay men will go back to being straight - if you disagree or point out the flaws in my study, you're saying those straight people should have been converted to be gay"
  • 2) Conversion therapy is the pseudoscientific practice of attempting to change an individual's sexual orientation, gender identity, or gender expression to align with heterosexual and cisgender norms - Zucker attemped to clamp down on gender variant expression as pathological. For the record, when the paper I quoted said all of these studies employed techniques to actively decrease the gender-deviant behavior, leading to psychological trauma for many of the participants. - you can read Zucker's article - that was because he thought the gay kids should be gender conforming. He thought kids who explicitly identified as trans should be discouraged. He definitely put the trans kids through conversion therapy, but he also did it to the gay kids. Unless, it's not conversion therapy to tell effeminate gays they're not masculine enough and having their parents try and correct that? FFS read Kenneth Zucker and gender identity change efforts.
  • 3) The demographics presenting have changed drastically since this cohort, in terms of age, sex, numbers, and standard of intervention. - the cognitive dissonance here is actually shocking. The old demographic was "anybody gender noncomforming", the new one is "people who explicitly want to transition" - you are simultaneously saying "these are so different we can't compare them" and "the majority of people who want to transition grow out of it, look at the study of gender noncomforming youth"
  • 4) Can you manage, or try, to not misgender and infantilize trans kids in your comments? Virtually the entire dutch protocol was based on same-sex attracted boys (only one was heterosexual in the initial cohort IIRC) - straight transgender girls. Now this has been applied to orders of magnitude more same/both-sex attracted girls, presenting in adolescence, with a lower diagnostic threshold, and if they are given puberty blockers less than 1% grow out of it. - straight/bisexual transgender boys. Not "girls who don't grow out of it".
  • 5) I'd like to interact with you on one article where I didn't have to deal with your promotion of fringe nonsense and conversion therapy as a "difference of opinion".
Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 14:51, 14 May 2024 (UTC)[reply]
I disagree quite strongly with your continual overuse of accusations of WP:FRINGE but in particular I would like you to not accuse me of promoting conversion therapy please. Void if removed (talk) 16:01, 14 May 2024 (UTC)[reply]
Let's move this conversation over here please, it's quite hard to read out by the right margin. Loki (talk) 17:14, 14 May 2024 (UTC)[reply]
It would help if you read what I wrote, and you quoted, rather than leap into a lecture on word origins. I never said that term itself was an activist term or inherently problematic. I said dividing the world into two blunt groupings is not helpful and is an activist tactic: one sees it in every form of activism and politics. It is an indicator the writer wants simply to score points rather than understand or explain nuance, and to push people and works into good and bad boxes.
I'm not here to debate the pathologizing of being trans. Do you any sources to back up your claim that children wishing physical transition have not since "decades ago" been referred to a team of clinical psychologists. The Dutch Protocol comes from: Annelou L. C. de Vries, "a child and adolescent psychiatrist working at the Amsterdam UMC/ Levvel Amsterdam Academic Center of Child and Adolescent psychiatry" and Peggy T Cohen-Kettenis is "is Professor of gender development and psychopathology at the Department of Child and Adolescent Psychiatry, University Medical Center Utrecht." and "a registered clinical psychologist and psychotherapist". In the UK, GIDS was part of a mental health trust and its director, Polly Carmichael, a consultant clinical psychologist. This is basic stuff, YFNS. -- Colin°Talk 16:33, 12 May 2024 (UTC)[reply]
I semi-divided it into 2 blunt groupings, I was also being a fair bit more nuanced than you're giving me credit for, my thesis was PBs developed as part of a dialectic between a trend towards pathologization and a trend away from it and cannot be classified fully into either approach because both poles both approve/disapprove of them for different reasons. And as I've explained to you a few times, I think PBs are overall a stupid treatment - and insofar as I'm on a "side" I'm on the depathologizing one, which is currently the main champion of blockers, so your accusations of binary thinking fall flat when I'm calling a plague on both their houses.
You framed the assumption being transgender and transitioning are things to be avoided if possible as a fear that psychologist might do a bit of their actual job. That's categorically wrong, a psychologist doing their actual job treating trans kids should absolutely not assume transition should be avoided and a cis identity is preferable to a trans one. That assumption is the key underlying idea behind the pathologizing approach.
I did however make a mistake, my apologies, requiring psychotherapy to transition was somewhat dropped decades ago for adults in the WPATH SOC 5 (1998). It did however, keep the requirement of psychotherapy for youth and recommend against social transition until 18 (with at least 6 months of a shrink before social transition in case they want to do so earlier) [28]
Instead of Mandating psychotherapy as a requirement to transition ended decades ago, perhaps more clear and truthful would have been assuming that transition should be avoided if possible and mandating that trans people wanting to transition should be subject to psychotherapy aiming to figure out how trans they are or if they're just crazy ended about a decade and a half ago. Noting your dutch protocol example, they low-key assumed being trans should be avoided, which is why they gave the kids PBs instead of HRT. However, they did not encourage the kids not to be trans and did not mandate conversion therapy and etc, they just assumed some were wrong and thus PBs gave them time to figure it out without forcing them through an incongruent puberty in the meantime. A little pathologizing, mostly not. For the context of its time, incredibly depathologizing. A better example of high-key assuming being trans is pathological is Kenneth Zucker, whose treatment for trans kids was explicitly based on trying to steer them away from 1) transition and 2) transgender identity at all - even he wasn't 100% pathologizing (more like 95%) as he supported transition if conversion therapy during childhood didn't work.
Anyways, I'm not sure what we're even discussing with relation to the article. Getting back on track, it is my belief that we should better cover 1) the reasons given for why PBs are given to trans kids (primarily the suggestion it buys time for them to figure out their gender) 2) the contradictory fact the requirement for being prescribed them is being explicit you're trans and want to transition in the first place, and 3) the historical context for why they prescribed. Wrt the latter: for an article on a treatment for trans kids we should probably mention what treatment it replaced, which was at best going through an incongruent puberty until at least 16 years old if you were lucky and at worst just straight up getting conversion therapy. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 22:24, 12 May 2024 (UTC)[reply]
the reasons given for why PBs are given to trans kids
I cited MEDRS above, giving multiple reasons, we should stick to those. Void if removed (talk) 11:05, 13 May 2024 (UTC)[reply]
You cited a MEDRS, which doesn't contradict what I said at all.
  • 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.
  • I said the reasons given for why PBs are given to trans kids (primarily the suggestion it buys time for them to figure out their gender), which the original and newer reasons cited both include. I'm somewhat surprised they split them as separate though, the "time for gender exploration" in the original was pretty clearly it was because they didn't think the kids could commit to HRT/SRS at that age and they wanted them to be older when they started HRT in case they changed their mind - it's different language for the same premise.
I think the lead is overly politicized at the moment and should better cover
  1. the reasons why they are given (per the above, we're not actually disagreeing about anything)
  2. in what cases they are perscribed (per that same MEDRS National and international guidelines have changed over time and outline that medications to suppress puberty can be considered for adolescents experiencing gender dysphoria/incongruence., but through other MEDRS like those I cited to WID in this thread we can more clearly say that means kids who explicitly identity as trans and desire/are seriously considering medical transition). Relatedly, I think we should better summarize the dutch protocol and affirming shift.
  3. what treatment option they replaced (ie, letting even the youth that the clinicians, shrinks, parents, and kids themselves involved were 100% sure were trans and would benefit from transition go through an incongruent puberty until the age of majority, and those who went through that had more difficulty passing and more stress)
Thoughts on updating the lead to better cover those 3 points? Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 16:59, 13 May 2024 (UTC)[reply]
Well... I looked at the first paragraph of the lead, and I'm thinking that WP:TNT might be the best approach. For example, it says "used to postpone puberty in children", but it's mostly used in teenagers (and also young adults).
But for your #1, I think that the reasons (plural) are sort of sub-reasons. The "one reason" is: these young people want medical transition. The "multiple sub-reasons" are that we're not sure if a teenager not meeting the Dutch protocol actually knows what they're talking about, etc. WhatamIdoing (talk) 19:54, 13 May 2024 (UTC)[reply]
I'm not sure if we need TNT, just to draft a new lead.
Wrt your point on the "one reason", I don't think you can split it up like that, I think it's more accurately: these young people want medical transition and we don't believe they're old enough to consent to that but letting them go through an incongruent puberty is not a neutral option. PBs don't make sense unless the second part is included. we're not sure if a teenager not meeting the Dutch protocol actually knows what they're talking about - doesn't track because the Dutch Protocol had the same root issue: those meeting all the stringent requirements were given blockers instead of HRT until 16 years old in case they changed their minds anyways.
This is why I think we need to better frame it in terms of the previous / alternative treatments for transgender adolescents - the reasons for perscribing PBs need the context of what they replaced.
  1. no medical care / psychotherapy only (what preceded PBs): kids who wanted to transition kept identifying as trans and transitioned when they reached the age of majority, but the delay caused irreversible pubertal changes that caused them lasting distress and difficulty passing
  2. HRT (what they chose PB over): had been known to work for trans adults for decades, but they worried minors couldn't consent to that and might change their mind so didn't perscribe them
  3. PB's therefore addressed the issues with both treatments by being the middle ground between "let them transition now" and "let them transition as an adult after incongruent puberty", settling on "let them transition as late teens if they still want to without having to go through incongruent puberty".
Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 20:49, 13 May 2024 (UTC)[reply]
I keep getting reminded of a statement Cass made in the interim review, that BOTH SIDES cite WEAK or NON-EXISTENT science and made BOLD CONFIDENT CLAIMS. We end up with arguments like above where old poor studies on AMAB kids are fought about when that isn't even the referral cohort any longer.
The interview with Cass in the NYT sheds light on how the US is being forced into a not-giving-an-inch position as a result of politicians writing the clinical rules in over two dozen states. There's just too much in the above discussion which seems to be personal opinions, which are at one end of the scale, and don't acknowledge the existence of either alternative opinions, or even actual practice on the ground.
Further up a MotherJones article was linked as though evidence that Cass was seriously criticised by anyone we might take seriously. The text in that article says "More than once she cites notable exploratory therapists like Ken Zucker." As Void notes above, Cass immediately goes on to criticise that research. More importantly, you can check for yourself. Just open the Cass Review yourself and search for Zucker. He only appears in the "History of gender services for children and young people" where a study from prehistoric 1985 is mentioned and then immediately criticised and later in a summary of guidelines on social transition, where he is mentioned as being party of "early papers" and then also immediately criticised. This article also bangs on about RCTs and repeats the misinformation myth that seems now to be going around that although the York Reviews carefully examined the majority of research, none of which was RCT, Cass herself set a higher bar, with the confusing line "Some experts suspect that may be because she compared the research to RCTs despite their inappropriateness." Some unnamed experts eh? With their "suspicions". Or maybe the author's twitter echo chamber? I mean, Cass spends a lot of time citing and commenting on low quality research, with a critical eye, so we'd expect them to cite the odd discredited researcher if they played a role in the history of trans guidelines. It is a bit like, if Cass had concluded differently, a Telegraph writer had complained that Cass kept mentioning "the discredited WPATH". There's a body of research, and some of it, in a review like this, needs mentioned, even if to then be critical of it. We really don't need BS articles like that one informing our minds.
I think some of the "history" in the Cass Review may be useful to describe how thinking in this area has come about and whether in 2024 with the population cohort we are seeing at gender clinics, it is evidence based. We need to be careful to separate "this is why people, in the past, who mostly saw one or two AMAB kids a week, thought these might be useful" to whether there is a clinical consensus and evidence that this is the case in 2024. -- Colin°Talk 16:17, 14 May 2024 (UTC)[reply]

Public opinion

The ==Public opinion== section is a laundry list of American public opinion polls, most of which are not specific to puberty blockers. I'm inclined to blank the section. What do you think? WhatamIdoing (talk) 23:00, 9 May 2024 (UTC)[reply]

Yeah, that section makes sense for a theoretical puberty-blockers-as-political-issue article, but if we're focusing this article on puberty-blockers-as-treatment it makes zero sense here. Loki (talk) 23:15, 9 May 2024 (UTC)[reply]
Agreed, this also helps bring the article a bit more in line with the medical focus as was called out further up on the talk page in Talk:Puberty blocker# Overall article structure. Raladic (talk) 06:02, 10 May 2024 (UTC)[reply]
Completely agree with all of the above. Removing it entirely is the best option it seems. Cixous (talk) 12:56, 10 May 2024 (UTC)[reply]
The ayes have it, then. I've removed the section. WhatamIdoing (talk) 18:53, 10 May 2024 (UTC)[reply]

Summary

Is this correct? And are there any others (NHS?) that would be relevant?

Comparison
Requirement 1990 Dutch protocol 2017 Endocrine Society guideline 2022 WPATH SOC (Other?)
Diagnosis gender identity disorder? transsexualism? (would have been the DSM-III era) gender dysphoria per "the newer, stricter criteria of the DSM-5" gender incongruence per ICD-11, if a formal diagnosis is legally required
Starting age minimum of 12 (per Dutch law) Tanner 2 (gives example of age 9) Tanner 2 (gives example of age 7 for AFAB and 9 for AMAB as earliest expected Tanner 1)
Expected end age 16 (per Dutch law) age 16 (old enough to consent to CSH) age 16 (old enough to consent to CSH)
Persistence lifelong trans identity "long-lasting and intense" "marked and sustained over time", usually "several years"; for newly identified pubertal trans kids, consider menstrual suppression/androgen blocking instead of PBs
Psychological status must be stable, with no serious untreated psychiatric conditions GD worsened with the onset of puberty, plus otherwise "stable enough to start treatment" other mental health issues addressed sufficiently to being treatment
Family support required parental consent if legally required –
Informed consent required required required
Fertility consent – should be "informed" required

Looking at this, I see several areas of agreement, a few that are different, and a few that strike me as very different from what the politicians claim (e.g., none of them accept sudden changes, none of them recommend PBs for all trans-identifying people).

I wonder whether a table like this might be helpful for this article. WhatamIdoing (talk) 05:14, 14 May 2024 (UTC)[reply]

This is a great summary of everything! For the Dutch protocol, the diagnosis would either have been 'gender identity disorder' (per the DSM-IV-TR) or 'transsexualism' (per ICD-10). I would need to check if fertility counseling was a part of the original protocol, but per the 2017 Dutch guidelines it is deemed necessary before PBs and (again) before GAHT. The official first version of the Dutch protocol was published in 2006 and probably goes into more depth than I can do here.
It may be interesting to add another column on the current Dutch guidelines: the minimum age of 12 was changed to Tanner stage 2G/2M (though a retrospective study found that no one actually got onto PBs before 13, IIRC, with the average of getting blockers being around 14.5) and children were allowed to get onto GAHT at age 15 if they had their puberty suppressed for a longer amount of time (not sure about what amount of time we're talking about, but probably longer than a year).
The Finnish guidelines can be found in an English document at the site of COHERE Finland. It stresses that other mental health issues need to be tackled before adolescents can be referred to one of the two Finnish GID clinics.
Again, great work! I think a table can really clarify the differences between guidelines.
PS: Sorry for not providing any links. I can't access my laptop atm. I'll look if I can add them later :) Cixous (talk) 15:13, 14 May 2024 (UTC)[reply]
Is the "official" Dutch (whether 2006 or 2017) something like a government regulation, or is it a more independent industry thing? I guess I'm asking whether it's more like an NHS rule (the public health system isn't allowed to deviate from it) or more like WPATH's SOC (not really binding on anyone). WhatamIdoing (talk) 23:03, 14 May 2024 (UTC)[reply]
If I am correct, the original protocol (2006) was published in a European Proceedings of Endocrinology journal (or sth to that effect). Back in the day, only VUmc had a GID clinic, so you might extrapolate that it was simply used by one clinic and not 'binding'. The 2017 guidelines, however, was written in a context where multiple providers had emerged and/or started to emerge (up to the point that two extra dedicated hospital centres have been opened for GID treatments for minors). The latter was published by the Ministery of Health, Wellfare and Sport and makes stringent recommendations about the minimal requirements for caregivers and surgeons (it's a collaborative guideline created by multiple Dutch health bodies), so that one is binding Cixous (talk) 06:21, 15 May 2024 (UTC)[reply]

Timing

This is related to the tangent above about desistance. I noticed this line in the Endocrine Society's treatment guideline yesterday: "the GD/gender incongruence of a minority of prepubertal children appears to persist in adolescence".

As in: An actual majority of young children with gender dysphoria do not become teenagers with gender dysphoria.

I think this article is unclear about matters of timing, and the picture I'm forming looks like this (additions, corrections, and clarifications are welcome):

  • Nobody recommends PBs to prepubertal GD kids, because most of them will stop having GD during puberty. (Also, they'd get all side effects and no benefit at that stage, because there's no puberty to block yet.)
  • Dutch + Endo + WPATH recommends PBs no sooner than Tanner 2.
  • Dutch + Endo + WPATH expect kids to get off PBs and on to GAHT around age 16 (i.e., when legally and mentally capable of consenting).

Which means that the duration of use could be as much as eight years for AFAB (if on the early end of normal puberty) and six for AMAB, but a more typical length is around one to three years.

What I'd like to move towards is a section that says how long is normal, to set the article up for a statement in Puberty blocker#Bone health that the risks to bone health depend on how long you're on the drugs. Eight years is kind of bad for bone health. Two years is probably not. WhatamIdoing (talk) 23:33, 14 May 2024 (UTC)[reply]

Minority who desire medical transition?

In this edit, WhatamIdoing edited text - cited to a 2015 "perspective" article about insurance coverage - to say that the number of young transgender people who desire medical transition are a minority. This seems like a very significant and surprising claim, to me at least. Is it actually supported by reviews or other high quality sources at this point in time? What does that source say, exactly (I could not find a free version)? Crossroads -talk- 00:30, 15 May 2024 (UTC)[reply]

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