Talk:Cass Review/Archive 2

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Separating 'Reception' into public and scientific responses?

What do editors think of separating the Reception section into two categories: scientific reactions (i.e., peer-reviewed articles and statements organisations) on the one hand and public opinions (published in news papers etc.) on the other hand? It might be beneficial to create this distinction because of differences in international applicability, scientific generalisability etc. Obviously, this is simply a suggestion which we perhaps cannot realise at this stage, not in the least because the Cass Review has been published only a few days ago. Further scientific responses may take a while. Another issue would be that the two cannot be distinguished at this stage (or even, at all): would an email response of WPATH in a newspaper article classify as a scientific or public statement? As of now, this approach may be fraught with all kinds of problems, but I wanted to initiate a discussion on this. After all, public opinion and scientific statements do significantly differ in crucial aspects.

PS: Slightly off-topic, but including page numbers when citing sources is generally advised. I hope to add page numbers when I've finished reading the report and its responses from the medical community (e.g., Norton 2024 etc.). Cixous (talk) 10:51, 14 April 2024 (UTC)

My question is where would we place the opinions of medical professionals? What about those with relevant experience? What about those without? That is, I could see putting Sallie and Ada in scientific and Kamran in public, but really there are arguments for all manner of organization Snokalok (talk) 10:54, 14 April 2024 (UTC)

That is indeed one of the most difficult questions here. It may be better to move all citations that are not derived from (a) peer-reviewed articles or (b) statements of scientific organisations to the public section. I think I'd prefer that, but you can really argue both ways. Some sort of separation seems warranted, though, as the British press seems to generally appreciative of the review, whereas it is scrutinised much more critically by health professionals. I'd actually recommend mentioning that in the introduction, like: "Generally lauded by British media, the review has received criticism from various medical organisations, such as WPATH." Cixous (talk) 11:08, 14 April 2024 (UTC)

I believe I said this somewhere else but the fact that (afaik) only British sources seem to support the Cass report, seems noteworthy. Especially considering the international criticism. Although I do accept this is probably OR and should be more conservative on any statement making it to the page.LunaHasArrived (talk) 11:24, 14 April 2024 (UTC)

I don't think there are enough HQ responses to warrant such a split, and I really wouldn't start bringing the already hotly contested arguments over the response section into the lede anytime soon. Void if removed (talk) 11:24, 14 April 2024 (UTC)

I see. For now, the best option might be just to wait with the split until responses to the Cass Review have consolidated - after all, it's been less than a week. At the end of the day, however, a split may eventually be beneficial, not in the least because I expect more responses from the medical community (e.g., from WPATH, perhaps in a joint statement with EUPATH).

To come back to your last point: I agree with @LunaHasArrived: I believe there is sufficient ground to include such a sentence in the lead. We've seen a joint response of WPATH, ASIAPATH, EUPATH, APATH and UPATH when NHS England provisionally suggested that puberty blockers would not be routinely prescribed any more. We've seen a joint response of WPATH and EUPATH criticising the exclusion of various studies by the NICE Review and NHS policiy which was based on the Cass Review. Lastly, we most certainly will see a joint response by WPATH and sister organisations about the Final Review and the final NHS England recommendations. This excludes multiple studies that mention that, for instance, ROCs are ethically unsound in transgender medicine, directly citing the NICE Review (e.g., Asley et al., 2023). I believe that this provides sufficient ground to mention its contested status in the introduction. Cixous (talk) 11:44, 14 April 2024 (UTC)

I wouldn’t call this hotly contested. The puberty blocker talk page was hotly contested. This is… a back and forth. Snokalok (talk) 12:09, 14 April 2024 (UTC)

I agree with including the split in the summary, I think enough orgs and UK sources have weighed in to justify it Snokalok (talk) 12:07, 14 April 2024 (UTC)

Okayy, I'll add it :). Cixous (talk) 12:07, 14 April 2024 (UTC)

I've added the sentence. I'm not sure if I did the citation right - I ran into some issues trying to cite the EPATH and WPATH joint statement -, so if somebody could check it (and change if necessary), that'd be really great. Cixous (talk) 12:30, 14 April 2024 (UTC)

Lede follows body anyway, as long as the underlying article supports it, you’re probably fine. Snokalok (talk) 13:06, 14 April 2024 (UTC)

The problem with the sentence now is that it elides the most relevant responses, which are not whether the British media like it, but the fact it was immediately welcomed by NHS England, and the two main political parties. That is more relevant. As presented it sounds like media vs medicine, which is wrong. Void if removed (talk) 07:46, 15 April 2024 (UTC)

I see. We could always add that it was also welcomed by NHS England (and by Labour and the Tories, if necessary). On a semi-related note: does anyone know if NHS Scotland issued a response? They are technically unaffected by the report and its recommendations (emphasis on 'technically' :/), but I could imagine them issuing an offical statement about it. Cixous (talk) 08:09, 15 April 2024 (UTC)

That both the current and (likely) future government immediately welcomed the report and committed to implementing it is one of the most significant aspects, given how politically polarised this topic is usually. Whether the Telegraph and the Mail thought it was great is neither here nor there, IMO. How NHS Scotland and the Sandyford clinic respond will no doubt play out in time. Void if removed (talk) 08:15, 15 April 2024 (UTC)

So, what would editors think if we changed the subclaused into sth like: "Welcomed by NHS England, the Labour and Conservative Party, ..."? Cixous (talk) 08:24, 15 April 2024 (UTC)

Perhaps it should be members of the labour and conservative party. I don't think there's been any party statements (and it would be usual for there to be) LunaHasArrived (talk) 09:25, 15 April 2024 (UTC)

Noted. So that 'd make it "Welcomed by NHS England as well as Labour and Conservative Party MPs..." Cixous (talk) 09:34, 15 April 2024 (UTC)

Wes Streeting is shadow health secretary and made clear party commitments in that capacity. Void if removed (talk) 11:14, 15 April 2024 (UTC)

Yes but given that there are labour MPs that oppose the recommendations being followed, without a party vote or new manifesto it's difficult to say the party as a whole supports it. LunaHasArrived (talk) 13:18, 15 April 2024 (UTC)

You are over complicating it. This is the health secretary remit. Speculating that the Labour party might decide to have a vote on it and that whether it is or isn't in the manifesto isn't relevant. Something not in the manifesto, for example, doesn't mean they don't intend to do it. Anyway, it is enough that he's the shadow health secretary. -- Colin°^Talk 13:47, 15 April 2024 (UTC)

This is specifically about what comment to put in the lede, I can't see any part of the body where the labour party welcomed the Cass report. I can see where a couple of labour MPs welcomed it. Unless there's a source that says the labour party welcomes it (in which case it should be added) this feels more accurate at the moment. This is mostly because it's still only been a few days, if Streeting and/or other labour MPs had been saying this for weeks/months that would be a very different situation. LunaHasArrived (talk) 14:09, 15 April 2024 (UTC)

Wes Streeting was practically first politician out of the gate, committing the Labour Party to the recommendations in full. There was a sky news source that's been lost along the way IIRC. This will do for now so I'll add it and make clear this is a party commitment. Void if removed (talk) 14:18, 15 April 2024 (UTC)

That's much much clearer LunaHasArrived (talk) 14:20, 15 April 2024 (UTC)

It's good to have a source that says so explicitly, but honestly if the (shadow) health sec says "we are committed to..." on a health issue, they'd get the sack if that wasn't either (a) their call to make or (b) something the (shadow) leader agrees with and (c) the rest of the party don't usually get a say in very much actually. Cabinets call the shots and if the (shadow) minister for department X says something about X then that's (shadow) government policy. You'd really need a source explicitly saying Streeting was out on a limb to think otherwise. -- Colin°^Talk 18:12, 15 April 2024 (UTC)

I don't think there is anything special about a peer reviewed source to indicate "scientific". And we have sources here such as newspapers quoting endocrinologists, so the type of source doesn't indicate who the speaker is. Different people have different ideas of what constitutes science. Someone writing a peer reviewed article in a soft science might be considered appropriate to talk about the various ideological approaches, but it wouldn't be accurate to pretend to our readers that this was a scientist who knew about how systematic reviews worked or what flaws they might have.

At some point there will need to be a cull of biomedical claims that fail to meet MEDRS. For example, Ada Cheung's disputing the puberty blocker systematic review, saying "four studies rated as high quality already showed those treated with puberty blockers had less depression, less anxiety, less self-harm suicidality, and fewer problems interacting with peers". It is one thing having differences of opinion over treatment guidelines and attitudes towards trans children, and discussing the various viewpoints on this. But for biomedical evidence claims we do not juxtapose systematic reviews in the BMJ with viewpoints of individual doctors the Sydney Morning Herald interviewed. -- Colin°^Talk 15:47, 14 April 2024 (UTC)

Perhaps instead of naming one of the separated sections 'scientific response' we could name it 'academic responses'? After all, you do raise an interesting point that not all peer-reviewed sources are per se scientific. That doesn't mean that they shouldn't be included - after all, criticism of the review process is relevant to add -, but does distinguish them from systematic reviews. When it comes to the 'public response', I'd advise simply to include editorial responses from various news outlets and/or noteworthy commentators. For the rest, I agree that, eventually, some of the sources will need to disappear and/or moved to different sections: not all responses and critiques are created equally. Cixous (talk) 17:39, 14 April 2024 (UTC)

I think we need to put a limit on "reception" here. I understand that the review is highly controversial, but if we add one more opinion/quote to the article, there will be more prose on the reception than on the actual report. Draken Bowser (talk) 19:03, 14 April 2024 (UTC)

I question though how much it being an MEDRS source comes into play with an article about the review itself. That is, the review's only capacity here is as the subject of the article. We cite the review only as a verified source of what the review is saying. We're not using the review as an MEDRS citation in service of a separate topic, thus we're not contrasting it with criticism from a weaker source, we're writing a section about the responses to the subject, and in that context sources like The Guardian and the SMH are perfectly reliable.

Additionally, I feel like if we remove individual criticisms of evidence findings, we have to remove individual praise for the evidence findings as well in the name of NPOV. Snokalok (talk) 04:51, 15 April 2024 (UTC)

I think we need to be careful to judge all inclusions and exclusion based on author and publisher, to weigh wether they are due. We only need to consider the actual content in order to decide how to best phrase it and/or what to quote. Draken Bowser (talk) 06:25, 15 April 2024 (UTC)

I think something we can do right now to adress this somewhat is to put the more scientific sources first in each section. Currently the first person we quote in the reception section for the final publication is a conservative politician, that doesn't strike me as the most sensible way to sort the responses. --Licks-rocks (talk) 09:39, 15 April 2024 (UTC)

Yeah, good idea. Draken Bowser (talk) 10:15, 15 April 2024 (UTC)

@Void if removed I don't agree with you that a politician's take on a medical issue is more important than a medical organisation's, and I think I have WP:DUE on my side in that. Care to comment? --Licks-rocks (talk) 11:06, 15 April 2024 (UTC)

This is a government-initiated review of domestic health services.

Whether the government then accepts the recommendations is relevant. Whether the opposition also accepts them is relevant. That this has bipartisan support is hugely significant. The domestic politics are more relevant than whether a New Zealand trans organisation doesn't like them based on asinine comments about haircuts. What is spinning out as a result is demands for further reviews, and insistence that adult clinics turn over data they had previously stonewalled on. Void if removed (talk) 11:12, 15 April 2024 (UTC)

I'm going to turn that around on you, the reaction of other medical organisations (many of which we regularly quote as MEDRS) trumps local-level politics in this case, based on the fact that this is about a medical publication, and thus at least partially falls under the remit of WP:MEDRS in terms of order of priority. I don't know what you mean with "adult clinics turn over data", and I don't particularly see how that changes the discussion about what order we should place the responses in. --Licks-rocks (talk) 11:16, 15 April 2024 (UTC)

I have to agree with @Licks-rocks here. Responses from international medical organisations, even if one disagrees with them, trump the reactions from UK politicians. Medical stances on the science behind and recommendations of the report clearly have more weight here. Cixous (talk) 11:22, 15 April 2024 (UTC)

Hm, I guess I would like to add the caveat that if there is broad political agreement over the interpretation of the report – in the country where it was ordered, and where such sentiments would directly influence the enforcement of its recommendations – I won't object to briefly mentioning this first under "reception". Followed by all the "academic responses", and only thereafter any other reactions that couldn't qualify as expert opinions. Draken Bowser (talk) 12:14, 15 April 2024 (UTC)

Fair, but in that case I'd still argue that separating 'public responses' and 'academic responses' is preferable Cixous (talk) 12:18, 15 April 2024 (UTC)

I think this strikes a very reasonable compromise between the "government body" and "medical claims" perspectives on this, and would support this. --Licks-rocks (talk) 13:38, 15 April 2024 (UTC)

A further suggestion - move the NHS & conservative/labour commitments to the "recommendations" section, as this is the domestic bodies acting upon the recommendations. Void if removed (talk) 12:41, 15 April 2024 (UTC)

I mean, for actions the NHS has said they'll take based on the recommendations sure but with what's currently in the article I do not think anything should be moved. Politicians opinions certainly shouldn't be in there and I don't think the NHS wanting to launch an investigation into an adjacent area should be in their either. LunaHasArrived (talk) 12:53, 15 April 2024 (UTC)

I agree with Void. You have to remember this is a review for NHS England, not a review for the USA or Denmark or Australia. That people outside have comments is interesting but really the primary concern for a government-commissioned review is whether the government of the day (or the impending government in six months) is intends to implement it and whether they succeed. Many times such independent reviews either gets shelved and never see the light of day, or are published and promptly ignored, or is explicitly rejected by the government, or superficially accepted and then ignored, and so on. So really the most important thing about the Cass Review today and in the coming years, is whether our government and future government actually implement its recommendations.

Put it another way, suppose Biden commissioned a review into some healthcare reform in the US. Do you think such an article would waste much time on the opinions of some doctor in the UK or healthcare organisation in Australia? No, it would focus on what that means for US healthcare and about how Trump then overturned everything in January 2025.

I don't support public/academic split. If anything I'd be veering towards domestic vs international. -- Colin°^Talk 12:22, 15 April 2024 (UTC)

I see, but I'd still argue for a public/academic split. In the public section, more weight could be given to the obviously more relevant English response. A domestic/international split is interesting, but potentially obfuscates things even further. For example, where would you put Horton (2024) [assuming we include her study, which we most likely will]. She's an English academic, but she published in an international journal. What about international organisations specifically criticising the NHS recommendations? Technically they criticise a distinctly domestic policy, but they do so from an international scientific perspective. I'd personally say such an approach makes categorising sources even harder Cixous (talk) 12:29, 15 April 2024 (UTC)

Per Void's comment above, maybe we need some place for official reactions from the people who the report was aimed at and matter, and a separate place for all the other responses. And wrt your comment about fallout into e.g. adult services and so on, yes they should be here. This Cass Review exists within the healthcare and political world around it and that commissioned it. If there's a Cass Review II for adult services, then it is highly relevant that this one spawned it. And just because the NHS says they will take action doesn't mean they can, because the recommendations really will require an injection of money into child mental health, which I don't think our current government is remotely likely to do. -- Colin°^Talk 13:02, 15 April 2024 (UTC)

I feel like that'd be a decent compromise. Section A for official responses from UK political figures and NHS England, section B for international organisations, academic responses and other responses we care to include.

PS: I don't remember bringing adult services into the discussion. Might have forgotten that or you're confusing me with another editor. Generally I see why one would want to include a Cass Review II on adult services here (although there's also a case to be made for separating the two when this article gets too long). Cixous (talk) 13:38, 15 April 2024 (UTC)

Yes the adult services was what I thought "I don't think the NHS wanting to launch an investigation into an adjacent area should be in their either" referred to, which came from LunaHasArrived. I probably thought both you red-link usernames were the same. -- Colin°^Talk 18:16, 15 April 2024 (UTC)

Ah that makes sense, I know it wasn't explicitly obvious in my comment but I wasn't talking about a place in the article but a place in the recommendations section. LunaHasArrived (talk) 19:12, 15 April 2024 (UTC)

I think you've hit on an important point here although I have doubts it will ever be covered sufficiently that we can mention it hence I'm making this small and won't object if some hats it or outright deletes it. While there may be significant disagreement on the aspects like the existing evidence and need for clinical trials and whether puberty blockers should only be given as part of a clinical trial, when and how to guide social transitioning, and whether mental health support should be purely affirming or something else; I think one area where both advocates and organisations like WPATH etc agree with Cass is the need for far more resourcing and especially mental health support. Indeed one thing there seemed to be agreement on before the review is that the old system was seriously broken in part because it was taking so long for most patients to get any sort of real care.

The problem for the earlier group is that while Cass may have said it's needed, even if we put aside concerns about what form the mental health support may take, the group feels probably correctly that it's simply not going to really happen in a significant degree. Probably even under Labour things won't be that much improved. So the areas where the Cass review has advocated for improvements is probably only going to happen to a limited degree at most. But the areas she's advocated for change that they disagree with is probably going to happen much more, indeed we're already seeing it's affecting not just the NHS in E&W but private healthcare and healthcare in Scotland too.

So they're expecting, probably correctly, what they consider the positives from the review to have little effect but the negatives to have substantial effects. So the end result of the review is pretty much all bad. Indeed some of the issues raised like the need for clinical support for transitioning is made much more acute if it takes ages to get that clinical support. (As it seems unlikely this is something that be just from a GP but instead specialised support.)

Cass was of course between a rock and a hard-place. She couldn't exactly say, 'This is what needs to happen, if you're just going to cherry pick parts of my review that you want to implement this isn't actually going to work and who knows if you might make things better or worse so pretty please with a cherry on top do not do that.'

I'd say the big unknown is what actually happens with puberty blockers. While you're right the NHS has done some good large scale clinical trials, I'd say it's very unclear at this stage how much they're actually going to do them with puberty blockers. Frankly given the way things are in the UK in the moment, even with a Labour government I'd say there's reason to think the other European countries who've suggested clinical trials are needed might be a more fruitful place to hope for progress; along with those who already feel the evidence is good enough but accept there sufficient disagreement to justify further research e.g. those associated with WPATH. OTOH, clinical trials are much more politically "sexy" so it's possible real progress may be made, regardless of disagreement on whether that progress is needed.

Edit: IMO the timing of the infected blood scandal investigation [1] is also unfortunate since I suspect all sides are going to read from that what they will into trans healthcare in the UK.

Nil Einne (talk) 21:40, 20 April 2024 (UTC) 22:09, 20 April 2024 (UTC)

I don't think your analysis of positive/negative is correct, even if one is only looking at it from the POV of activists at one end of the spectrum. For example, the clinics were becoming so massively overloaded with referrals that nearly all children referred would end up with the first appointment in adult services some time in their mid 20s. So really, whether one banned puberty blockers or not was somewhat by-the-by and only about 100 kids were on them at the time anyway.

We don't have a crystal ball, but I'm optimistic provided we get rid of the current bunch. Perhaps one day mental health will get the attention in the NHS it deserves. Btw, "Fighting for Life: The Twelve Battles that Made Our NHS, and the Struggle for Its Future" by Isabel Hardman is good if one is interested in the various battles around the NHS. Colin°^Talk 11:52, 21 April 2024 (UTC)

More International Responses

Scotland: Sandyford Clinic halts puberty blockers. https://www.bbc.co.uk/news/uk-scotland-68844119

Amsterdam UMC: Claims to already be doing what Cass Recommends in terms of assessment and gatekeeping, and that RCTs are unethical. https://amsterdamumc.org/nl/vandaag/een-reactie-van-amsterdam-umc-op-de-cass-review-over-transgenderzorg.htm

Norway: clinician quoted here welcoming the result and saying its in line with Norwegian guidelines (translated archived version) https://web-archive-org.translate.goog/web/20240417164023/https://www.aftenposten.no/verden/i/9zg9L5/england-foelger-etter-norden-strammer-inn-paa-kjoennsbehandling-for-mindreaarige?_x_tr_sl=no&_x_tr_tl=en&_x_tr_hl=en-US&_x_tr_pto=wapp

Anne Wæhre, senior physician at the National Treatment Service for Gender Incongruence at Oslo University Hospital. - This is probably the most thorough work that has ever been done in this field, says Wæhre [...] Young people have been treated for many years, but it is now clear that there is little evidence that the treatment is effective and safe.

The British conclusion points in the same direction as the conclusion drawn in Norway over the past year, following last year's report from the National Commission of Inquiry into the Health and Care Service.

Void if removed (talk) 15:06, 18 April 2024 (UTC)

Of these, I think the Sandyford response is notable, as is the Dutch one (as originators of the protocol).

The Norwegian one is more of one clinician's opinion and probably not adding much as yet. Void if removed (talk) 15:10, 18 April 2024 (UTC)

I think your summary of the Amsterdam UMC source is not great. This is going by Google Translate, but, here are a few quotes:

As a basis for the recommendations, Cass and colleagues simultaneously published 7 reviews of the scientific basis of transgender care, which found insufficient evidence for the various steps in this care. Amsterdam UMC disagrees with the conclusion that there is insufficient scientific evidence for the use of puberty blockers. Cass indicates that many studies lack an untreated control group, so the certainty of these studies is considered low to moderate. However, double-blind randomized placebo-controlled studies, the type of research that leads to the highest level of evidence in healthcare but which is not possible in many types of care, is not considered feasible by Amsterdam UMC from an ethical point of view for evaluating transgender care for young people.

Puberty blockers have been offered for about 20 years. Various studies show beneficial effects of hormonal treatment on psychological well-being and quality of life, in the Netherlands but also in other countries. Puberty inhibition, provided that it is preceded by careful assessment, is considered an effective intervention.

Cass recommends that from now on puberty blockers should only be offered to young people in a research context. However, there are doubts about the ethical issues surrounding it. If diagnosis, assessment and possible prescription of puberty blockers are only possible through participation in scientific research, people will not have access to necessary care if they do not participate in scientific research. Amsterdam UMC does not think it is ethical to ask patients this.

My overall summary here is that they agree with the Cass Review in the parts about local care and disagree with the meaty bits about evidence and about restricting access to puberty blockers except for research. Notably for Colin, who keeps complaining about this, they specify that it's only double-blind RCTs that they ethically object to and even suggest waiting-list controlled trials. (But on the other hand they do take a snipe at England, and notably they say England specifically and not the UK, for politicizing trans healthcare.) Loki (talk) 03:22, 20 April 2024 (UTC)

From what you quoted in green, it looks like classic strawman. That they supposedly found insufficient evidence because they excluded too much with unethically high standards. But the moderate quality studies were actually included in the systematic reviews (of hormones and of puberty blockers) and in fact the majority of studies were felt of sufficient quality to be worth drawing from, but this press release wouldn't tell you that. They setup the strawman of a blinded RCT despite none of the two BMJ systematic reviews and nowhere in the Cass Review demanding such. As you note, but didn't quote, they do say Waiting list control groups and comparisons between clinics could possibly be used as alternatives. Overall, they don't really give any good reason for why they disagree that there is evidence for puberty blockers, so I can only repeat that maybe some of these organisations claiming there is evidence should publish their own systematic review with that as its finding, rather than just waving hands about. It's what Wikipedia would need for us to say, in Wiki voice, that there is evidence: no amount of press releases from various international groups can dismount a solid systematic review in a top tier journal. Expert opinion is low down on the evidence pyramid.

They endorse the request for more research, and there's far far more to the research requirement that Cass is now insisting on than trying to figure out how to do a control. Just following the patients up and ensuring we have data on their long-term health would be a start, which isn't something England did. In fact, overall the press release has the air of a group boasting about how they did it right, per Cass, and rubbing their English colleagues noses in their mess.

The NHS has done some astounding research some of which is only possible due to the nature of our system. See RECOVERY Trial. We shall have to see what NHS England do in this regard. But offering treatment only as part of a clinical trial is I'm afraid absolutely routine in the NHS and I'm sure elsewhere too. I think their ethical complaint on that regard doesn't really stand up to evidence. Unlicenced drugs (as these are for this group) are quite typically offered only as part of a trial. Totally normal. In fact, the idea of giving out these unlicenced drugs but not including the patients in a trial, with long-term follow up, is something Cass and many others have commented on as being astoundingly abnormal. -- Colin°^Talk 10:24, 20 April 2024 (UTC)

Perhaps one of the things is this is fairly unique to the UK and that's why it's causing so much controversy? My impression is it's very common elsewhere that approved drugs are prescribed off-label without including the patients in a trial. See e.g. [2] for NZ. (While it doesn't definitely say they're not being given as part of a trial, the fact there's no mention they must only be given as part of a trial and it's clearly targeted at those making such prescriptions strongly suggests they're not. In fact it mentions concern about some widespread practices.) Likewise in the US [3] [4]. Indeed in the US AFAIK it's been a significant controversy when manufacturers seem to have aggressively promoted off-label use e.g. Quetiapine#Lawsuits but notably the Opioid epidemic in the United States is often blamed in part on manufacturers heavily promoting their use both over prescribing but also off-label usage. (The examples do demonstrate that excessive off-label usage can be problematic or at least highly controversial but also that they often happen without requiring a clinical trial. And I didn't even touch on the highly controversial off-label usage of ivermectin and some other drugs during the worst parts of COVID-19 pandemic in some countries, which I'm fairly sure is still happening in at least some places.) Nil Einne (talk) 22:00, 20 April 2024 (UTC)

Yeah, the idea of prescribing a drug off-label is completely routine in the US. Our own article on the practice says Off-label use is very common and generally legal unless it violates ethical guidelines or safety regulations. The ability to prescribe drugs for uses beyond the officially approved indications is commonly used to good effect by healthcare providers. Loki (talk) 22:26, 20 April 2024 (UTC)

I don't want to overplay the idea that unlicenced means it must be in a trial. For example, some epilepsy drugs are not tested and therefore not licenced in children but they may still be prescribed, likely not as first choice and likely only by a tertiary specialist hospital. Or you get a drug that is licenced only for some rare disease, and a specialist consultant is faced with someone with a different rare disease and similar symptoms and gives it a go. The likelihood that someone says hold on a sec is proportional to lots of factors like how hazardous the treatment is, the side effects, the alternatives available, the cost, and so on. For example, when Vagus nerve stimulation was first used in the UK for epilepsy, you couldn't get it outside of a trial. My point is that it is very common and someone saying that it needs to be part of a trial can't possibly be "unethical" since that is very common in the NHS.

Since I wrote the text above yesterday, I've read Cass's interview in the Times and find it reassuring that they have the same concerns I've raised about spreading misinformation, not only on the number of studies rejected but also on the supposed need for blinded randomised controlled trials. And yet we get this guff repeated in pink news saying "One of the biggest concerns is the report’s assertion that almost all existing research into clinical guidance for trans youth is of “poor quality”" which is easily proven false with some simple maths. As Cass themselves said in the interview, the systematic reviews took into account 60 out of 103 studies, which were of moderate or high quality. And then we get this nonsense "There actually is a lot of evidence, just not in the form of randomised clinical trials,” he said. “That would be kind of like saying for a pregnant woman, since we lacked randomised clinical trials for the care of people in pregnancy, we’re not going to provide care for you.… It’s completely unethical." This is from someone who's "a family physician from Calgary", like how some random GP on the other side of the world is an authority worth citing. They are talking out of their backsides anyway, since there are lots of randomised clinical trials for the care of people in pregnancy. Just think of when there are concerns about the baby: do we give this drug to speed up delivery or postpone it, do we do a caesarean or natural, do we attempt some manoeuvre or let nature decide, do we pull as well as push, and so on. The idea there aren't RCTs for pregnancy healthcare is a sure sign someone has let their mouth get ahead of their brain. -- Colin°^Talk 12:17, 21 April 2024 (UTC)

Social transition

The text currently says "stated that children who socially transitioned were more likely to continue on to medical transition." The report doesn't say this (AFAIKS). It does discuss one study (Olson et al, 2022) but emphasises that the group of patients studied was "a self-selected community sample of children (the Trans Youth Project). Children had to be between three and 12 years of age at enrolment and had to have made a “complete” binary social transition, including changing their pronouns to the binary gender pronouns that were not those used at their births" Looking at the paper here shows two-thirds were AMAB which is not the demographic seen today and the study excludes non-binary as an option. So this is primary-school aged children, mostly AMAB, who already had a strong binary transgender at the start of the study and Cass says "This study also demonstrated that the majority of children who had socially transitioned went on to progress to medical interventions". But they are talking about the facts of that study, not what may or may occur in the cohort of children presenting to the clinics today, which are often AFAB adolescents and not neccesary binary. Since the study doesn't have a control, it cannot possibly conclude "more likely to" as our article text says, and Cass doesn't say that either. Simply that the majority of kids in that particularly study did. Cass repeatedly emphasises that one can't separate cause from effect (e.g. those who socially transition may have had stronger feelings which inevitably made it more likely they would medically transition, regardless). This is just another example of where Cass concludes a lot of "don't know" rather than "do know". I don't think we can make the claim in this sentence. I think we should summarise that chapter better in some other way. -- Colin°^Talk 18:16, 21 April 2024 (UTC)

Replaced "children who socially transitioned were more likely to continue on to medical transition" with a rewording of the conclusions in 12.36, page 164. Flounder fillet (talk) 20:07, 21 April 2024 (UTC)

Criticism

The sentence that begins "Academic criticism also fell on the report..." in the Criticism section references a paper (Horton, 14 Mar 2024) that pre-dates the publication of the final report. Is there a better source for this? Zeno27 (talk) 15:49, 11 April 2024 (UTC)

Trying to track the original source for this: "Dr. Natacha Kennedy of the Feminist Gender Equality Network described the Cass review as "attempting to establish an all-enveloping ambient conversion therapy approach to trans children".[21]". This cites PinkNews but the article says, "In an opinion piece on the report, Dr Natacha Kennedy, co-chair of the Feminist Gender Equality, criticised the report’s approach to analysing research." but there's no link to where Kennedy says this and a Google returns nothing. Any idea where this opinion piece is? Zeno27 (talk) 16:42, 11 April 2024 (UTC)

Just answering both comments in 1, I believe the Horton paper is a response to the interim report and this should be noted in that section. And with 2 I don't believe it is the editors job to ask where a source got it's sources. However googling that sentence got a blogspot up authored by a Natacha which checking her twitter she does in fact link to so it does seem she did author that comment. LunaHasArrived (talk) 17:20, 11 April 2024 (UTC)

Yes, it should be noted that the Horton paper was referring to the Interim report. I was unable to find Kennedy's blog post - all I got was this page and PinkNews. I'll take another look. Ta! Zeno27 (talk) 17:34, 11 April 2024 (UTC)

Dropping in the PinkNews quote:

“In an opinion piece on the report, Dr Natacha Kennedy, co-chair of the Feminist Gender Equality, criticised the report’s approach to analysing research.

Kennedy wrote that she believes the Cass Report is “attempting to establish an all-enveloping ambient conversion therapy approach to trans children,” saying that the report, if implemented, would remove “their autonomy, freedom of expression, mental health, helpful support and healthcare.”” Snokalok (talk) 17:21, 11 April 2024 (UTC)

This sentence is wrong: "Criticism was also levied for the exclusion of transgender expertise - wherein the original terms of reference for the Cass Review explicitly stated that it "deliberately does not contain subject matter experts or people with lived experience of gender services".[14]"

The quote comes from that reference (Horton) but the full sentence is, "The original published Terms of Reference (ToR) for the Cass Review’s assurance group explicitly excluded trans expertise, stating that it “deliberately does not contain subject matter experts or people with lived experience of gender services”"

That quote does not come from the ToR and the ToR make no mention of the Assurance Group, but from an early description of the Assurance Group on the Cass website. It is therefore not about the review itself, but about the Assurance Group. The purpose of the Assurance Group is explained clearly:

"Members are independent of NHS England and NHS Improvement and of providers of gender dysphoria services, and of any organisation or association that could reasonably be regarded as having a significant interest in the outcome of the Review.

Because the group is advising on process and not outcomes, it deliberately does not contain subject matter experts or people with lived experience of gender services. Professional and lived experience will be used to determine the outcomes of the Review and will be captured through our participative and consensus development approach.

Members have been appointed by the Chair to provide expert challenge from broad perspectives and have proven expertise relating to the conduct of the Review."

So, the Assurance Group is simply about ensuring the review was conducted to high standards.

Therefore, the reference does not say what that sentence says - and neither does the ToR - and is therefore highly misleading and needs to go. Zeno27 (talk) 18:44, 11 April 2024 (UTC)

Yes you are correct, the review engaged extensively with patients at the clinic, this is detailed in the review itself. Unfortunately this criticism has been made, it's one of various pieces of misinformation that's floated around on Twitter 86.21.75.203 (talk) 21:14, 21 April 2024 (UTC)

Criticism sections are generally discouraged as they wrongly create a binary reaction to the subject, and can clump opinions that are more nuanced or varied into being "critical". I don't think we should do that. Also, way way too much room is being given to this opinion piece by some random academic at Oxford Brookes Business School. Not only is it only based on the interim report, but it is just some guy's opinion. If it has weight to be included at all (which I doubt), it would be something like "Dr Cal Horton criticised the interim review as an example of cis-supremacy" and that frankly is it. And our readers would be going "Who the heck is Dr Cal Horton and why should we care what they think" and rightly so. We do not bang on about "the International Journal of Transgender Health" nor do we confused one guy's opinion with facts we can present in Wikivoice. That entire section should be deleted: we don't contrast major four year healthcare reviews with someone from the business school of a minor university. -- Colin°^Talk 19:21, 11 April 2024 (UTC)

Agreed. Zeno27 (talk) 19:26, 11 April 2024 (UTC)

While I understand the view on criticism sections, it's somewhat difficult to not have one here given, everything. Like I get the criticisms of the Cal Horton paper, but a criticism section is somewhat necessary here given the controversial nature of the review. Snokalok (talk) 19:27, 11 April 2024 (UTC)

Oh and this sentence, also sourced to Horton "Academic criticism fell on the report for centering the concerns of professionals who did not believe in the existence of transgender children, for the demand for what is widely recognized as an "infeasible and unethical" level of evidence from studies for affirming treatments, due to requiring a control group to be subjected to what some consider conversion therapy; while non-affirming treatments were not held to the same standard of evidence" is not something we can say in Wikivoice at all, and is frankly such complete bs we should not be even quoting it. Dr Cal Horton is not "academic criticism" as though he speaks for all of academia who are all critical. It is not in any shape or form a universal (or even widespread) belief that what systematic reviews do (assess evidence) is demanding the infeasible and unethical. We are giving way too much voice to extremist positions critical of evidence based medicine.

Snokalok, once you get a Criticism section, it becomes a dumping ground for everyone who gets their opinion published. Do you think all serious minded analysis of the Cass review will entirely fall into wholesale criticism and . oh, wait, nobody created a Praise section. What a surprise. Life is not so simple. There will be serious sources on this review who take a very nuanced reaction. Right now, you only have a place for the critics. That's not NPOV. And it isn't solved by creating a Praise section, I was only joking about that. We just aren't recommended to do this at all. -- Colin°^Talk 19:40, 11 April 2024 (UTC)

I agree with what Colin says. Especially on "criticism"-sections in general, no matter the intention they invariably turn into flypaper for POV-edits. Draken Bowser (talk) 19:47, 11 April 2024 (UTC)

You say this as though crictism/controversy sections are not, incredibly common across Wikipedia. Calling it not NPOV is somewhat ridiculous. As for "infeasible and unethical", it is an incredibly commonly held position in medicine that there are some treatments for which the requirement of blind or double blind tests, are infeasible and/or unethical. Acting as though that's some unique idea here is, flat out incorrect. There are no double blind tests of "One person receives insulin, the other receives water" - that's ethics. Likewise, for feasibility, there are many treatments that are impossible to do blind because when one group starts growing a beard or tits, suddenly everyone knows which side has received hormones. Snokalok (talk) 19:48, 11 April 2024 (UTC)

Many bad ideas are common across Wikipedia, the compendium is a work in progress. Draken Bowser (talk) 19:56, 11 April 2024 (UTC)

I think at the very least if there is going to be a section it needs to be handled with great care. Just a few days ago when reading stuff related to this I came across Great Ormond Street Hospital#Controversies which IMO shows how absolutely terrible such sections can become when not handled properly. [5]

If you don't want to read it, that section currently includes quite a few stuff in the form of "In X date it was revealed". Worse than that, many of these and others in different form seem to be just random mostly clearly bad stuff that undoubtedly happened that was mentioned in the media that some editor decided to add. Some of them might belong, but many of them don't seem to have long term significance. And at least thing there in the gender identities subsection is just a random thing where the controversy isn't even established or obvious.

I mean this article doesn't quite carry the same risks since there won't be so much new stuff all the time, but still the point remains just because plenty of articles have such sections it doesn't mean they're working properly.

Nil Einne (talk) 07:09, 13 April 2024 (UTC)

I don’t actually mind the combined sections here anymore. It’s less organized, to be certain, but not unworkably so Snokalok (talk) 07:40, 13 April 2024 (UTC)

Snokalok, can I suggest you type "RCT on insulin" into your favourite search engine. So much nonsense gets written about this, please let's not be like Twitter where the ignorant argue with the ignorant. Cass is neither stupid nor evil and I'm sure knows more about evidence based medicine than everyone on this talk page many times over. Do you really think they aren't aware of these tired arguments about EBM?

Complaints about infeasibility or ethics are a deflection from basic statistical facts. Let's imagine I toss a coin three times and get heads each time: a 1/8 chance. It isn't proof the coin has two heads. If I now accidentally drop the coin in a drain, continuing the tossing to get a statistically convincing number is now both infeasible and asking you to retrieve it for me would be unethical, as you'd get stuck and drown. That fact doesn't magically make the coin any more likely to have two head. People playing this card, which demonstrates basic statistical ignorance, are like the folk that tell you bumblebees shouldn't be able to fly according to aerodynamics. They are spinning a story while ignoring the obvious: the bumblebees really can fly and the evidence about e.g. puberty blockers really doesn't make the grade any more than my three coin tosses do. -- Colin°^Talk 20:20, 11 April 2024 (UTC)

"Do you really think they aren't aware of these tired arguments about EBM?"

Somewhere around 90% of modern medical practice doesn't have "high quality" evidence backing it up. I think most medical researchers are aware of these arguments, they just don't care about the need for "high quality" evidence because RCT's are an impossible bar for many treatments. My question is why it suddenly matters so much more for this highly politicized and controversial treatment?

"Complaints about infeasibility or ethics are a deflection from basic statistical fact"

They're not, they're an observation that the overwhelming majority of medical care is without such studies backing it up for exactly this reason, and that it's thus unreasonable to demand that standard of evidence for only this specific treatment and no others. Snokalok (talk) 20:32, 11 April 2024 (UTC)

"Somewhere around 90% of modern medical practice doesn't have "high quality" evidence backing it up." This is an old trope caused by a misunderstanding (promulgated extensively by quacks) and usually originates from the BMJ Clinical Evidence page. I don't think that exists any more but it's explained by Prof Ernst here. It's also a tu quoque fallacy. Zeno27 (talk) 21:26, 11 April 2024 (UTC)

https://www.jclinepi.com/article/S0895-4356(20)30777-0/fulltext

As you can see above, "only a minority of outcomes (9.9%) for healthcare interventions are supported by high quality evidence". I'm not saying that high quality means good evidence, I'm saying that the standard for high quality is unfeasible to meet for a wide array of medical treatments, and that's being used here by others to say that there is no good evidence - because for some reason high quality means good evidence only when it applies to gender transition. Snokalok (talk) 21:48, 11 April 2024 (UTC)

No, but what quality of research does the vast majority of children's healthcare require. And let's not pretend that the research is anything like the coin toss example in terms of actual probability (although I do appreciate the good comparison). Also there is this study which is outside of the time period considered but shows that the research is being done and Is there (although the ethics have been questioned about this study). LunaHasArrived (talk) 20:34, 11 April 2024 (UTC)

Your giving undue weight to the review simply because it is a review, and not considering that there is legitimate criticism about it. In general I agree with the points made above, that RCT's is both unethical and largely impossible to implement in the studies rejected. If your review rejects most of the evidence on criteria that has been judged unreasonable on the basis of ignoring the ethical problems inherent with trying to implement said criteria, it is not something that can be ignored in the article itself. I agree Wikipedia shouldn't attempt to balance both sides of the debate in the case where one is overwhelmingly incorrect, but in this case claiming all the opposition are 'extremist voices critical of evidence based medicine' is completely and utterly ridiculous. Not only is there no consensus apart from the Labour Party and a couple of other organisations whether or not the Cass Review is even correct in its findings, it's completely ignoring the legitimate position taken by some critics. Keep and expand the Criticism section if necessary, because it's a reflection of the actual response to the review: Considering how controversial it is to pretend that the response was unending praise and zero backlash is factually incorrect. Angryman120344 (talk) 08:01, 12 April 2024 (UTC)

RCT's is both unethical and largely impossible to implement in the studies rejected

That's not why studies were rejected, and this article should not be a forum for spreading ill-informed opinion about MEDRS. Include the backlash, sure, but some of these specifics need to be backed up and corroborated with far stronger sources IMO.

And just to add, this is now the fourth systematic review into puberty blockers in as many years finding the exact same thing. Void if removed (talk) 13:33, 12 April 2024 (UTC)

The NOS still requires a blind assessment (impossible to do for this form of medicine), and an external control group (meaning one side gets forced through the wrong puberty, raising tremendous ethical concerns) Snokalok (talk) 14:11, 12 April 2024 (UTC)

You can read it in the review itself, but alongside a large number of incredibly vague assertations such as them being 'low quality', yes that is why they were rejected. It's not spreading an 'ill-informed opinion' the point of a criticism section is to reflect the reality that a large group of people have genuine concerns about the methodology and intentions behind the review. Again ignoring this is fundamentally misunderstanding how Wikipedia works. Also you are now making a personal assertation in the same response criticising me for giving weight to a single viewpoint, by once again arguing there is a consensus that puberty blockers are harmful.Just to add, this is now the fourth systematic review into puberty blockers in as many years finding the exact same thing. - This is not only completely irrelevant to my initial point, but is also not a point in of itself, because 1. there is no large scientific consensus on the efficiacy of puberty blockers and 2. To argue that because a review is 'systematic' automatically makes it correct or more worthwhile than the studies that it rejected and should be linked in the article in the Criticism page, is absolutely absurd. This isn't a debate on puberty blockers, but its generally accepted there is no consensus, so kindly stop trying to pretend there is. Angryman120344 (talk) 14:25, 12 April 2024 (UTC)

genuine concerns about the methodology

I think raising specific methodological concerns about a MEDRS, in wikivoice - particularly one of the highest quality - needs a source stronger than popular press, per WP:MEDPOP. Statements from recognised orgs like AUSPATH are, IMO, fine, but a person making an unverifiable claim in passing to the press is not.

To argue that because a review is 'systematic' automatically makes it correct or more worthwhile than the studies that it rejected and should be linked in the article in the Criticism page, is absolutely absurd

That is why a systematic review sits at the top of the MEDRS pyramid. Void if removed (talk) 15:24, 12 April 2024 (UTC)

agreed. it would be better if the criticism sectionw as retitled either "reactions" or "reception" Bird244 (talk) 15:16, 20 April 2024 (UTC)

Haircuts

Requiring clinical approval for haircuts and wardrobe changes is intrusive, inappropriate, and a waste of money and time. I’m sorry @Snokalok but this is just garbage - a ridiculous straw man of a “requirement” that is not proposed anywhere in Cass. Just because a supposedly reputable organisation said it doesn’t mean it’s not misinformation. We’re not obliged to repeat misleading nonsense even if the person who said it should have known better. Barnards.tar.gz (talk) 15:56, 13 April 2024 (UTC)

"We refer to social transitioning as changing your name and/or pronouns, appearance or expression (such as clothing or hairstyles), the washroom you use, and so on." [6] Nova Scotia Health Library

---

"Social Transition

Presenting in public part- or full-time in your identified gender, may include:

• Changing your wardrobe or hair style" [7] University of California San Francisco

---

"Social transitioning is changing the way you present yourself to the world so that your gender expression matches your gender identity. That can include changing your hair or clothes, using a new name, and being called by the correct pronouns for your gender identity."[8] Mt. Sinai Hospital (really top tier hospital in NYC if you're not aware)

---

"social transition, in which a transgender or gender diverse child would be able to use a name, pronouns, and gender expression (including haircut or clothing) that aligns with their gender." [9] WPATH

---

Clothing and haircut explicitly fall into the agreed upon definition of social transition. Thus, this isn't a strawman, this is the definition of social transition - which the Cass Review said needed clinical involvement. Snokalok (talk) 16:07, 13 April 2024 (UTC)

Quotes from the Cass Review:

There is no single definition of social transition, but it is broadly understood to refer to social changes to live as a different gender such as altering hair or clothing, name change, and/or use of different pronouns. p 31

Recommendation 4: When families/carers are making decisions about social transition of pre-pubertal children, services should ensure that they can be seen as early as possible by a clinical professional with relevant experience. p 32

From it's section on social transition in children:

Social transition may not be thought of as an intervention or treatment, because it is not something that happens in a healthcare setting and it is within the agency of an adolescent to do for themselves. However, in an NHS setting it is important to view it as an active intervention because it may have significant effects on the child or young person in terms of their psychological functioning and longer-term outcomes p 158

Parents should be encouraged to seek clinical help and advice in deciding how to support a child with gender incongruence and should be prioritised on the waiting list for early consultation on this issue. p 164

Clinical involvement in the decision-making process should include advising on the risks and benefits of social transition as a planned intervention, referencing best available evidence. This is not a role that can be taken by staff without appropriate clinical training. p 164

The Cass Review says social transition must be considered an active intervention and stresses that parents should receive clinical guidance on it as a planned intervention covering all the risks. Which is ridiculous, if a kid says "I'm trans" and starts going by a different name and wearing different outfits - the active intervention is stressing their family needs a doctor to counsel them on whether it's the right move and if it should be respected, it is not respecting their basic human rights to free gender expression. PATHA's criticism is not misinformation for pointing out one of the worst takes of the Cass Review. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 16:30, 13 April 2024 (UTC)

Unless the Cass report has a markedly different definition of social transition to common parlance (in which case that should be noted in the article) Or it explicitly states what parts of social transition should be stopped (yet again should be noted). This is in fact what the report says and I think you get why people find it so silly and find social transition "bans" so silly. LunaHasArrived (talk) 16:30, 13 April 2024 (UTC)

As YFNS has pointed out, this criticism is in fact a fairly direct paraphrase of the Cass Review's recommendations on social transition, and the fact that you think they're so ridiculous that they must be a strawman is perhaps indicative of why they're being criticized. Loki (talk) 18:37, 13 April 2024 (UTC)

Social transition is not only haircuts and wardrobe changes. It is those things (and maybe more, and sometimes not even) as part of an effort to live as a different gender. The PATHA statement makes two errors: 1) in saying that Cass demands clinical approval for haircuts. It’s not haircuts, it’s social transition, of which haircuts might be one part but actually the critical part is the intention to live as a different gender and really the haircuts are neither here nor there. 2) in saying that Cass demands clinical approval for social transition at all. Seriously folks, have you actually read the report? It’s not in there. YFNS has provided full excerpts and page numbers and it’s plain as day that “clinical approval” is not to be found amongst those sentences! What she has written is significantly more nuanced, and concerns dialogue on risks and benefits, and prioritisation for early consultation - not “clinical approval” or any other heavy-handed straw man. She is certainly critical of the evidence for the purported benefits of social transition, and she wants to encourage parents to seek clinical guidance, but she stops well short of the haircut-police that PATHA would like you to imagine.

By the way, our article is currently wrong in the Findings section on social transition, probably being mislead by The Times who wrote about “the need” for clinical involvement, which is not the language of the report. Barnards.tar.gz (talk) 21:31, 13 April 2024 (UTC)

By the way, our article is currently wrong in the Findings section on social transition

You are correct, we should revise this. The points Cass makes are that within an NHS setting it should be viewed as an active intervention because it can impact gender identity development, and there's an association between social transition and intensifying gender dysphoria or desire to transition.

The bullet points on page 164 are, roughly:

For children

• Encourage parents to seek clinical advice for supporting a child with gender incongruence
• Advise on the risks/benefits of social transition as a planned intervention
• Ensure the child is heard and parents are not unconsciously influencing their decision
• Maintain flexibility and keep options open

For adolescents

• Exploration is normal, rigid binary stereotypes are unhelpful
• Given that adolescents have greater agency and waiting lists are long, try to ensure those involved in their welfare have support and information

For both

• Supportive family is best
• The child or young person needs help and support if they change their mind

Void if removed (talk) 21:52, 13 April 2024 (UTC)

I mean it says directly that professionals with clinical training should advise on the risks and benefits on social transition. Which means the theoretically a doctor could recommend against wardrobe changes and/or a haircut. Whilst not quite as severe as stated I do think it is possible people could see this as requiring medical approval (i.e. parents saying let's get the doctor to say whether you get a masculine hair cut or not.) LunaHasArrived (talk) 21:59, 13 April 2024 (UTC)

I will go even further than Luna and say I think you're just plain reading the section incorrectly. It clearly advises going to a clinician before allowing children to socially transition, and it clearly, if somewhat euphemistically, advises that clinician to reject a full social transition in children at least some if not most instances:

For those going down a social transition pathway, maintaining flexibility and keeping options open by helping the child to understand their body as well as their feelings is likely to be advantageous. Partial rather than full transition may be a way of ensuring flexibility, particularly given the MPRG report which highlighted that being in stealth from early childhood may add to the stress of impending puberty and the sense of urgency to enter a medical pathway.

I don't know what you would call that other than Requiring clinical approval for haircuts and wardrobe changes. It doesn't matter that they don't say the words "clinical approval". They don't say the words "clinical approval" in the puberty blockers section either, yet they clearly advise clinicians to not give approval for puberty blockers there, right? Loki (talk) 01:55, 14 April 2024 (UTC)

It encourages parents to seek clinical involvement. It doesn't mandate anything. Doctors have no signoff. Nothing is framed as "allowed" or "disallowed". Parent and child remain free to ignore the clinical advice, or to not seek it in the first place. It recognises that there are risks, and that the best people to advise on those risks are those with clinical experience. None of this is even close to "approval required", and "approval required" is not an accurate paraphrase of anything in Cass. That PATHA sentence is hyperbolic, and makes them look like amateur activists. It's not encyclopedic to amplify it. Barnards.tar.gz (talk) 08:05, 14 April 2024 (UTC)

“ This is not a role that can be taken by staff without appropriate clinical training. “

That reads very clearly in the context of the UK as a statement about people such as teachers and GP’s in the child’s life using their preferred name and pronouns, and it’s not unreasonable for professional orgs to agree. If it seems like a ridiculous requirement, then you understand why it’s being criticized. Snokalok (talk) 10:09, 14 April 2024 (UTC)

The fact is that while requiring clinical approval for social transition may not be how you read it, it is a reasonable reading, and thus PATHA’s criticisms are worth including. Snokalok (talk) 10:16, 14 April 2024 (UTC)

I personally find it an obtuse reading, and I suggest excluding the sentence to spare PATHA the embarrassment of having written it. Void if removed (talk) 12:24, 14 April 2024 (UTC)

It’s not our job to determine what embarrasses PATHA or to spare them from it Snokalok (talk) 13:51, 14 April 2024 (UTC)

@Snokalok, how would you feel about changing the PATHA quote from and that "Requiring clinical approval for haircuts and wardrobe changes is intrusive" and "inappropriate" to and that "Restricting access to social transition is restricting gender expression, a natural part of human diversity."? I was sidetracked but meant to recommend it earlier as I think it captures the essence of the issue in a clearer way. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 22:33, 16 April 2024 (UTC)

It feels less… direct to the heart of the criticism for me, but if you think it’d be better, I don’t feel strongly enough to dispute it. By all means go ahead. Snokalok (talk) 22:57, 16 April 2024 (UTC)

To me the difference is the former points out how ridiculous the practicality of it is, the second is more so criticizing the idea behind it - that gender expression should be restricted and isn't natural. I think part of the issue was that was the only place we defined social transition in the article, the findings section talked about restricting access to it without saying what it was so we needed that voice of sanity in the article saying "we're talking about haircuts and outfits ffs". I just added Cass's definition to that subsection which should fix the issue and let PATHA's main criticism shine through. Your Friendly Neighborhood Sociologist ⚧ Ⓐ (talk) 23:34, 16 April 2024 (UTC)

The review is making recommendations to the NHS, not to parents 86.21.75.203 (talk) 21:50, 21 April 2024 (UTC)

PATHA is obviously ridiculing the recommendation, and they've published something that will feed the internet outrage machine. It worked; their made-for-retweeting soundbite is getting attention for their views.

I think the first question for us is whether we want to include a reaction from PATHA at all (e.g., are they notable? If not, that might suggest a lower priority for including them. On the other hand, we tend to prioritize organizations from English-speaking countries, which suggests that including them is desirable), followed by whether we should do so by quoting their statement or by summarizing their views in a more encyclopedic style (e.g., "expressed concern about the medicalization of some parts of social transition, such as changing hairstyles or clothing preferences").

One thing I appreciate about the article's current state is that there is slightly more content describing the subject than criticizing the subject. I wonder whether it would be useful to integrate the Wikipedia:Criticism section into the subject matter. For example, instead of "PATHA said something tweetable about social transition", we might have a paragraph that says "The report suggested that families be prioritized for an early evaluation before beginning social transition. PATHA thought that this was ridiculous, the Anxious Parents Club thought queue jumping was a great idea because it'd be easier to get the school on board if they had a letter from a doctor in hand, and the United Hairstylists Association posted a list of their 10 favorite transitional hairstyles". WhatamIdoing (talk) 06:41, 15 April 2024 (UTC)

WPATH statement

Is there really no better source for WPATH's response to this than a passing reference in a mediocre website? Screenshots of the actual statement are circulating on social media, but it's been 5 days and there's nothing better? Void if removed (talk) 22:58, 16 April 2024 (UTC)

@Void if removed The discussion in Talk:Cass_Review#Mostly_news_articles? is relevant to this issue, you might want to have a look at it. 13tez (talk) 12:27, 23 April 2024 (UTC)